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Objectives: To compare level of supervision (LOS) ratings of graduating pediatric residents with their assessments as fellows for the five Entrustable Professional Activities (EPAs) common to general pediatrics and the subspecialties and to determine if the difference between ratings from residency to fellowship is less for the QI and Practice Management EPAs, since the skills needed to perform these may be less context-dependent., Methods: We compared ratings of graduating residents with their assessments as fellows using LOS data from two sequential EPA studies., Results: There were 65 ratings from 41 residents at the first fellow assessment. At graduation, most residents needed little to no supervision for all EPAs with 94% (61/65) of ratings level four or five. In contrast, only 5/65 (8%) of the first fellow assessments were level four or five. The ratings difference for the QI and Practice Management EPAs was similar to the others., Conclusions: LOS ratings for the EPAs common to generalists and subspecialists reset as residents become fellows. There was no evidence that the QI and Practice Management EPAs are less context-dependent. This study provides additional validity evidence for using these LOS scales to assess trainees in pediatric residency and fellowship., Competing Interests: Declaration of Competing Interest Dr. Turner is employed by the American Board of Pediatrics. The other authors have no conflicts of interest relevant to this article to disclose. The content of this manuscript is solely the responsibility of the authors and does not necessarily represent the official views of the American Board of Pediatrics or the American Board of Pediatrics Foundation., (Copyright © 2024 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Background and Objective: The Pediatric Resident Burnout and Resilience Consortium (PRB-RSC) has described the epidemiology of burnout in pediatric residents since 2016. We hypothesized burnout rates during the pandemic would increase. We explored resident burnout during the COVID-19 pandemic and its relationship to resident perception of workload, training, personal life, and local COVID burden., Methods: Since 2016, PRB-RSC has sent an annual, confidential survey to over 30 pediatric and medicine-pediatrics residencies. In 2020 and 2021, seven questions were added to explore the relationship of COVID-19 and perceptions of workload, training, and personal life., Results: In 2019, 46 programs participated, 22 in 2020, and 45 in 2021. Response rates in 2020 (n = 1055, 68%) and 2021(n = 1702, 55%) were similar to those of previous years (P = .09). Burnout rates in 2020 were significantly lower than in 2019 (54% vs 66%, P < .001) but returned to pre-COVID levels in 2021 (65%, P = .90). In combined 2020-2021 data, higher rates of burnout were associated with reported increased workload (Adjusted Odds Ratio (AOR) 1.38, 95% CI 1.19-1.6) and concerns regarding the effect of COVID on training (AOR 1.35, 95% CI 1.2-1.53). Program-level county COVID burden in combined 2020-2021 data was not associated with burnout in this model (AOR=1.03, 95% CI 0.70-1.52)., Conclusions: Burnout rates within reporting programs decreased significantly in 2020 and returned to prepandemic levels in 2021. Increased burnout was associated with perceived increases in workload and concerns regarding effect of the pandemic on training. Given these findings, programs should consider further investigation into workload and training uncertainty on burnout., Competing Interests: Declaration of Competing Interest Dr Schwartz serves as Director of the Association of Pediatric Program Directors’ Longitudinal Education Assessment Research Network through a contract from the Association of Pediatric Program Directors to the Department of Medical Education at the University of Illinois at Chicago. The other authors indicated that they have no conflicts of interest and no financial or personal relationships with other people or organizations that could inappropriately influence their work., (Copyright © 2023 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Background: Entrustable Professional Activities (EPA) and competencies represent components of a competency-based education framework. EPAs are assessed based on the level of supervision (LOS) necessary to perform the activity safely and effectively. The broad competencies, broken down into narrower subcompetencies, are assessed using milestones, observable behaviors of one's abilities along a developmental spectrum. Integration of the two methods, accomplished by mapping the most relevant subcompetencies to each EPA, may provide a cross check between the two forms of assessment and uncover those subcompetencies that have the greatest influence on the EPA assessment., Objectives: We hypothesized that 1) there would be a strong correlation between EPA LOS ratings with the milestone levels for the subcompetencies mapped to the EPA; 2) some subcompetencies would be more critical in determining entrustment decisions than others, and 3) the correlation would be weaker if the analysis included only milestones reported to the Accreditation Council for Graduate Medical Education (ACGME)., Methods: In fall 2014 and spring 2015, the Subspecialty Pediatrics Investigator Network asked Clinical Competency Committees to assign milestone levels to each trainee enrolled in a pediatric fellowship for all subcompetencies mapped to 6 Common Pediatric Subspecialty EPAs as well as provide a rating for each EPA based upon a 5-point LOS scale., Results: One-thousand forty fellows were assessed in fall and 1048 in spring, representing about 27% of all fellows. For each EPA and in both periods, the average milestone level was highly correlated with LOS (rho range 0.59-0.74; p < 0.001). Correlations were similar when using a weighted versus unweighted milestone score or using only the ACGME reported milestones (p > 0.05)., Conclusions: We found a strong relationship between milestone level and EPA LOS rating but no difference if the subcompetencies were weighted, or if only milestones reported to the ACGME were used. Our results suggest that representative behaviors needed to effectively perform the EPA, such as key subcompetencies and milestones, allow for future language adaptations while still supporting the current model of assessment. In addition, these data provide additional validity evidence for using these complementary tools in building a program of assessment., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Objective: The Accreditation Council of Graduate Medical Education requires an "individualized curriculum" (IC) in pediatric residency. A shared understanding across programs of methods to evaluate the IC is lacking. We explored pediatric program leaders' perceptions of assessment and evaluation within the IC to further understand and inform most useful practices., Methods: We conducted a phenomenology study using semi-structured interviews to 1) determine what IC assessment and evaluation strategies are utilized in pediatric residency programs, and 2) explore program leaders' perceptions of the feasibility and value of assessment and evaluation in the IC. We recruited a purposive sample of leaders from 15 pediatric residency programs of various sizes and regions. Interviews were recorded and transcribed. Data were analyzed to produce themes., Results: Three themes arose from our analysis: 1) Systematic assessment of the IC, though desired, is not robust in pediatric residency training; 2) Program differences present unique barriers and facilitators that impact the feasibility of assessment within the IC; and 3) Meaningfulness of assessment in the IC varies by stakeholder. Themes reflected perspectives on individual learner assessment and program evaluation., Conclusions: While systematic assessment and evaluation of the IC in pediatric residency training is lacking, program leaders desire feasible strategies that are meaningful to the resident, the program, and its leadership team. Leveraging current assessment and evaluation tools and aligning new assessment strategies could promote the integration of IC assessment with other assessments, minimizing burden. More structured IC assessment and evaluation could inform how to best achieve curricular goals of the IC., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to disclose., (Copyright © 2023 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Background: Despite recognition by both the Accreditation Council of Graduate Medical Education (ACGME) and the American Board of Paediatrics (ABP) of the importance of bioethics education, curricular crowding, lack of perceived significance, and insufficient administrative support remain significant barriers to trainees gaining competency in bioethics. Few bioethics curricula at the graduate medical education level are evidence-based or comprehensive. We sought to develop and assess the effectiveness of a Team Based Learning (TBL) curriculum in improving residents' bioethics knowledge and their ability to evaluate ethical dilemmas., Methods: We integrated L. Dee Fink's curricular design principles of "Significant Learning," Jonsen et. al 's "Four-Box Method" of ethical analysis, and ABP bioethics content specifications to create 10 TBL bioethics sessions. Paediatric residents at a major academic centre then completed a 3-year longitudinal, integrated TBL-based bioethics curriculum. Primary outcomes included individual and group readiness assessment tests (iRAT/gRAT), pre-work completion, and satisfaction with sessions., Results: The TBL-based bioethics curriculum contains 10 adaptable modules. Paediatric residents ( n  = 348 total resident encounters) were highly engaged and satisfied with the curriculum. gRAT scores (mean 89%) demonstrated significant improvement compared to iRAT scores (72%) across all TBLs and all post-graduate years ( p  < .001). Higher gRAT scores correlated with higher level of training. Although pre-work completion was low (28%), satisfaction was high (4.42/5 on Likert scale)., Conclusions: Our TBL-based bioethics curriculum was effective in improving knowledge, practical and flexible in its implementation, and well-received. We attribute its success to its grounding in ethical theory, relevance to ABP specifications, and a multi-modal, engaging format. This curriculum is easily modified to different specialties, virtual formats, or other specific institutional needs.Key messagesDespite formidable challenges to teaching bioethics in residency education, evidence-based methods such as Team-Based Learning (TBL) can be employed to increase knowledge and satisfaction.This study reports the first successful TBL bioethics curriculum, planned and executed longitudinally over 3 years, with paediatric residents at a large academic children's hospital in the US.TBL can be utilised to teach bioethics at the graduate medical education level and is adaptable to different situational factors, disciplines, and levels of clinical experience.

Objective: To determine the relationship between level of supervision (LOS) ratings for the Common Pediatric Subspecialty Entrustable Professional Activities (EPAs) with their associated subcompetency milestones across subspecialties and by fellowship training year., Methods: Clinical Competency Committees (CCCs) in 14 pediatric subspecialties submitted LOS ratings for 6 Common Subspecialty EPAs and subcompetency milestone levels mapped to these EPAs. We examined associations between these subcompetency milestone levels and LOS ratings across subspecialty training year by fitting per-EPA linear mixed effects models, regressing LOS rating on milestone level and on training year., Results: CCCs from 211 pediatric fellowship programs provided data for 369 first, 336 second, and 331 third year fellows. Mean subcompetency milestone levels increased similarly among subspecialties for most EPAs compared with the reference, Adolescent Medicine. Mean subcompetency milestones mapped to each EPA and mean EPA LOS ratings generally increased by training year across all subspecialties., Conclusions: Subcompetency milestones levels mapped to each Common Subspecialty EPA and the EPA LOS ratings increase similarly across subspecialties and by training year, providing validity evidence for using EPA LOS to assess pediatric subspecialty trainee performance. This study supports the development of tools to facilitated the CCC evaluation process across all pediatric subspecialties., (Copyright © 2022. Published by Elsevier Inc.)

Objectives: Many medical disciplines incorporate point-of-care ultrasound (POCUS) into their practice. Despite well-defined applications, POCUS has not been widely adopted in pediatrics and is not commonly taught during residency. Our objective was to profile the current state of POCUS education in pediatric residency training from the resident perspective., Methods: We surveyed pediatric trainees about their POCUS education, general opinions about POCUS, and perceived barriers to POCUS training in residency. We distributed the survey to a random sample of Ohio pediatric residents, stratified by program size and training level. Descriptive statistics were used to characterize responses., Results: We sampled 66.4% of the population (371 of 559) of Ohio pediatric residents and achieved a response rate of 59.3%. Only 15% of respondents received POCUS training during residency, with 85% having never performed a POCUS scan. Most (86%) desired POCUS education and 67% believed it should be required during residency. Residents felt that POCUS would be useful for procedural guidance (95%), clinical diagnosis (94%), and patient safety (74%). Most residents (61%) believed POCUS education would benefit their careers, particularly those planning on subspecialization. Barriers to POCUS education included lack of an established curriculum (75%), competing educational priorities (58%), and a shortage of qualified instructors (52%)., Conclusions: Although Ohio pediatric residents do not receive formal POCUS education in residency, they desire such training and believe it would benefit their future practice. Consensus on scope of practice, development of a standardized curriculum, and increased faculty training in POCUS may help address this educational gap., (Copyright © 2022 by the American Academy of Pediatrics.)

Importance: Mindfulness curricula can improve physician burnout, but implementation during residency presents challenges., Objective: To examine whether a novel mindfulness curriculum implemented in the first 6 months of internship reduces burnout., Design, Setting, and Participants: This pragmatic, multicenter, stratified cluster randomized clinical trial of a mindfulness curriculum randomized 340 pediatric interns to the intervention or control arm within program pairs generated based on program size and region. Fifteen US pediatric training programs participated from June 14, 2017, to February 28, 2019., Interventions: The intervention included 7 hour-long sessions of a monthly mindfulness curriculum (Mindfulness Intervention for New Interns) and a monthly mindfulness refresher implemented during internship. The active control arm included monthly 1-hour social lunches., Main Outcomes and Measures: The primary outcome was emotional exhaustion (EE) as measured by the Maslach Burnout Inventory 9-question EE subscale (range, 7-63; higher scores correspond to greater perceived burnout). Secondary outcomes were depersonalization, personal accomplishment, and burnout. The study assessed mindfulness with the Five Facet Mindfulness Questionnaire and empathy with the Interpersonal Reactivity Index subscales of perspective taking and empathetic concern. Surveys were implemented at baseline, month 6, and month 15., Results: Of the 365 interns invited to participate, 340 (93.2%; 255 [75.0%] female; 51 [15.0%] 30 years or older) completed surveys at baseline; 273 (74.8%) also participated at month 6 and 195 (53.4%) at month 15. Participants included 194 (57.1%) in the Mindfulness Intervention for New Interns and 146 (42.9%) in the control arm. Analyses were adjusted for baseline outcome measures. Both arms' EE scores were higher at 6 and 15 months than at baseline, but EE did not significantly differ by arm in multivariable analyses (6 months: 35.4 vs 32.4; adjusted difference, 3.03; 95% CI, -0.14 to 6.21; 15 months: 33.8 vs 32.9; adjusted difference, 1.42; 95% CI, -2.42 to 5.27). None of the 6 secondary outcomes significantly differed by arm at month 6 or month 15., Conclusions and Relevance: A novel mindfulness curriculum did not significantly affect EE, burnout, empathy, or mindfulness immediately or 9 months after curriculum implementation. These findings diverge from prior nonrandomized studies of mindfulness interventions, emphasizing the importance of rigorous study design and suggesting that additional study is needed to develop evidence-based methods to reduce trainee burnout., Trial Registration: ClinicalTrials.gov Identifier: NCT03148626.

A physician workforce that reflects the patient population is associated with improved patient outcomes and promotes health equity. Notwithstanding, racial and ethnic disparities persist within US medical schools, making some individuals underrepresented in medicine (URM). We sought to increase the percentage of URM residents who matched into our pediatric residency programs from a baseline of 5% to 35% to achieve demographic parity with our patients. We developed a multifaceted approach using multiple iterative tests of change, with the primary strategy being increased visibility of URM trainees and faculty to residency applicants. Strategies included applicant interviews with URM faculty, interview dinners with URM residents, visibility at academic conferences for URM trainees, development of targeted marketing materials, and a visiting student program supported by networking with URM residents. The primary outcome measure was the percentage of matched residents in the categorical pediatrics, child neurology, and medical genetics training programs who identified as URM. The percentage of URM residents increased to 16% (6 of 37) in 2018, 26% (11 of 43) in 2019, 19% (8 of 43) in 2020, and 21% (9 of 43) in 2021 (a four-year average of 22% URM residents; P = .0002). This progress toward a more representative residency program was met by challenges, such as pipeline concerns, the minority tax, and recruitment during a pandemic. We were able to implement small, low-resource strategies that had a large cumulative impact and could be implemented in other residency programs. Specific tactics and challenges encountered are discussed in this special article., Competing Interests: FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose., (Copyright © 2022 by the American Academy of Pediatrics.)

Phenomenon: The phenomenon of individualized education, an essential component of competency-based medical education, addresses individual learner needs while working toward standardized learning outcomes. One challenge with broadly implementing individualized education is the lack of a pragmatic operational definition. To formalize expectations for individualized education, the Accreditation Council of Graduate Medical Education in 2013 began requiring six months of individualized curriculum (IC) during pediatric residency; however, there is not a national standard of formal curricular goals for the IC as an educational entity. Examining and describing the overarching curricular goals of IC could provide a framework for discourse about and further study of individualized education in medicine across disciplines and the continuum of medical education. Thus, we aimed to describe the phenomenon of individualized education through the lens of the goals of the IC in pediatric residency in the United States. Approach: In 2017, a purposeful sample of Pediatric Residency leaders were recruited to represent a diverse sample of program sizes, regions of the country, and importance of the IC to the program leadership. They completed an online survey with open-ended questions describing formal and implicit goals of their program's IC. The authors analyzed responses initially using conventional content analysis, then investigated whether the themes for program goals aligned with any existing educational theory. The concepts and language aligned with the principles of self-determination theory (SDT); therefore, the IC goals were subsequently grouped using the SDT domains of relatedness, autonomy, and competence. A focus group with a subset of survey respondents was conducted for member checking and elaboration of concepts. Findings: Program leaders from a diverse sample of 36 programs participated in the survey and a subset of 11 programs participated in the focus group. The common goals across all programs are listed in parentheses and organized by domains of SDT: 1) Relatedness goals (engage in mentorship, select a career) cultivate resident's professional identity based on their desired future career path; 2) autonomy goals (create a learning plan, practice accountability) help residents plan their path; and fulfillment of their plans lead to 3) competence goals (develop targeted clinical skills and knowledge, ensure comprehensive exposure, address learning gaps), ensuring they have a comprehensive skill set for their chosen identity. Insights: This study provides a framework to describe the phenomenon of individualized education through the lens of IC curricular goals in pediatric residency. The goals for IC that emerged from this study serve as a pragmatic framework for implementation of individualized education. They provide a common language and structure to promote more rigorous and collaborative study of individualized education across programs, disciplines, and settings in medicine. They may function as a roadmap for learners to navigate educational activities and for programs to help shape the experiences of their learners and examine outcomes of individualized education in their programs. The framework can also help individual pediatric residency programs structure improvements to their IC. Disciplines beyond pediatrics may also use this framework to better structure elective experiences to capitalize on the benefits of individual education.

Objective: There are few opportunities in medical education dedicated to learning skills for effective communication in life altering patient scenarios. We therefore aimed to develop and assess a longitudinal advanced communication curriculum for pediatric residents using patient feedback and deliberate practice., Methods: Pediatric residents at a large academic center were randomized into 2 groups. The intervention group received 6 educational sessions from 2019 to 2020, parent feedback of performance via the Communication Assessment Tool (CAT), and monthly communication tips. Communication skills of both groups were assessed at the end of the intervention., Results: We collected 937 CAT assessments on 36 first-year residents. The intervention group demonstrated statistically significant improvement in communication skills from pre to post assessment (p = 0.0063, (odds ratio (OR) 1.76, 95 % confidence interval (CI) [1.17, 2.63]) compared to the control group (p = 0.080, OR 1.41, 95 % CI [0.96, 2.05])., Conclusions: There are patient and self-identified performance gaps in communication skills for pediatric residents, underscoring the need for formalized curricula dedicated to these skills., Practice Implications: Our study highlights the value of deliberate practice and the integration of family feedback as an educational tool in communication skills development., Competing Interests: Declaration of Competing Interest All authors have indicated they have no potential conflicts of interest to disclose., (Published by Elsevier B.V.)

Purpose: To examine the association of resident perception of colleague and faculty support with performance, as measured by milestones-based competency scores, exploring associations between race and gender and perception of support and milestone scoring., Methods: Resident satisfaction was measured using an annual survey of residents at 49 pediatric residency programs in 2016, 2017, and 2018. Satisfaction with colleague and faculty support was measured using Likert scale survey questions. Pediatric Milestone Competency scores were obtained from the Association of Pediatric Program Directors' Longitudinal Educational Assessment Research Network. Analysis included linear fixed-effects models to examine the relationship between support satisfaction, race, gender, and spring milestone scores., Results: Over 60% of eligible residents responded to the survey. The majority of residents were satisfied with colleague and faculty support, with those identifying as Asian or underrepresented in medicine (URM) reporting lower rates of satisfaction than White peers. Residents satisfied with colleague support had higher milestone scores compared to those with a neutral degree of satisfaction. Residents reporting dissatisfaction with colleague and faculty support had lower milestone scores in most competency domains. Residents identifying as URM had lower milestone scores than White residents, which was partially mediated by lower rates of support satisfaction., Conclusions: Resident satisfaction with colleague and faculty support correlates with milestone performance. In particular, dissatisfied residents have lower scores than those who are neutral or satisfied. Racial inequities in resident milestone scores may be partially driven by lower rates of support satisfaction among underrepresented residents., (Copyright © 2020 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Introduction: Prior work demonstrating that burnout is associated with decreased performance in medical trainees has relied on self-report and/or single-site studies. We explored the relationship between burnout status and Milestones-based scores in pediatric residents nationally., Methods: In April to June 2016, we confidentially surveyed residents using the Maslach Burnout Inventory. Separately, programs submitted resident Milestones scores in June 2016. We examined the relationship between burnout and performance as assessed by Milestones scores for each domain of competence. We performed multivariate analysis to determine which components of burnout (depersonalization [DP], emotional exhaustion, and lack of personal accomplishment [PA]) were most impactful., Results: About 1494 of 2368 (63%) residents at 32 programs completed the Maslach Burnout Inventory and had Milestones scores submitted. Residents who scored positive for burnout scored lower in all Milestones domains. Subgroup analysis demonstrated that this association was only significant (P < .05) in the post-graduate year 1 (PGY1) categorical pediatric cohort. In the PGY1 residents (n = 442), those positive for burnout had lower Milestones scores in patient care (PC) (2.78 vs 2.98), systems-based practice (2.69 vs 2.87), practice-based learning and improvement (2.77 vs 2.93), professionalism (3.09 vs 3.24), and interpersonal and communication skills (2.95 vs 3.12), but not medical knowledge. Multivariate analysis demonstrated that, in PGY1 residents, lower PC score was associated with lower PA and higher DP., Conclusions: Burnout is associated with decreased Milestones performance for pediatric PGY1 residents. DP and low PA were associated with lower PC scores in PGY1 residents. Future research should address whether strategies to mitigate burnout improve PGY1 performance., (Copyright © 2020 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Background: Excessive inpatient administrative tasks can lead to adverse consequences for residents and their patients. Furthermore, this burden has been linked to depersonalization, a major component of physician burnout., Objective: To describe the development, implementation, feasibility, acceptability, and early outcomes of Resident Team Assistant (RTA) programs., Methods: Three large academic medical centers created RTA programs in which administrative assistants are incorporated into inpatient medical teams. First steps included a needs assessment and driver diagram creation to identify key issues and to solidify goals. Program directors were assigned, and RTAs were hired, trained, and incorporated into inpatient teams at each institution (2003, 2016, 2018). Program leadership and institutional stakeholders met regularly to discuss development and quality assurance. Surveys and direct interviews were performed to evaluate impact and acceptability. Institutional goals in accordance to RTAs tasks were also investigated., Results: Resident surveys and interviews have shown acceptability with RTAs completing a large percentage of resident administrative tasks while promoting time spent in direct clinical care and job satisfaction. Hospital-specific improvements have included increase in referring physician communication rate and decrease in work hour violations. The programs have maintained high feasibility and sustainability with a relatively low time commitment from leadership and cost for the institutions., Conclusions: The RTA programs at the 3 institutions have continued to be sustained over time with perceived improvements in administrative task burden and job satisfaction for the residents. They have maintained high acceptability and feasibility in terms of effort and costs for the hospitals., Competing Interests: Conflict of interest: The authors declare they have no competing interests., (© 2020.)

Introduction: Patients receiving pediatric tracheostomy have significant risk for mortality due to compromised airway. Timely management of airway emergencies in children with tracheostomies is an important clinical skill for pediatricians. We developed this curriculum to improve residents' self-efficacy with tracheostomy management., Methods: We collected baseline data on 67 residents from two hospitals while creating a blended curriculum with video-based instruction on routine tracheostomy change and team management of tracheostomy emergency. Forty residents enrolled in the curriculum. During an ICU rotation, they received face-to-face instruction on routine tracheostomy change in small groups, followed by assessment of managing a tracheostomy emergency during a simulation. A video completed prior to the simulation took 9 minutes, the routine tracheostomy change didactic session took 15 minutes, and the simulation instruction was completed in 10-15 minutes. We collected feedback on the effectiveness of the curriculum from the participants., Results: All 107 residents from the baseline and intervention groups completed the self-efficacy survey. The intervention group had significantly higher changes in scores across all self-efficacy domains than the baseline group. On the curriculum feedback survey, residents rated the curriculum very highly, between 4.4 and 4.8 on a 5-point Likert scale., Discussion: Our blended curriculum increased learners' self-efficacy and promoted learner competence in tracheostomy management. Residents scored more than 80% across all aspects of simulation assessment and reported higher self-efficacy scores following our curricular intervention., (© 2020 Benjamin et al.)

Objective: Describe the demographics of pediatric and internal medicine/pediatric residents participating in global health (GH) experiences and examine relationships between GH involvement and self-perceived burnout, resilience, mindfulness, empathy, and spirituality., Methods: The Pediatric Resident Burnout and Resilience Study Consortium developed a national longitudinal study through collaboration with the Association of Pediatric Program Directors' Longitudinal Educational Assessment Research Network. Electronic surveys were administered to pediatric trainees annually (2016-2018). GH and well-being data were extracted. Descriptive statistics were calculated., Results: Of 9653 eligible pediatric and medicine/pediatric residents from 55 institutions, 6150 responded to the survey in 1 or more years, with average completion rate of 63.7% over a 3-year period. Controlling for repeat survey-takers, 12.7% (536/4213) of residents reported involvement in a GH-specific pathway, curricula, or track. GH participants were significantly more likely to be unmarried (P < .001), childless (P = .003), and medicine/pediatric trainees (P < .001). Controlling for repeated measures and demographic factors, GH participants demonstrated higher levels of empathic concern (P < .001) and higher spirituality scores in 2 of 3 domains (P < .01/<.05). GH involvement was not associated with lower reports of burnout or improved resilience/mindfulness., Conclusion: Although GH involvement is associated with increased levels of empathy and spirituality, it was not protective against burnout in this study. This highlights the need to study and promote the well-being of all residents, and perhaps especially those experiencing the challenges of working in low-resource settings. Future efforts should determine the impact of predeparture training, programmatic support, and post-trip debriefing on resident well-being., (Copyright © 2020 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Applying for a pediatric residency position has become an increasingly stressful event and recently medical educators have described it as a "Match Frenzy." Match statistics demonstrate increased competition for pediatric residency positions and a record number of applications. Faculty who mentor medical students are now challenged to counsel them through the intensified process and pediatric residency programs are now forced to navigate the rising number of applications. We define the Match Frenzy and its implications, review historical and current match statistics, and describe a data-driven approach to the problem. Through mitigating the frenzy surrounding this process, we can help students and residency programs better allocate their precious resources., (Copyright © 2019 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Background: We aimed to describe the national epidemiology of burnout in pediatric residents., Methods: We conducted surveys of residents at 34 programs in 2016, 43 programs in 2017, and 49 programs in 2018. Survey items included the Maslach Burnout Inventory, demographics, program characteristics, personal qualities, experiences, and satisfaction with support, work-life balance, and learning environment. Analyses included cross-sectional comparisons and cross-sectional and longitudinal regression., Results: More than 60% of eligible residents participated; burnout rates were >50% in all years and not consistently associated with any demographic or residency characteristics. Cross-sectional associations were significant between burnout and stress, sleepiness, quality of life, mindfulness, self-compassion, empathy, confidence in providing compassionate care (CCC), being on a high-acuity rotation, recent major medical error, recent time off, satisfaction with support and career choice, and attitudes about residency. In cross-sectional logistic regression analyses, 4 factors were associated with an increased risk of burnout: stress, sleepiness, dissatisfaction with work-life balance, and recent medical error; 4 factors were associated with lower risk: empathy, self-compassion, quality of life, and CCC. Longitudinally, after controlling for 2017 burnout and 2018 risk factors (eg, recent error, sleepiness, rotation, and time off), 2017 quality of life was associated with 2018 burnout; 2017 self-compassion was associated with lower 2018 stress; and 2017 mindfulness, empathy, and satisfaction with learning environment and career choice were associated with 2018 CCC., Conclusions: A majority of residents met burnout criteria. Several identified factors (eg, stress, sleepiness, medical errors, empathy, CCC, and self-compassion) suggest targets for interventions to reduce burnout in future studies., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2020 by the American Academy of Pediatrics.)

It is clear that graduates of osteopathic medical schools desire to maintain their Osteopathic Manipulative Medicine (OMM) and Osteopathic Principles and Practice (OPP) skills and mindset of their professional identity. In a recent survey, 68% of 1,523 third year osteopathic medical students indicated that it would be more appealing to attend a residency with osteopathic recognition, with more than half indicating this would play an important role in how they made their rank list. There are currently few options available to DO students that would like to maintain their OMM and OPP skills during pediatric residency programs, and with an increasing number of DO graduates each year, there may be a need to provide more opportunities for them. In this article we describe our pediatric Osteopathic Recognition Track, which has the goal of providing an appropriate level of osteopathic focused training to our small number of residents in the track (4 annually) while incorporating them fully into a large and very busy pediatric program. We use Bloom's taxonomy as the framework upon which to provide details about our approach., (Copyright © 2019 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Background: Measuring burnout symptoms is important, but the Maslach Burnout Inventory (MBI) has 22 items. This project compared 3 single-item measures with the MBI and other factors related to burnout., Methods: Data were analyzed from the 2016 and 2017 Pediatric Resident Burnout-Resilience Study Consortium surveys, which included standard measures of perceived stress, mindfulness, resilience, and self-compassion; the MBI; and the 1- and 2-item screening questions., Results: In 2016 and 2017, data were collected from 1785/2723 (65%) and 2148/3273 (66%) eligible pediatric residents, respectively. Burnout rates on the MBI were 56% in 2016 and 54% in 2017. The Physician Work Life Study item generated estimates of burnout prevalence of 43% to 49% and, compared with the MBI for 2016 and 2017, had sensitivities of 69% to 72%, specificities of 79% to 82%, positive likelihood ratios of 3.4 to 3.8, and negative likelihood ratios of 0.35 to 0.38. The combination of an emotional exhaustion item and a depersonalization item generated burnout estimates of 53% in both years and, compared with the full MBI, had sensitivities of 85% to 87%, specificities of 84% to 85%, positive likelihood ratios of 5.7 to 6.4, and negative likelihood ratios of 0.18 for both years. Both items were significantly correlated with their parent subscales. The single items were significantly correlated with stress, mindfulness, resilience, and self-compassion., Conclusions: The 1- and 2-item screens generated prevalence estimates similar to the MBI and were correlated with variables associated with burnout. The 1- and 2-item screens may be useful for pediatric residency training programs tracking burnout symptoms and response to interventions., (Copyright © 2018 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Introduction: Children with neuromuscular disabilities (NMD) receive care in a wide variety of clinical settings. Residents lack training to develop physical examination skills for evaluating patients with NMD. We devised a curriculum to teach residents how to examine patients with NMD using a systematic and simplified approach., Methods: Creation of this resource was a response to a survey of final-year residents that revealed the need for education focused on developing physical examination skills. The curriculum has four components-multimedia PowerPoint with embedded video, knowledge assessment, clinical exam (CEX) assessment, and module feedback-and was completed by 37 residents over an 8-month period from January to September 2016. We utilized knowledge assessment, direct clinical skills observation using the CEX, and module-feedback responses as part of the evaluation., Results: All 37 residents completed the curriculum, with an overall knowledge score of greater than 80%. Residents demonstrated most of the desired patient care behaviors on the CEX assessment and provided positive feedback on the quality, usefulness, and applicability of the module, in addition to requesting more curricula to develop their physical examination skills., Discussion: The CEX assessment provided a unique opportunity for faculty feedback on residents' physical exam performance. After completing the module, residents achieved high scores in most areas of the standardized CEX and were able to conduct the NMD physical exam in a sensitive manner. The assessment highlighted the need to improve residents' skills of detecting abnormal clinical findings and communicating with the patient during the physical exam., Competing Interests: None to report.

Background: Traditionally, quizzes have been applied as a tool for summative assessment, though literature suggests their use as a formative assessment can improve motivation and content retention. With this premise, we implemented a series of intermittent, online quizzes known as the Board Examination Simulation Exercise (BESE). We sought to demonstrate an association between BESE participation and scores and performance on the American Board of Pediatrics (ABP) Certifying Examination (CE)., Methods: Residents were assigned online quizzes on a single topic at 2 week intervals that consisted of 20 multiple choice questions written by the study authors. This analysis includes graduates of 3 Pediatric and Internal Medicine-Pediatrics residency programs., Results: Data were available for 329 residents. The overall BESE score weakly correlated with ABP CE score (n = 287; r = 0.39, p < 0.0001). ABP CE pass rates increased from 2009 to 2016 at all programs combined (p = 0.0001). A composite BESE score ≤ 11 had sensitivity of 54% and specificity of 80% for predicting ABP CE failure on the first attempt. There was no difference in ABP CE failure rates or scores by number of completed quizzes., Conclusion: Intermittent online quizzes implemented at three pediatric residency programs were associated with overall increasing ABP CE pass rates. BESE increased program emphasis on board preparation. Residents with lower BESE scores more often failed ABP CE. Though additional data are needed, BESE is a promising tool for pediatric resident learning and board preparation. It may also aid in earlier identification of residents at higher risk of failing the ABP CE and facilitate targeted interventions.

Despite increasing numbers of patients with neurodisability, residents lack training to develop physical examination skills. Following a blended educational intervention combining online and bedside teaching, residents demonstrated desired patient-care behaviors on standardized clinical exam assessment., (Copyright © 2018 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Purpose: To perform a derivation study to determine in which subcompetencies marginal/unsatisfactory pediatric residents had the greatest deficits compared with their satisfactorily performing peers and which subcompetencies best discriminated between marginal/unsatisfactory and satisfactorily performing residents., Method: Multi-institutional cohort study of all 21 milestones (rated on four or five levels) reported to the Accreditation Council for Graduate Medical Education, and global marginal/unsatisfactory versus satisfactory performance reported to the American Board of Pediatrics. Data were gathered in 2013-2014. For each level of training (postgraduate year [PGY] 1, 2, and 3), mean differences between milestone levels of residents with marginal/unsatisfactory and satisfactory performance adjusted for clustering by program and C-statistics (area under receiver operating characteristic curve) were calculated. A Bonferroni-corrected significance threshold of .0007963 was used to account for multiple comparisons., Results: Milestone and overall performance evaluations for 1,704 pediatric residents in 41 programs were obtained. For PGY1s, two subcompetencies had almost a one-point difference in milestone levels between marginal/unsatisfactory and satisfactory trainees and outstanding discrimination (≥ 0.90): organize/prioritize (0.93; C-statistic: 0.91) and transfer of care (0.97; C-statistic: 0.90). The largest difference between marginal/unsatisfactory and satisfactory PGY2s was trustworthiness (0.78). The largest differences between marginal/unsatisfactory and satisfactory PGY3s were ethical behavior (1.17), incorporating feedback (1.03), and professionalization (0.96). For PGY2s and PGY3s, no subcompetencies had outstanding discrimination., Conclusions: Marginal/unsatisfactory pediatric residents had different subcompetency gaps at different training levels. While PGY1s may have global deficits, senior residents may have different performance deficiencies requiring individualized counseling and targeted performance improvement plans.

Residency is a high-risk period for physician burnout. We aimed to determine the short-term stability of factors associated with burnout, application of these data to previous conceptual models, and the relationship of these factors over 3 months. Physician wellness questionnaire results were analyzed at 2 time points 3 months apart. Associations among variables within and across time points were analyzed. Logistic regression was used to predict burnout and compassionate care. A total of 74% of residents completed surveys. Over 3 months, burnout ( P = .005) and empathy ( P = .04) worsened. The most significant cross-sectional relationship was between stress and emotional exhaustion (time 1 r = 0.61, time 2 r = 0.68). Resilience was predictive of increased compassionate care and decreased burnout ( P < .05). Mindfulness was predictive of decreased burnout ( P < .05). Mitigating stress and fostering mindfulness and resilience longitudinally may be key areas of focus for improved wellness in pediatric residents. Larger studies are needed to better develop targeted wellness interventions.

Objective: Our objective was to evaluate the utility of an educational program consisting of a workshop based on the Take the HEAT communication strategy, designed specifically for addressing patients who are angry, using a novel tool to evaluate residents' skills in employing this method., Methods: 33 first-year pediatric and internal medicine-pediatrics residents participated in the study. The workshop presented the Take the HEAT (Hear, Empathize, Apologize, Take action) strategy of communication. Communication skills were assessed through standardized patient encounters at baseline and post-workshop. Encounters were scored using a novel assessment tool., Results: After the workshop, residents' Take the HEAT communication improved from baseline total average score 23.15 to total average score 25.36 (Z=-3.428, p<0.001). At baseline, empathy skills were the lowest. Intraclass Correlation Coefficient demonstrated substantial agreement (0.60 and 0.61) among raters using the tool., Conclusion: First-year pediatric trainees' communication with angry families improved with education focused on the Take the HEAT strategy. Poor performance by residents in demonstrating empathy should be explored further., Practice Implications: This study demonstrates the utility of a brief communications curriculum aimed at improving pediatric residents' ability to communicate with angry families., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Purpose: To describe clinical skills progression during pediatric residency using the distribution of pediatric milestone assessments by subcompetency and year of training and to determine reasonable milestone expectations at time of graduation., Method: Multi-institutional cohort study of the milestones reported to the Accreditation Council for Graduate Medical Education for all 21 pediatric subcompetencies. Most subcompetencies were measured using five milestone levels (1 = novice, 2 = advanced beginner, 3 = competent, 4 = proficient, 5 = master); 3 subcompetencies had only four levels defined., Results: Milestone assessments for 2,030 pediatric residents in 47 programs during academic year 2013-2014 were obtained. There was significant variation in end-of-year milestone ratings for residents within each level of training, which decreased as training level increased. Most (78.9%; 434/550) graduating third-year pediatric residents received a milestone rating of ≥ 3 in all 21 subcompetencies; fewer (21.1%; 116/550) received a rating of ≥ 4 in all subcompetencies. Across all training levels, professionalism and interpersonal communication skills were rated highest; quality improvement was rated lowest., Conclusions: Trainees entered residency with a wide range of skills. As they advanced, skill variability within a training level decreased. Most graduating pediatric residents were still advancing on the milestone continuum toward proficiency and mastery, and an expectation of milestone ratings ≥ 4 in all categories upon graduation is unrealistic; milestone ratings ≥ 3 upon graduation may be more realistic. Understanding current pediatric residents' and graduates' skills can help to identify key areas that should be specifically targeted during training.

The aim of this study was to evaluate whether the current state of child neurology education during pediatric residency provides adequate preparation for pediatric practice. A survey was sent to recent graduates from 3 pediatric residency programs to assess graduate experience, perceived level of competence, and desire for further education in child neurology. Responses from generalists versus subspecialists were compared. The response rate was 32%, half in general pediatric practice. Only 22% feel very confident in approaching patients with neurologic problems. This may represent the best-case scenario as graduates from these programs had required neurology experiences, whereas review of Accreditation Council of Graduate Medical Education-accredited residency curricula revealed that the majority of residencies do not. Pediatric neurologic problems are common, and pediatric residency graduates do encounter such problems in practice. The majority of pediatricians report some degree of confidence; however, some clear areas for improvement are apparent.

Objective: To evaluate the preparedness of pediatric residents entering accredited neonatal-perinatal medicine (NPM) fellowships in the United States., Study Design: A multi-domain, validated survey was distributed to Program Directors (PDs) of US NPM fellowship programs. The 47-item survey explored 5 domains: professionalism, independent practice, psychomotor ability, clinical evaluation, and academia. A systematic, qualitative analysis on free-text comments was also performed., Results: Sixty-one PDs completed the survey, for a response rate of 62% (61/98). For entering fellows, PDs assessed performance in professionalism positively, including 76% as communicating effectively with parents and 90% treating residents/house-staff with respect. In contrast, most PDs rated performance in psychomotor abilities negatively, including 59% and 79% as deficient in bag-and-mask ventilation and neonatal endotracheal intubation, respectively. Although 62% of PDs assessed entering fellows positively for genuine interest in academic projects, fewer than 10% responded positively that entering fellows understood research protocol design, basic statistics, or were capable of writing a cohesive manuscript well. Thematic clustering of qualitative data revealed deficits in psychomotor ability and academia/scholarship., Conclusions: On the basis of the perspective of front line educators, graduating pediatric residents are underprepared for subspecialty fellowship training in NPM. To provide the best preparation for pediatric graduates who pursue advanced training, changes to residency education to address deficiencies in these important competencies are warranted.

Purpose: Medical education aims to equip physicians for lifelong learning, an objective supported by the conceptual framework of self-regulated learning (SRL). Learning goals have been used to develop SRL skills in learners across the medical education continuum. This study's purpose was to elicit residents' perspectives on learning goal use and to develop explanations suggesting how aspects of the learning environment may facilitate or hinder the meaningful use of learning goals in residency., Method: Resident focus groups and program director interviews were conducted in 2012-2013, audio-recorded, and transcribed. Programs were selected to maximize diversity of size, geographic location, type of program, and current use of learning goals. Data were analyzed using the constant comparative method associated with grounded theory. Further analysis compared themes frequently occurring together to strengthen the understanding of relationships between the themes. Through iterative discussions, investigators built a grounded theory., Results: Ninety-five third-year residents and 12 program directors at 12 pediatric residency programs participated. The analysis identified 21 subthemes grouped into 5 themes: program support, faculty roles, goal characteristics and purposes, resident attributes, and accountability and goal follow-through. Review of relationships between the themes revealed a pyramid of support with program support as the foundation that facilitates the layers above it, leading to goal follow-through., Conclusions: Program support facilitates each step of the SRL process that leads to meaningful use of learning goals in residency. A strong foundation of program support should include attention to aspects of the implicit curriculum as well as the explicit curriculum.

Background: While both patients and physicians identify communication of bad news as an area of great challenge, the factors underlying this often complex task remain largely unknown. Emotional intelligence (EI) has been positively correlated with good general communication skills and successful leadership, but there is no literature relating EI to the delivery of bad news., Purpose: Our objectives were to determine: 1) performance of first-year pediatric residents in the delivery of bad news in a standardized patient (SP) setting; and 2) the role of EI in these assessments. Our hypothesis was that pediatric trainees with higher EI would demonstrate more advanced skills in this communication task., Methods: Forty first-year residents participated. Skill in bad news delivery was assessed via SP encounters using a previously published assessment tool (GRIEV&#95;ING Death Notification Protocol). Residents completed the Emotional and Social Competency Inventory (ESCI) as a measure of EI., Results: Residents scored poorly on bad news delivery skills but scored well on EI. Intraclass correlation coefficients indicated moderate to substantial inter-rater reliability among raters using the delivering bad news assessment tool. However, no correlation was found between bad news delivery performance and EI., Conclusions: We concluded that first-year pediatric residents have inadequate skills in the delivery of bad news. In addition, our data suggest that higher EI alone is not sufficient to effectively deliver death news and more robust skill training is necessary for residents to gain competence and acquire mastery in this important communication domain.

Objective: To determine incidence of learning goals by competency area and to assess which goals fall into competency areas with lower self-assessment scores., Methods: Cross-sectional analysis of existing deidentified American Academy of Pediatrics' PediaLink individualized learning plan data for the academic year 2009-2010. Residents self-assessed competencies in the 6 Accreditation Council for Graduate Medical Education (ACGME) competency areas and wrote learning goals. Textual responses for goals were mapped to 6 ACGME competency areas, future practice, or personal attributes. Adjusted mean differences and associations were estimated using multiple linear and logistic regression., Results: A total of 2254 residents reported 6078 goals. Residents self-assessed their systems-based practice (51.8) and medical knowledge (53.0) competencies lowest and professionalism (68.9) and interpersonal and communication skills (62.2) highest. Residents were most likely to identify goals involving medical knowledge (70.5%) and patient care (50.5%) and least likely to write goals on systems-based practice (11.0%) and professionalism (6.9%). In logistic regression analysis adjusting for postgraduate year (PGY), gender, and degree type (MD/DO), resident-reported goal area showed no association with the learner's relative self-assessment score for that competency area. In the conditional logistic regression analysis, with each learner serving as his or her own control, senior residents (PGY2/3+s) who rated themselves relatively lower in a competency area were more likely to write a learning goal in that area than were PGY1s., Conclusions: Senior residents appear to develop better skills and/or motivation to explicitly turn self-assessed learning gaps into learning goals, suggesting that individualized learning plans may help improve self-regulated learning during residency., (Copyright © 2015 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Objective: Patients and physicians identify communication of bad news as a skill in need of improvement. Our objectives were to measure change in performance of first-year pediatric residents in the delivery of bad news after an educational intervention and to measure if changes in performance were sustained over time., Methods: Communication skills of 29 residents were assessed via videotaped standardized patient (SP) encounters at 3 time points: baseline, immediately post-intervention, and 3 months post-intervention. Educational intervention used was the previously published "GRIEV&#95;ING Death Notification Protocol.", Results: The intraclass correlation coefficient demonstrated substantial inter-rater agreement with the assessment tool. Performance scores significantly improved from baseline to immediate post-intervention. Performance at 3 months post-intervention showed no change in two subscales and small improvement in one subscale., Conclusions: We concluded that breaking bad news is a complex and teachable skill that can be developed in pediatric residents. Improvement was sustained over time, indicating the utility of this educational intervention., Practice Implications: This study brings attention to the need for improved communication training, and the feasibility of an education intervention in a large training program. Further work in development of comprehensive communication curricula is necessary in pediatric graduate medical education programs., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Objective: To evaluate the skills and team behavior of pediatric residents during resuscitation with a high-fidelity mannequin before and after a deliberate practice intervention., Methods: Each month residents participate in two 90-minute videorecorded sessions (2-3 weeks apart) in an "off-site" delivery room during their neonatal ICU rotation. Teams responded to a scenario that required 5 skills (positive pressure ventilation, chest compressions, endotracheal intubation, umbilical vein catheterization, and epinephrine administration). Skills were scored for technique and timeliness and team behaviors for communication, management, and leadership. A 2-hour focused intervention was given between sessions., Results: In all, 33 residents (11 teams) completed the sessions. Gaps in procedural skills noted during the first session were corrected. Timeliness for completion of skills remained below expectations. Improvements in team behaviors were noted., Conclusions: Deliberate practice improved procedural skills and team performance. Lack of improvement in timeliness suggests that a different educational paradigm is required.

Objective: To determine the effectiveness of an interactive Web-based module on knowledge acquisition, retention, and clinical practice by residents., Methods: Residents were randomized to complete an interactive Web-based module on injury prevention or a noninteractive Web-based module of identical content. Acquisition and retention of medical knowledge were measured by pretest, posttest, and long-term test scores, and change in clinical practice was measured by videotaped clinical encounters., Results: Fifty-seven residents completed the modules. The control group had higher posttest scores than the intervention group (P = .036). Thirty-seven residents completed the long-term test with scores that were significantly higher than pretest scores (P = .00). Thirty-six residents had videotaped encounter scores (232 visits), with no difference in these scores after the intervention (P = .432)., Conclusion: The noninteractive module was more effective in promoting knowledge acquisition. Residents successfully demonstrated knowledge retention with completion of either module. The modules were insufficient to change clinical practice.

Objective: Pressures on academic faculty to perform beyond their role as educators has stimulated interest in complementary approaches in resident medical education. While fellows are often believed to detract from resident learning and experience, we describe our preliminary investigations utilizing clinical fellows as a positive force in pediatric resident education. Our objectives were to implement a practical approach to engage fellows in resident education, evaluate the impact of a fellow-led education program on pediatric resident and fellow experience, and investigate if growth of a fellowship program detracts from resident procedural experience., Methods: This study was conducted in a neonatal intensive care unit (NICU) where fellows designed and implemented an education program consisting of daily didactic teaching sessions before morning clinical rounds. The impact of a fellow-led education program on resident satisfaction with their NICU experience was assessed via anonymous student evaluations. The potential value of the program for participating fellows was also evaluated using an anonymous survey., Results: The online evaluation was completed by 105 residents. Scores were markedly higher after the program was implemented in areas of teaching excellence (4.44 out of 5 versus 4.67, p<0.05) and overall resident learning (3.60 out of 5 versus 4.61, p<0.001). Fellows rated the acquisition of teaching skills and enhanced knowledge of neonatal pathophysiology as the most valuable aspects of their participation in the education program. The anonymous survey revealed that 87.5% of participating residents believed that NICU fellows were very important to their overall training and education., Conclusions: While fellows are often believed to be a detracting factor to residency training, we found that pediatric resident attitudes toward the fellows were generally positive. In our experience, in the specialty of neonatology a fellow-led education program can positively contribute to both resident and fellow learning and satisfaction. Further investigation into the value of utilizing fellows as a positive force in resident education in other medical specialties appears warranted.

Background and Objectives: Emerging needs in pediatric nephrology (PN) have made the number of nephrologists entering the workforce of critical importance. This study aimed to discern factors that influence PN fellows to choose their career path and decide to enter the PN workforce., Design, Setting, Participants, & Measurements: A survey was sent to the American Society of Pediatric Nephrology list of PN fellows (n = 103) in 2008. The 57 fellows (55%) who completed the survey were representative of the group., Results: The majority decided on a career in PN as senior residents, most commonly due to their interest in renal physiology and academics. They felt residents chose other fields due to lack of interest/exposure to PN, financial constraints, and perceived PN workload. Fellows identified workload and their perception of faculty dissatisfaction as important concerns with PN. None of the respondents planned to leave fellowship, but 21% have considered this. Twenty-eight percent knew a PN fellow who resigned, thought to be due to workload, personal conflicts, and perceived faculty dissatisfaction., Conclusions: Exposing residents to PN earlier in training and emphasizing positive features may create greater interest in PN. PN programs should be cognizant of workload and the influence of faculty dissatisfaction. Ongoing evaluation of PN fellow perceptions can assist in efforts to enhance recruitment and retention.