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BACKGROUND Illness complications are condition-specific adverse outcomes. Detecting complications of pediatric illness in administrative data would facilitate widespread quality measurement, however the accuracy of such detection is unclear. METHODS We conducted a cross-sectional study of patients visiting a large pediatric emergency department. We analyzed those RESULTS We analyzed 1534 encounters. PPVs and NPVs for complications were >80% for 8 of 14 conditions: appendicitis, bacterial meningitis, intussusception, mastoiditis, myocarditis, orbital cellulitis, sepsis, and testicular torsion. Lower PPVs for complications were observed for DKA (57%), empyema (53%), encephalitis (78%), ovarian torsion (21%), and septic arthritis (64%). A lower NPV was observed in stroke (68%). The κ between reviewers was 0.88. CONCLUSIONS An automated method to measure complications by using administrative data can detect complications in appendicitis, bacterial meningitis, intussusception, mastoiditis, myocarditis, orbital cellulitis, sepsis, and testicular torsion. For DKA, empyema, encephalitis, ovarian torsion, septic arthritis, and stroke, the tool may be used to screen for complicated cases that may subsequently undergo manual review.

BACKGROUND AND OBJECTIVES Several studies have revealed the success of nonoperative management (NOM) of uncomplicated appendicitis in children. Large studies of current NOM utilization and its outcomes in children are lacking. METHODS We queried the Pediatric Health Information System database to identify children RESULTS We identified 117 705 children with appendicitis over the 9-year study period. Of the 73 544 children with nonperforated appendicitis, 10 394 (14.1%) underwent NOM. The odds of NOM significantly increased (odds ratio 1.10 per study quarter, 95% confidence interval [CI] 1.05–1.15). The 1-year and 5-year failure rates were 18.6% and 23.3%, respectively. Children who experienced failure of NOM had higher rates of perforation at the time of failure than did the general cohort at the time of initial presentation (45.7% vs 37.5%, P < .001). Patients undergoing NOM had higher rates of subsequent related emergency department visits (8.0% vs 5.1%, P < .001) and hospitalizations (4.2% vs 1.4%, P < .001) over a 12-month follow-up period. CONCLUSIONS NOM of nonperforated appendicitis in children is increasing. Although the majority of children who undergo NOM remain recurrence-free years later, they carry a substantial risk of perforation at the time of recurrence and may experience a higher rate of postoperative complications than children undergoing an immediate appendectomy.

BACKGROUND AND OBJECTIVESThere are no effective interventions to prevent hospital admissions in infants with bronchiolitis. The American Academy of Pediatrics recommends against routine bronchodilator use for bronchiolitis. The objective of this study was to characterize trends in and outcomes associated with the use of bronchodilators for bronchiolitis.METHODSThis is a multicenter retrospective study of infants RESULTSA total of 446 696 ED visits of infants with bronchiolitis were included. Bronchodilator use, hospital admissions, and ED return visits decreased between 2010 and 2018 (all P < .001). ICU admissions and invasive and noninvasive ventilation increased over the study period (all P < .001). Hospital-level early bronchodilator use (hospitals with high versus low use) was not associated with differences in patient-level hospital admissions, ICU admissions, ED return visits, noninvasive ventilation, or invasive ventilation (all P > .05).CONCLUSIONSIn a large study of infants at children’s hospitals, bronchodilator therapy decreased significantly from 2010 to 2018. Hospital-level early bronchodilator use was not associated with a reduction in any outcomes. This study supports the current American Academy of Pediatrics recommendation to limit routine use of bronchodilators in infants with bronchiolitis.

OBJECTIVES:Unlike community-acquired pneumonia (CAP), there is a paucity of data characterizing the patient demographics and hospitalization characteristics of children with aspiration pneumonia. We used a large national database of US children’s hospitals to assess the patient and hospitalization characteristics associated with aspiration pneumonia and compared these characteristics to patients with CAP.METHODS:We identified children hospitalized with a diagnosis of aspiration pneumonia or CAP at 47 hospitals included in the Pediatric Health Information System between 2009 and 2014. We evaluated whether differences exist in patient characteristics (median age and proportion of patients with a complex chronic condition), and hospital characteristics (length of stay, ICU admission, cost, and 30-day readmission rate) between children with aspiration pneumonia and CAP. Lastly, we assessed whether seasonal variability exists within these 2 conditions.RESULTS:Over the 6-year study period, there were 12 097 children hospitalized with aspiration pneumonia, and 121 489 with CAP. Compared with children with CAP, children with aspiration pneumonia were slightly younger and more likely to have an associated complex chronic condition. Those with aspiration pneumonia had longer hospitalizations, higher rates of ICU admission, and higher 30-day readmission rates. Additionally, the median cost for hospitalization was 2.4 times higher for children with aspiration pneumonia than for children with CAP. More seasonal variation was observed for CAP compared with aspiration pneumonia hospitalizations.CONCLUSIONS:Aspiration pneumonia preferentially affects children with medical complexity and, as such, accounts for longer and more costly hospitalizations and higher rates of ICU admission and readmission rates.

BACKGROUND: Although oral antibiotics are recommended for the management of most urinary tract infections (UTIs), the administration of parenteral antibiotics before emergency department (ED) discharge is common. We investigated the relationship between the administration of a single dose of parenteral antibiotics before ED discharge and revisits requiring admission among children with UTIs. METHODS: A retrospective analysis of administrative data from 36 pediatric hospitals was performed. Patients aged 29 days to 2 years who were evaluated in the ED with a UTI between 2010 and 2016 were studied. Primary outcome was adjusted 3-day ED revisit rates resulting in admission. All revisits, regardless of disposition, served as a secondary outcome. Average treatment effects were estimated by using inverse probability weighted regression, with adjustment for demographic factors, diagnostic testing, ED medications, and hospital-level factors. RESULTS: We studied 29 919 children with a median age of 8.6 (interquartile range: 5.1–13.8) months. Of those studied, 36% of the children received parenteral antibiotics before discharge. Patients who received parenteral antibiotics had similar adjusted rates of revisits leading to admission as those who did not receive parenteral antibiotics (1.3% vs 1.0%, respectively; risk difference: 0.3% [95% confidence interval: −0.01% to 0.6%]), although overall revisit rates were higher among patients who received parenteral antibiotics (4.8% vs 3.3%; risk difference 1.5% [95% confidence interval: 0.9% to 2.1%]). CONCLUSIONS: Among discharged patients, a parenteral dose of antibiotics did not reduce revisits leading to admission, supporting the goal of discharging patients with oral antibiotics alone for most children with UTIs.

BACKGROUND: Patients with septic hip arthritis require surgical drainage, but they can be difficult to distinguish from patients with Lyme arthritis. The ability of synovial fluid white blood cell (WBC) counts to help discriminate between septic and Lyme arthritis of the hip has not been investigated. METHODS: We assembled a retrospective cohort of patients ≤21 years of age with hip monoarticular arthritis and a synovial fluid culture obtained who presented to 1 of 3 emergency departments located in Lyme disease endemic areas. Septic arthritis was defined as a positive synovial fluid culture result or synovial fluid pleocytosis (WBC count ≥50 000 cells per µL) with a positive blood culture result. Lyme arthritis was defined as positive 2-tiered Lyme disease serology results and negative synovial fluid bacterial culture results. All other patients were classified as having other arthritis. We compared median synovial fluid WBC counts by arthritis type. RESULTS: Of the 238 eligible patients, 26 (11%) had septic arthritis, 32 (13%) had Lyme arthritis, and 180 (76%) had other arthritis. Patients with septic arthritis had a higher median synovial fluid WBC count (126 130 cells per µL; interquartile range 83 303–209 332 cells per µL) than patients with Lyme arthritis (53 955 cells per µL; interquartile range 33 789–73 375 cells per µL). Eighteen patients (56%) with Lyme arthritis had synovial fluid WBC counts ≥50 000 cells per µL. Of the 94 patients who underwent surgical drainage, 13 were later diagnosed with Lyme arthritis. CONCLUSIONS: In Lyme disease endemic areas, synovial fluid WBC counts cannot always help differentiate septic from Lyme arthritis. Rapid Lyme diagnostics could help avoid unnecessary operative procedures in patients with Lyme arthritis.

BACKGROUND AND OBJECTIVES: Migraine headache is a common pediatric complaint among emergency department (ED) patients. There are limited trials on abortive therapies in the ED. The objective of this study was to apply a comparative effectiveness approach to investigate acute medication regimens for the prevention of ED revisits. METHODS: Retrospective study using administrative data (Pediatric Health Information System) from 35 pediatric EDs (2009–2012). Children aged 7 to 18 years with a principal diagnosis of migraine headache were studied. The primary outcome was a revisit to the ED within 3 days for discharged patients. The primary analysis compared the treatment regimens and individual medications on the risk for revisit. RESULTS: The study identified 32 124 children with migraine; 27 317 (85%) were discharged, and 5.5% had a return ED visit within 3 days. At the index visit, the most common medications included nonopioid analgesics (66%), dopamine antagonists (50%), diphenhydramine (33%), and ondansetron (21%). Triptans and opiate medications were administered infrequently (3% each). Children receiving metoclopramide had a 31% increased odds for an ED revisit within 3 days compared with prochlorperazine. Diphenhydramine with dopamine antagonists was associated with 27% increased odds of an ED revisit compared with dopamine antagonists alone. Children receiving ondansetron had similar revisit rates to those receiving dopamine antagonists. CONCLUSIONS: The majority of children with migraines are successfully discharged from the ED and only 1 in 18 required a revisit within 3 days. Prochlorperazine appears to be superior to metoclopramide in preventing a revisit, and diphenhydramine use is associated with increased rates of return.

BACKGROUND: Provision of high-quality care to acutely ill and injured children is a challenge to US hospitals because many have low pediatric volume. Delineating national trends in definitive pediatric acute care would inform improvements in care. METHODS: We analyzed emergency department (ED) visits by children between 2008 and 2016 in the Nationwide Emergency Department Sample, a weighted sample of 20% of EDs nationally. For each hospital annually, we determined the Hospital Capability Index (HCI) to determine the frequency of definitive acute care, defined as hospitalization instead of ED transfer. Hospitals were classified annually according to 2008 HCI quartiles to understand shifts in pediatric capability. RESULTS: The national median HCI was 0.06 (interquartile range: 0.01–0.17) in 2008 and 0.02 (interquartile range: 0.00–0.09) in 2016 (P CONCLUSIONS: Across the United States from 2008 to 2016, hospital provision of definitive acute pediatric care decreased, and ED visits to the hospitals least likely to provide definitive care increased. Systems improvements are needed to support hospital-based acute care of children.

BACKGROUND AND OBJECTIVES: Diagnostic imaging is often used in the evaluation of children with possible appendicitis. The utility of imaging may vary according to a patient’s age and gender. The objectives of this study were (1) to examine the use of computed tomography (CT) and ultrasound for age and gender subgroups of children undergoing an appendectomy; and (2) to study the association between imaging and negative appendectomy rates (NARs) among these subgroups. METHODS: Retrospective review of children presenting to 40 US pediatric emergency departments from 2005 to 2009 (Pediatric Health Information Systems database). Children undergoing an appendectomy were stratified by age and gender for measuring the association between ultrasound and CT use and the outcome of negative appendectomy. RESULTS: A total of 8 959 155 visits at 40 pediatric emergency departments were investigated; 55 227 children had appendicitis. The NAR was 3.6%. NARs were highest for children younger than 5 years (boys 16.8%, girls 14.6%) and girls older than 10 years (4.8%). At the institutional level, increased rates of diagnostic imaging (ultrasound and/or CT) were associated with lower NARs for all age and gender subgroups other than children younger than 5 years, The NAR was 1.2% for boys older than 5 years without any diagnostic imaging. CONCLUSIONS: The impact of diagnostic imaging on negative appendectomy rate varies by age and gender. Diagnostic imaging for boys older than 5 years with suspected appendicitis has no meaningful impact on NAR. Diagnostic strategies for possible appendicitis should incorporate the risk of negative appendectomy by age and gender.

OBJECTIVE. Identify clinical predictors of Lyme arthritis among patients with acute monoarticular arthritis. METHODS. A medical chart review was conducted of children ≤18 years of age with monoarticular arthritis who underwent arthrocentesis in a pediatric emergency department located in the northeast United States. Patients were classified into 3 categories of arthritis: septic, Lyme, or nonseptic non-Lyme arthritis. Historical, clinical, and laboratory data were compared to identify distinguishing features of Lyme arthritis. RESULTS. One hundred seventy-nine patients were studied: 46 (26%) patients with septic arthritis, 55 (31%) patients with Lyme arthritis, and 78 (43%) patients with nonseptic non-Lyme arthritis. Compared with those with septic arthritis, patients with Lyme disease were more likely to have a tick-bite history, knee involvement, and less likely to have a history of fever or elevated temperature at triage. Erythrocyte sedimentation rate, C-reactive protein, joint white blood cell count, and joint neutrophil percentage were also statistically lower. In comparison to nonseptic non-Lyme arthritis, knee involvement and tick-bite history were predictors of Lyme. Erythrocyte sedimentation rate, joint white blood cell count, and joint neutrophil percentage were also statistically different. Multivariate analysis comparing Lyme to septic arthritis demonstrated fever history and elevated C-reactive protein level to be negative predictors of Lyme arthritis and knee involvement to be a positive predictor (model sensitivity: 88%; specificity: 82%). CONCLUSIONS. Lyme arthritis shares features with both septic and nonseptic non-Lyme arthritis. This overlap prevents the creation of a clinically useful predictive model for Lyme arthritis. In endemic areas, Lyme testing should be performed on all patients presenting with acute monoarticular arthritis.

Concussions in sports typically arise from a hard blow to the head. In soccer, for example, head-to-head impacts carry a high risk for concussion (Withnall et al., Br J Sports Med 39(Suppl 1):i49–i57, 2005). In the National Football League (NFL), an injury reconstruction study revealed that a striking player often lines up his head, neck, and torso to deliver maximum force to the other player in helmet-to-helmet impacts that result in concussive injuries to the player being struck (Viano and Pellman, Neurosurgery 56(2):266–280, 2005). Fortunately, most injuries in sports fall on the milder end of the spectrum of mild traumatic brain injuries (MTBI). Occasionally, however, athletes experience complicated mild, moderate, or severe traumatic brain injuries. In equestrian and auto racing, for example, accidents can result in much more serious injuries to the brain.

BACKGROUND. Some children who present with fever and erythroderma have rapid clinical deterioration or progress to toxic shock syndrome. Our primary objective was to determine whether specific clinical features of those who present with fever and erythroderma can predict who will develop hypotension or progress to toxic shock syndrome. Our secondary objective was to describe the clinical presentation, course, and outcome of children with fever and erythroderma.METHODS. We conducted a medical chart review of children ≤19 years of age with fever and erythroderma who presented to an urban pediatric emergency department over 60 months. Historical, clinical, and laboratory data were abstracted from the medical chart.RESULTS. Fifty-six patients with fever and erythroderma were studied. Eighteen percent of patients presented with hypotension. Thirty-three percent of the remaining patients who were normotensive on arrival developed shock. Fifty-two percent of patients with hypotension required vasopressor support. The most important predictors of developing hypotension after presentation were: age ≥3 years, ill appearance, vomiting, glucose ≥110 mg/dL, calcium ≤8.6 mg/dL, platelets ≤300000/μL, elevated creatinine, polymorphonuclear leukocytes ≥80%, and presence of a focal infection. Among all patients studied, 4 variables were determined to be the most important predictors of developing toxic shock syndrome: age ≥3 years, ill appearance, elevated creatinine, and hypotension on arrival.CONCLUSIONS. Overall, 45% of patients with fever and erythroderma developed shock, including 33% of those who were normotensive on presentation. Older age, presence of vomiting, identification of a focal bacterial source, as well as specific laboratory parameters can be used to help predict which patients are likely to have hemodynamic deterioration. Given the high rate of clinical decompensation, all of the patients with fever and erythroderma should be hospitalized, closely monitored, and managed aggressively.

Objective. Computed tomography (CT) has gained widespread acceptance in the evaluation of children with suspected appendicitis. Concern has been raised regarding the long-term effects of ionizing radiation. Other means of diagnosing appendicitis, such as clinical scores, are lacking in children. We sought to develop a clinical decision rule to predict which children with acute abdominal pain do not have appendicitis.Methods. Prospective cohort study was conducted of children and adolescents who aged 3 to 18 years, had signs and symptoms suspicious for appendicitis, and presented to the emergency department between April 2003 and July 2004. Standardized data-collection forms were completed on eligible patients. Two low-risk clinical decision rules were created and validated using logistic regression and recursive partitioning. The sensitivity, negative predictive value (NPV), and negative likelihood ratio of each clinical rule were compared.Results. A total of 601 patients were enrolled. Using logistic regression, we created a 6-part score that consisted of nausea (2 points), history of focal right lower quadrant pain (2 points), migration of pain (1 point), difficulty walking (1 point), rebound tenderness/pain with percussion (2 points), and absolute neutrophil count of >6.75 × 103/μL (6 points). A score ≤5 had a sensitivity of 96.3% (95% confidence interval [CI]: 87.5–99.0), NPV of 95.6% (95% CI: 90.8–99.0), and negative likelihood ratio of .102 (95% CI: 0.026–0.405) in the validation set. Using recursive partitioning, a second low-risk decision rule was developed consisting of absolute neutrophil count of Conclusions. Our low-risk decision rules can predict accurately which children are at low risk for appendicitis and could be treated safely with careful observation rather than CT examination.

BACKGROUND AND OBJECTIVES: In patients with appendicitis, the risk of perforation increases with time from onset of symptoms. We sought to determine if time from emergency department (ED) physician evaluation until operative intervention is independently associated with appendiceal perforation (AP) in children. METHODS: We conducted a planned secondary analysis of children aged 3 to 18 years with appendicitis enrolled in a prospective, multicenter, cross-sectional study of patients with abdominal pain ( RESULTS: Of 955 children with appendicitis, 25.9% ( n = 247) had AP. The median time from ED physician evaluation to operation was 7.2 hours (interquartile range: 4.8–8.5). Adjusting for variables associated with perforation, duration of time (≤ 24 hours) between initial ED evaluation and operation did not significantly increase the odds of AP (odds ratio = 1.0, 95% confidence interval, 0.96–1.05), even among children without perforation on initial computed tomography (odds ratio = 0.95, 95% confidence interval, 0.89–1.02). CONCLUSIONS: Although duration of abdominal pain is associated with AP, short time delays from ED evaluation to operation did not independently increase the odds of perforation.

Background.The reevaluation process for outpatients recalled for Streptococcus pneumoniae bacteremia has not been standardized. Children who return ill or with new serious focal infections require admission and parenteral antibiotic therapy. Limited data exist to guide the follow-up management of those patients identified as having occult pneumococcal bacteremia.Objectives.Characterize the outcomes of outpatients with pneumococcal bacteremia based on their evaluation at follow-up. For patients who are well-appearing without serious focal infection, propose a management scheme for reevaluation.Methods.Retrospective review of outpatients with pneumococcal bacteremia. Patients with immunocompromise, those identified with focal bacterial infection at the initial visit, or those admitted at the initial visit were excluded. Data were collected from the initial visit (when blood culture drawn) and follow-up visit with regard to clinical parameters, laboratory data, diagnoses, and any antibiotic treatment. Decision tree analysis was used to generate a model to predict children at high risk for persistent bacteremia (PB).Results.A total of 548 episodes of pneumococcal bacteremia were studied. Seventy-three children received no antibiotic, 239 oral antibiotic, and 236 parenteral antibiotic at the initial visit. Median age, temperature, and white blood cell (WBC) count were 13.5 months, 40.0°C, and 20 400/mm3. Forty-one patients had PB or new focal infections (15 with PB alone, 4 had focal infection and PB). Eight patients had meningitis at follow-up. Ninety-two percent returned because of notification of the positive blood culture result. A repeat blood culture was obtained in 92%, 23% had a lumbar puncture, 33% had a chest radiograph, and 12% were admitted. PB was associated with the antibiotic treatment group, elevation of temperature, and WBC count at follow-up. A simple management scheme using 2 sequential decision nodes of antibiotic treatment (none vs any) and then temperature at follow-up (>38.8°C) would have predicted 16/19 patients with PB (sensitivity = .84 and specificity = .86).Conclusions.All patients with pneumococcal bacteremia need prompt reevaluation. For well-appearing patients without new focal infection, the utility of diagnostic testing (specifically repeat blood cultures) and the need for admission may be determined by the use of antibiotics at the initial evaluation and the presence of fever at follow-up. The majority of patients can be managed as outpatients entirely. Patients who did not receive antibiotics at the initial evaluation and those treated with oral antibiotics but remain febrile are at the highest risk for persistent bacteremia.

Objective. To determine whether oral antibiotics prevent meningitis and serious bacterial infections in children with Streptococcus pneumoniae occult bacteremia. Data Sources. Using the Medline database, the English-language literature was searched for all publications concerning bacteremia, fever, or S pneumoniae from 1966 to April 1996. Study Selection. All studies that included a series of children with S pneumoniae occult bacteremia containing orally treated and untreated groups. Children were excluded from individual studies if they were immunocompromised, had a serious bacterial infection, underwent a lumbar puncture, or received parenteral antibiotics. Data Extraction. Three authors independently reviewed each article to determine the number of eligible children and the outcome of children meeting entry criteria. Data Synthesis. Eleven of 21 studies were excluded, leaving 10 evaluable studies with 656 total cases of S pneumoniae occult bacteremia identified. Patients who received oral antibiotics had fewer serious bacterial infections than untreated patients (3.3% vs 9.7%; pooled odds ratio, 0.35; 95% confidence interval, 0.17 to 0.73). Meningitis developed in 3 (0.8%) of 399 children in the oral antibiotic group and 7 (2.7%) of 257 untreated children (pooled odds ratio, 0.51; 95% confidence interval, 0.12 to 2.09). Conclusion. Although oral antibiotics modestly decreased the risk of serious bacterial infections in children with S pneumoniae occult bacteremia, there was insufficient evidence to conclude that oral antibiotics prevent meningitis. Published recommendations that oral antibiotics be administered to prevent serious bacterial infections in children with possible S pneumoniae occult bacteremia should be reevaluated in light of the lower risk of sequelae from S pneumoniae occult bacteremia and newer data concerning side effects from treatment.

These data characterize and illuminate an analysis of experiences about teaching during each year of a pediatric residency training program in a tertiary care center. The curriculum sought to introduce many concepts about teaching, and residents reported that they: 1. Used concepts introduced about feedback; 2. Began to appreciate that teaching is more than imparting knowledge; 3. Began to identify teaching opportunities in the context of patient care; and 4. Incorporated the practice of establishing goals and expectations for learning with their learners. These data suggest that as interns are exposed to concepts about teaching, they are able to identify what they can offer students, irrespective of the amount of knowledge and clinical experience they have about pediatric medicine. Helping interns appreciate that teaching stems from one's experiences and is much more than just "telling what one knows" was an explicit goal of the Teaching Program's curriculum design group. Another conclusion is that PGY-2 residents are aware that patient care responsibilities pose challenges to teaching. PGY-2 residents at CHB are transitioning from a relatively intense teaching experience as PGY-1 interns to becoming team leaders as PGY-3 residents. Thus, the issues about teaching in the PGY-2 year seem less defined. Helping PGY-2 residents better integrate teaching with patient care continues to be a challenge. Although the focus of the PGY-2 curriculum in the Teaching Program focused on developing skills to become teachers during the final year of residency, what emerged from PGY-2 residents were their concerns and insights about teaching better in situations in which patient care responsibilities were the priority. In addition to using concepts introduced in the sessions, residents in all three training years unanimously reported one impact of the Teaching Program: it made them more "aware" of the importance of teaching and of developing teaching skills. They also began to realize that they require feedback about their teaching from peers, attending physicians, and learner sources. By experiencing the Teaching Program, residents identified other useful approaches and resources to learning about teaching, mainly by observing their peers. Additionally, many residents were beginning to develop individualized approaches toward teaching based on their experiences in the clinical setting and their development as clinicians—the examples shared by interns about how they actually engaged learners—support this conclusion. Finally, the Teaching Program stimulated the process of reflection about teaching—mainly the importance of teaching, the challenges of performing as better teachers, and learning ways to understand how individuals learn. The importance of developing reflective practice skills about teaching has been stated by Schon28 and Boud et al,29 and as a result of the Teaching Program, residents identified situations and moments in which they thought more about their teaching. Assisting residents in developing reflective practice to improve their teaching and to understand their learners better remains a further challenge to resident-as-teacher programs. There was one unanimity: residents and faculty who taught in the program agreed to continue the Teaching Program. Residents became "co-owners" of the Teaching Program by becoming cofaculty with attending physicians. Residents replaced the medical educators as core teaching faculty. The educator's teaching role changed from direct contact to a consultant's role, allowing the resident-attending physician teams to teach the program. Finally, those resident-attending physician teaching teams meet to review and redesign the instructional formats and materials for each workshop. The chief resident assumed a more responsible role by getting the resident-faculty teams together to deliver their respective workshops. Potential for the Future In reviewing the 3-year experience with the Teaching Program—from conceptualization to realization to evaluation—several insights were gained, which may prove useful to other residency training program efforts. 1. Leadership was vital to implementing the Teaching Program. 2. Professional leaders from several levels of medical education were actively involved in the process: from the hospital, the CHB's associate physician-in-chief (also the residency training program director), the CHB's chief resident, and resident and faculty members of the planning group; and from the medical school, the HMS dean of medical education, the associate director for faculty development, and the HMS physician fellow in medical education. 3. Setting aside time simply to discuss teaching was an integral part of all processes, as were the opportunities for residents and attending faculty to share their experiences and perspectives on teaching as it related to their needs as developing physicians. 4. The workshop sessions were an integral aspect of the residents' work weeks. During these sessions, residents had opportunities to explore teaching and learning in relation to their concurrent experiences of residency training. 5. Educator and physician teams emerged as key and useful elements in collaborating to develop a strategy to develop residents as teachers. 6. Evaluation strategies and methods varied in their individual effectiveness in evaluating the Teaching Program; however, in combination they revealed useful insight into what residents think about their development as teachers and how they go about teaching based on their level of clinical training. This work provides one model for others to use in developing a curriculum on teaching. Given different circumstances—ie, if medical educators are not available, if the residency program is a small one, or if a hospital opts not to develop a separate, self-standing curriculum—faculty can elect to train themselves in the use of this curriculum and then implement the program. Copies of the curriculum are available on request from the corresponding author. In the end, the CHB experience with the Teaching Program can be looked at as an approach to how disciplines of education and medicine can merge to meet the teaching and learning needs of medical professionals as they develop as educators in a specialized training setting.