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Establishing and achieving learning goals (LGs) are important lifelong learning skills for residents. Faculty are critical in facilitation and achievement of residents' LGs, yet many have difficulty with this role in the busy inpatient setting.Our primary aim was to improve faculty engagement in resident LGs, targeting ≥80% of faculty achieving a mean score ≥goal, over a period of 1 year by setting prerotation expectations and stressing team-based faculty accountability during the rotation in the current inpatient learning environment.We identified key barriers to addressing LGs on an inpatient subspecialty service. Key interventions included 1) introducing LGs to faculty, 2) establishing a communication/handover process among faculty, 3) LGs development, and 4) tracking accountability. Baseline mean faculty milestone scores were determined from the prior year. Over 1 year, we developed and refined a system for residents to create and document LGs with faculty oversight and review. We reviewed faculty evaluations quarterly to measure progress and reviewed rotation evaluations.Faculty engagement with LGs improved through the course of the academic year. All but one faculty member had improved LGs scores during the intervention year. Most residents were very satisfied with the intervention and gave unprompted favorable feedback on rotation evaluations. The majority of submitted LGs were either partially or completely addressed.We demonstrated that a quality improvement approach to a faculty educational skill is feasible and effective. Our intervention related to LGs may be modified for any medical learner in any inpatient or outpatient setting.

To monitor pregnancy occurrence and outcomes among Nexplanon users in the United States during standard clinical practice.The Nexplanon Observational Risk Assessment (NORA) study was a large prospective cohort study conducted in the United States (US). Study participants with a newly inserted Nexplanon implant were recruited by health care professionals (HCPs) who had completed the Nexplanon clinical training. Via a survey, study participants were followed up at 6-month intervals for 36 months and 6 months after implant removal. Reported unintended pregnancies were validated and classified as noninsertion, preinsertion, during-use, or postremoval.Four hundred and twenty-eight HCPs in 47 states recruited 7364 Nexplanon users. Pregnancies included one noninsertion, eight preinsertion, three during-use, and 14 postremoval pregnancies; of these 26 pregnancies, 22 resulted in the birth of a healthy child, two resulted in an induced abortion, one resulted in a spontaneous abortion, and one resulted in an ectopic pregnancy. Six pregnancies occurred during-use (n = 3) or within 7 days following implant removal (n = 3), yielding a Pearl Index of 0.04 (95% CI, 0.02-0.09).Nexplanon is an effective contraceptive in real-world users; the Pearl Index was 0.02 (95% CI, 0.00-0.06) for during-use pregnancies, and 0.04 when including pregnancies that occurred within 7 days following implant removal.This large real-world-use study indicates that Nexplanon is as effective as shown in the preapproval clinical trials.

Objective To determine current practices for communication skills curriculum and assessment in pediatric residency programs and to identify programs’ greatest needs regarding communication curricula and assessment. Methods We surveyed pediatric residency program directors about their programs’ approach to teaching and assessing residents’ communication skills and how satisfied they were with their curricula and assessment of competence. Respondents were asked about their programs’ greatest needs for teaching and assessing communication skills. Results Response rate was 41% (82/202). Most programs did teach communication skills to residents; only 14% provided no formal training. Programs identified various 1) educational formats for teaching communication skills, 2) curricular content, and 3) assessment methods for determining competence. Many programs were less than satisfied with their curriculum and the accuracy of their assessments. The greatest programmatic need regarding curricula was time, while the greatest need for assessment was a tool. Conclusions While teaching and assessment of communication skills is common in pediatric residency programs, it is inconsistent and variable, and many programs are not satisfied with their current communication training. There is need for development of and access to appropriate and useful curricula as well as a practical tool for assessment which has been evaluated for validity evidence.

Benign adenoidal hypertrophy is the most common cause of nasopharyngeal obstruction. However, depending on size and location, masses may cause nasopharyngeal obstruction. We present our experiences with a ten-year-old female who presented with what appeared to be a large nasopharyngeal mass that was initially favored to be malignant and was ultimately found to be adenoid hypertrophy related to acute infection with adenovirus.

Background Although a huge portion of medical care involves communication, there is little time dedicated to these skills. Additionally, family-centered communication is collaborative and interactive, and these skills are best taught through case-based approaches rather than passive lecture-type didactics. Objectives: We aimed to develop a longitudinal communication curriculum utilizing learner-identified content, delivered via interactive workshops over a 6-month period, supplemented with and guided by family feedback. Methods The curriculum was developed using Kern's scholarly approach. A needs assessment for resident communication skills was conducted with a survey and focus group. The Communication Assessment Tool (CAT) was used for parent feedback of residents’ performance early in the curriculum. Content for workshop sessions was developed from needs assessments, CAT results, and input from program leadership. The curriculum underwent expert internal and external review. Pediatric interns were randomly assigned to a control or intervention group. Six sessions were delivered over 6-months to the intervention group. CAT feedback was shared with the intervention group as part of the curriculum. Results Survey and focus groups identified themes of 1) lack of comfort with communication skills in difficult encounters, and 2) desire for more feedback and practice with these encounters. Five hundred surveys were collected on 36 interns using the CAT prior to the intervention. A 5-point likert scale was graded as 5 or non-5 scores. Residents performed most poorly in discussion of next steps (38% non 5) and in showing interest in families’ ideas of their children's health (28% non 5). Discussion There are self- and patient-identified performance gaps in many pediatric interns, underscoring the need for formalized curricula to teach skills specific to communication in pediatrics, particularly with emphasis on shared decision making and teach back methods. Narrative feedback from resident curriculum participants has demonstrated increased confidence and comfort levels with difficult communication. Future directions include assessment of the patient and family impact of this curriculum using follow-up CAT surveys.

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_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.

Objectives The objective was to measure the rate of unintended pregnancies in women using levonorgestrel-releasing intrauterine systems (LNG IUSs, releasing 20 mcg LNG daily) and copper intrauterine devices (IUDs) in a typical population of IUD users and to describe associated complications. Methods A multinational, prospective, non-interventional cohort study of new users of LNG IUS and copper IUDs was performed. Following a baseline survey, study participants and their physicians completed one follow-up questionnaire after 12 months. A multifaceted four-level follow-up procedure minimized loss to follow-up. Patient-reported outcomes were validated by the treating physicians. Results A total of 61,448 women with a newly inserted IUD were enrolled in six European countries between 2006 and 2012. The copper IUD cohort contained more than 30 different types. Validated 1-year follow-up information for 58,324 users between 18 and 50 years of age (70% using LNG IUS, 30% using copper IUDs) was collected. A total of 118 contraceptive failures occurred (26 LNG, 92 copper). Both types of IUD were highly effective, with overall Pearl indices of 0.06 [95% confidence interval (CI): 0.04–0.09] and 0.52 (95% CI: 0.42–0.64) for LNG IUS and copper IUDs, respectively. The adjusted hazard ratio for LNG IUS vs. copper IUDs was 0.16 (95% CI: 0.10–0.25). Tenty-one pregnancies (7 LNG IUS, 14 copper IUD) were ectopic, yielding an adjusted hazard ratio for ectopic pregnancy of 0.26 (95% CI: 0.10–0.66). Conclusions The contraceptive failure rate was low with both IUDs. However, the LNG IUS was associated with a significantly lower risk of pregnancy, including ectopic pregnancy, than the copper IUDs. Implications To our knowledge, this is the first large-scale, multinational, prospective epidemiological study to measure and compare the contraceptive effectiveness of LNG IUSs and copper IUDs during routine clinical practice. Clinicians and patients should be aware of differences in rates of unintended pregnancies and associated complications in relation to IUD us.

Background Access to effective family planning is of great importance for women with sickle cell disease (SCD) due to the increased frequency of pregnancy complications. However, little is known regarding use of hormonal contraception, complications of contraception, and pregnancy in young women with SCD. Study Design We abstracted diagnostic codes, procedure codes and pharmacy claims from women with SCD, aged 13–21 years, enrolled in Michigan Medicaid between 1/1/2000 and 12/31/2003 with ≥9 months of continuous eligibility. Results We identified 250 women with SCD with an average period of continuous Medicaid enrollment of 20 months. Claims for hormonal contraception could be identified in only 20 patients (8%, 95% CI 5–12%). The most commonly prescribed method ( n =12) was depot medroxyprogesterone (DMPA) acetate. Venous thromboembolism and osteopenia were rarely identified ( n ≤10) and occurred only in women with no recorded use of hormonal contraception. In the total population, 64 patients had one pregnancy and 16 had ≥2 pregnancies during the 4-year study period. Among adolescents (13–18 years), 49 (30%) of 195 patients (95% CI 24–37%) had 59 pregnancies. By 12 weeks postpartum, few patients ( n ≤10) with a record of delivery had hormonal contraception claims. Conclusions In a publicly insured population of young women with SCD, pregnancy was more commonly identified than hormonal contraception use. Our work suggests that significant gaps may exist in family planning care for young women with SCD.