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Objectives: Partnership with parents is a tenet of pediatric medicine; however, initiatives to include parents in education and research have been limited. Through focus groups, we included parents at the beginning of curriculum development by asking them to identify the priorities, existing supports, and opportunities for improvement in their child's end-of-life (EOL) care., Methods: English and Spanish-speaking bereaved parents whose child had been cared for by the palliative care team and had died >18 months before the study initiation were invited to participate. In-person focus groups and a follow-up phone call were used to elicit opinions and capture a diversity of viewpoints. Themes were identified and clustered through an iterative analytic process., Results: Twenty-seven parents of 17 children participated, with the total sample size determined by thematic saturation. Four themes were identified as important to parents in their child's EOL care: (1) honoring the role of the parent, (2) having confidence in the care team, (3) receiving gestures of love and caring, and (4) navigating logistic challenges., Conclusions: We asked parents to be partners in guiding priorities for health care education and professional development to improve pediatric EOL care. In addition to strengthening skills in communication, confidence in the team, and compassion, parents in this study identified a need for hospital staff to anticipate financial and social stressors and provide supportive resources more readily. Additionally, parents described clinical and nonclinical staff as providing support, suggesting that a multidisciplinary and interdisciplinary curriculum be developed to improve pediatric EOL care., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Purpose: As the integral role of genetics in health and disease becomes increasingly understood, pediatricians must incorporate genetic principles into their care of patients. Structured exposure to genetics during residency may better equip future pediatricians to meet this goal., Methods: Pediatric interns in the Johns Hopkins pediatric residency program have the option to spend one week immersed in clinical genetics by attending outpatient clinics and seeing inpatient consults. A pretest assessing clinical genetics knowledge is given before the rotation and compared with an identical post-test. Interns have a "scavenger hunt" to introduce genetic resources useful to pediatricians and complete a logbook of patient experiences. An evaluation is completed at the end of the rotation., Results: Since the selective started in July 2016, 50 interns have participated. Average pretest score was 2.5/5 compared with a post-test score of 4.3/5, p < 0.0001. Interns saw on average ten patients and four different diagnoses. Overall evaluation was 4.4 on a 5-point scale, 5 being "excellent.", Conclusion: This experience suggests that a structured rotation in genetics provides pediatric interns with an opportunity to learn basic clinical genetics knowledge and skills and see patients whom they may otherwise not encounter during residency.

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.)

Objective: Describe current practices in systematic screening for social determinants of health (SDH) in pediatric resident clinics enrolled in the Continuity Research Network (CORNET)., Methods: CORNET clinic directors were surveyed on demographics, barriers to screening, and screening practices for 15 SDH, including the screen source, timing of screening, process of administering the screen, and personnel involved in screening. Incidence rate ratios were tabulated to investigate relationships among screening practices and clinic staff composition., Results: Clinic response rate was 41% (65/158). Clinics reported screening for between 0 and 15 SDH (median, 7). Maternal depression (86%), child educational problems (84%), and food insecurity (71%) were the items most commonly screened. Immigration status (17%), parental health literacy (19%), and parental incarceration (21%) were least commonly screened. Within 3 years, clinics plan to screen for 25% of SDH not currently being screened. Barriers to screening included lack of time (63%), resources (50%), and training (46%)., Conclusions: Screening for SDH in our study population of CORNET clinics is common but has not been universally implemented. Screening practices are variable and reflect the complex nature of screening, including the heterogeneity of the patient populations, the clinic staff composition, and the SDH encountered., (Copyright © 2019 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Challenging situations and intense emotions are inherent to clinical practice. Failure to address these emotions has been associated with health care provider burnout. One way to combat this burnout and increase resilience is participation in emotional debriefing. Although there are many models of emotional debriefings, these are not commonly performed in clinical practice. We provide a guide for implementing emotional debriefing training utilizing the American Academy of Pediatrics Resilience Curriculum into clinical training programs, with a focus on preparing senior residents and fellows to act as debriefing facilitators. Senior residents and fellows can provide in-the-moment emotional debriefing which allows for greater health care provider participation, including medical students and other pediatric trainees. Training of senior residents and fellows may allow more frequent emotional debriefing and in turn may help to improve the resilience of pediatricians when they face challenging situations in clinical practice., (Copyright © 2018 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.)

Training pediatric residents in Bright Futures and oral health concepts is critical to improving oral health. This study's objective was to determine the skill level of pediatric residents in integrating oral health promotion during health supervision visits of 12- to 35-month-old children. One hundred forty-three pediatric residents participated in an evaluation of the effectiveness of a Bright Futures oral health curriculum. Competencies assessed preintervention included partnership building, communication, and integration of oral health concepts. Pediatric residents' abilities to integrate oral health promotion into health supervision visits varied considerably. Residents demonstrated greater skill in communication and partnership building compared with oral health promotion behaviors and performance of an oral examination. Further education is needed at a national level if we are to meet Healthy People 2020 goals.

Objective: Resident mental health (MH) problems can be associated with reduced empathy and increased medical errors. The Accreditation Council for Graduate Medical Education mandates resident MH support services, but it is unknown if these services are accessible and meet resident needs. We sought to describe the prevalence of anxiety and depression in current pediatric residents in New York State (NYS), and their self-reported use of and barriers to support services., Methods: We developed an online survey and distributed it to all categorical pediatric residents in 9 NYS programs. Items addressing self-concern for clinical anxiety and depression and use of MH services were pilot tested for content and construct validity. The validated Patient Health Questionnaire-2 (PHQ-2) measured depressive symptoms. Analyses used descriptive and chi-square tests., Results: Respondents included 227 residents (54% response rate) distributed across training levels and programs. Many reported "often" or "almost always" feeling stress (52%), physical exhaustion (41%), and mental exhaustion (35%); 11% had PHQ-2-defined depressive symptoms. Some thought that their stress levels raised concern for clinical depression (25%) or anxiety (28%); among these, only 44% and 39%, respectively, had sought care. More women reported physical exhaustion (P < .05). Only 45% of residents reported educational offerings on resident MH; 66% wanted to know more about available resources. Barriers to receipt of services included inflexible schedules (82%), guilt about burdening colleagues (65%), fear of confidentiality breach (46%), and difficulty identifying services (44%)., Conclusions: Pediatric residents frequently experience MH symptoms, but many do not know about or use support services. Programs should enhance MH support by overcoming barriers and increasing resident awareness of services., (Copyright © 2017 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

A career in pediatrics can bring great joy and satisfaction. It can also be challenging and lead some providers to manifest burnout and depression. A curriculum designed to help pediatric health providers acquire resilience and adaptive skills may be a key element in transforming times of anxiety and grief into rewarding professional experiences. The need for this curriculum was identified by the American Academy of Pediatrics Section on Medical Students, Residents and Fellowship Trainees. A working group of educators developed this curriculum to address the professional attitudes, knowledge, and skills essential to thrive despite the many stressors inevitable in clinical care. Fourteen modules incorporating adult learning theory were developed. The first 2 sections of the curriculum address the knowledge and skills to approach disclosure of life-altering diagnoses, and the second 2 sections focus on the provider's responses to difficult patient care experiences and their needs to develop strategies to maintain their own well-being. This curriculum addresses the intellectual and emotional characteristics patient care medical professionals need to provide high-quality, compassionate care while also addressing active and intentional ways to maintain personal wellness and resilience., (Copyright © 2016 by the American Academy of Pediatrics.)

Background End-of-life care for a child is an emotionally charged experience for pediatric trainees. Objectives Describe the progression of medical trainee experiences with end-of-life care and determine personal/professional experiences that facilitated integration of experiences. Methods Medical students (MS4) and pediatric residents (PL-1-3) completed a 30-question survey about experiences with patient deaths and integration of these experiences. Results A total of 307 of 404 residents (76%) participated. Mean number of deaths ranged from 3.0 to 6.5 in the prior 12 months, and the most common location was neonatal intensive care unit or pediatric intensive care unit. In total, 18% to 27% experienced a death in their personal life. Between 26% and 41% of the residents made contact with a family after death, and 15% to 35% attended a funeral. Characteristics of good deaths included good communication and discussion of end-of-life issues. Conclusions Trainees experienced patient deaths along the educational continuum. These findings have implications for the optimal timing and method of end-of-life care education., (© The Author(s) 2016.)

Objective: Training residents in oral health helps eliminate disparities and improves access. The American Academy of Pediatrics Bright Futures Guidelines curriculum is used as a training guide. We assessed knowledge, confidence, and perceived barriers to incorporating Bright Futures oral health concepts into well-child care for children below 3 years in a national sample of pediatric residents., Methods: A sample of postgraduate year 1 and 2 residents from CORNET sites completed demographic, Bright Futures oral health concepts confidence and knowledge cross-sectional surveys before any intervention. Measures were tested for reliability using Cronbach's alpha coefficient., Results: One hundred sixty-three residents from 28 CORNET sites completed the surveys. One third reported no prior training in oral health. Time (42%) and knowledge (33%) led the perceived barriers to addressing these concepts in well visits. Although 63% rated their confidence as excellent in identifying tooth decay risk factors, a significant percentage rated their oral health risk assessment skills as poor or neutral (64%) and identifying caries at examination (53%). Only 49% conveyed oral health messages during encounters and 80% correctly scored 75% or higher on knowledge questions., Conclusions: This cross-sectional study shows that residents from a wide geographic range have high self-reported oral health knowledge but low perceived skills and competency in clinical implementation. Lack of time and knowledge in identifying caries led the perceived barriers. Barriers are addressed by implementing oral health curricula that promote competence and skill-development. This study helps programs effectively implement Bright Futures concepts to train graduates to incorporate oral health in well visits., (Copyright © 2015 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the variability of the institutional review board (IRB) process for a minimal risk multicenter study., Methods: Participants included 24 Continuity Research Network (CORNET) sites of the Academic Pediatric Association that participated in a cross-sectional study. Each site obtained individual institutional IRB approval. An anonymous questionnaire went to site investigators about the IRB process at their institution., Results: Twenty-two of 24 sites (92%) responded. Preparation time ranged from 1 to 20 hours, mean of 7.1 hours. Individuals submitting ≤3 IRB applications/year required more time for completion than those submitting >3/year (P < .05). Thirteen of 22 (59%) study sites received approval with "exempt" status, and 6 (27%) approved as "expedited" studies., Conclusions: IRB experiences were highly variable across study sites. These findings indicate that multicenter research projects should anticipate barriers to timely study implementation. Improved IRB standardization or centralization for multicenter clinical studies would facilitate this type of practice-based clinical research.

Objective: To compare asthma treatment decisions by pediatric residents to current asthma guidelines and to learn whether treatment decisions vary by postgraduate year in training., Methods: We conducted a Web-based survey of residents from 10 training programs through the Continuity Research Network of the Academic Pediatric Association (CORNET). Surveys included 6 vignettes of patients receiving low-dose inhaled steroids with guideline- and non-guideline-based indicators of asthma status and 1 stable patient on high-intensity medication., Results: There were 369 resident respondents (65% response rate), 26% postgraduate year (PGY) 1, 38% PGY2, and 36% PGY3+. Seventy-five percent of each resident group reported seeing fewer than 1 asthma patient per continuity clinic session. A majority of residents made appropriate treatment recommendations in 2 of 4 vignettes of guideline-based indicators of asthma status: first, 97% overall stepping up treatment for mild persistent asthma; and second, 52% overall stepping down treatment for a patient with well-controlled asthma on high-intensity medications. Inconsistent with guideline recommendations, 82% of residents overall did not step down treatment for a patient with well-controlled asthma receiving low-intensity therapy; 75% of residents did not step up treatment for a patient with a recent hospitalization for asthma. Of the 3 vignettes evaluating non-guideline-based indicators of asthma status, a majority of residents (60%) stepped up treatment for parental reports of worse asthma, while a minority did so for a parental report of being bothered by their child's asthma (27%) or when wheezing was reported at physical examination (43%). There were no statistically significant differences for any of the comparisons by year in training., Conclusions: Pediatric residents' management of asthma is consistent with national guidelines in some cases but not in others. There were no differences in the outpatient asthma management decisions between residents by years in training. Educational efforts should be focused on strategies to facilitate pediatric resident adherence to national asthma guideline recommendations for outpatient asthma management., (Copyright © 2014 Academic Pediatric Association. All rights reserved.)

Objective: To determine whether pediatric continuity clinics integrate mental health (MH) services into care delivery; and to determine whether the level of MH integration is related to access to MH services, types of MH screening performed, self-efficacy, satisfaction with referral sites, and communication with the primary care provider., Methods: Pediatric Residency Integrated Survey of Mental Health in Primary Care (PRISM&#95;PC) is a newly designed cross-sectional, Web-based survey of continuity clinic directors participating in a national network of pediatric continuity clinics (CORNET). Definitions of MH models included integrated or nonintegrated MH models or traditional care. The survey included questions regarding access, screening that was performed at sites, comfort with MH management as well as provider satisfaction and communication with referral sites., Results: Seventy-eight percent (57 of 73) of CORNET site directors responded, representing input from 30% of US pediatric residency continuity programs. Thirty-five percent (n = 20) reported an integrated MH model while 65% (n = 37) reported a nonintegrated MH model. Seventy-nine percent screened for attention-deficit/hyperactivity disorder, 44% for behavioral-emotional issues, and 19% for pediatric depression. No differences were found in terms of screening or tools used on the basis of the level of MH integration. Those with integrated programs were more likely to have access to an on-site psychologist (P = .001) or psychiatrist (P = .006)., Conclusions: Directors from one-third of training programs surveyed reported some level of MH integration in their primary care teaching clinics. Future studies are needed to compare patient and resident education outcomes between integrated and nonintegrated sites., (Copyright © 2013 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Objective: To describe the Health Begins at Home (HBH) intervention and examine pediatric resident change in knowledge, attitudes, and self-reported behaviors after the HBH intervention., Methods: A prospective mixed-methods cohort study was conducted in 2 outpatient clinics at an urban academic pediatric residency program. Residents serving as primary care providers (n = 50) of newborn infants participated in HBH, an educational home visit intervention. Study outcomes included resident pre- and post-home visit surveys and an end-of-residency survey assessing knowledge of community, attitudes, and self-reported practice behaviors. Qualitative comments from surveys and small group post-home visit debriefing sessions were coded and themes identified., Results: After intervention, residents demonstrated a significant positive change (all P < .05) in the following: adequacy of medical knowledge, understanding of home and community, excitement about home visits, and less concern about personal safety in the community. These changes were sustained in an end-of-residency survey administered 14 to 22 months after the intervention. Sixty-two percent reported a change in how they treated patients, and 94% indicated home visits should be part of the permanent curriculum., Conclusions: Conducting home visits was associated with residents' improved understanding of the community and home environment of their patients, which was sustained throughout the remainder of training. Residents reported that home visits provide an important educational experience and should be part of the permanent curriculum. Training programs should consider incorporating home visiting programs into curricula to improve resident knowledge of family home, community, and social determinants of health., (Copyright © 2013 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Objective: Training in Bright Futures and oral health concepts is critical for delivery of high-quality primary care and preventive health services by residents, our future pediatric workforce. The goal of this study was to evaluate the effectiveness of an online health promotion curriculum on pediatric residents' confidence, knowledge, and clinical performance in Bright Futures and oral health practice., Methods: Residents from sites that had been stratified by size and randomized were assigned to the Bright Futures Oral Health curriculum (intervention group) or an active control group. Confidence and knowledge were measured by self-report and multiple-choice questions, respectively. Clinical performance was measured with structured clinical observations, performed by trained faculty, of Bright Futures and oral health performance before and after intervention. Mean scores between intervention and control groups were compared using a 2-tailed, repeated-measures F test., Results: A total of 143 pediatric residents from 27 Continuity Research Network (CORNET) sites participated in the study. At a median of 3 months after intervention, the intervention group demonstrated significant improvement in general Bright Futures confidence (n = 128, F = 6.564, P = .012) and knowledge (n = 102, F = 5.296, P = .023), oral health confidence (n = 123, F = 15.220, P < .001), and clinical performance skills in oral health (n = 96, F = 11.315, P = .001) compared with the control group., Conclusions: The Bright Futures Oral Health curriculum promoted an increase in confidence and knowledge in Bright Futures concepts and in confidence and clinical performance in oral health concepts among pediatric residents. This online curriculum demonstrated a positive impact on documented resident behavior, maintained for 3 months after intervention, and provides a replicable national training model to advance important elements of primary care pediatrics., (Copyright © 2013 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Purpose: Morbidity and Mortality conference (MMC) serves an important role in medical care and education. We restructured our Department of Pediatrics MMC to focus on multidisciplinary participation and improved communication among disciplines, quality improvement, and system changes for safer clinical care and enhanced learning from adverse outcomes., Method: The structure and philosophy of the Department of Pediatrics MMC was changed. We present guiding principles for the restructuring process and evaluation results postrestructuring, which examined achievement of conference goals, including quality improvement., Results: The MMC led to system changes within the Department of Pediatrics as well as other parts of the hospital. Satisfaction with these changes was high among conference participants, who felt that the conference achieved its goals of including multiple disciplines and creating system changes., Conclusions: The successful change in the focus of the pediatric MMC conference resulted in significant hospital-wide system changes, quality improvements, enhanced education, and departmental satisfaction.

Background: The traditional role of the faculty inpatient attending providing clinical care and effectively teaching residents and medical students is threatened by increasing documentation requirements, pressures to increase clinical productivity, and insufficient funding available for medical education. In order to sustain and improve clinical education on a general pediatric inpatient service, we instituted a comprehensive program change. Our program consisted of creating detailed job descriptions, setting clear expectations, and providing salary support for faculty inpatient attending physicians serving in clinical and educational roles. This study was aimed at assessing the impact of this program change on the learners' perceptions of their faculty attending physicians and learners' experiences on the inpatient rotations., Methods: We analyzed resident and medical student electronic evaluations of both clinical and teaching faculty attending physician characteristics, as well as resident evaluations of an inpatient rotation experience. We compared the proportions of "superior" ratings versus all other ratings prior to the educational intervention (2005-2006, baseline) with the two subsequent years post intervention (2006-2007, year 1; 2007-2008, year 2). We also compared medical student scores on a comprehensive National Board of Medical Examiners clinical subject examination pre and post intervention., Results: When compared to the baseline year, pediatric residents were more likely to rate as superior the quality of didactic teaching (OR=1.7 [1.0-2.8] year 1; OR=2.0 [1.1-3.5] year 2) and attendings' appeal as a role model (OR=1.9 [1.1-3.3] year 2). Residents were also more likely to rate as superior the quality of feedback and evaluation they received from the attending (OR=2.1 [1.2-3.7] year 1; OR=3.9 [2.2-7.1] year 2). Similar improvements were also noted in medical student evaluations of faculty attendings. Most notably, medical students were significantly more likely to rate feedback on their data gathering and physical examination skills as superior (OR=4.2 [2.0-8.6] year 1; OR=6.4 [3.0-13.6] year 2)., Conclusions: A comprehensive program which includes clear role descriptions along with faculty expectations, as well as salary support for faculty in clinical and educational roles, can improve resident and medical student experiences on a general pediatric inpatient service. The authors provide sufficient detail to replicate this program to other settings.

The Academic Pediatric Association (APA, formerly the Ambulatory Pediatric Association) first encouraged multi-institutional collaborative research among its members over 30 years ago. Individual APA members subsequently went on to figure prominently in establishing formal research networks. These enduring collaborations have been established to conduct investigations in a variety of generalist contexts. At present, 4 generalist networks--Pediatric Research in Office Settings (PROS), the Pediatric Emergency Care Applied Research Network (PECARN), the COntinuity Research NETwork (CORNET), and Pediatric Research in Inpatient Settings (PRIS)--have a track record of extensive achievement in generating new knowledge aimed at improving the health and health care of children. This review details the history, accomplishments, and future directions of these networks and summarizes the common themes, strengths, challenges, and opportunities inherent in pediatric generalist network research., (Copyright © 2011 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Objectives: Teaching at the bedside during attending rounds is considered to be fundamental to medical education. We conducted an ethnographic case study to investigate such teaching in general paediatrics as a social phenomenon and to explore change over time in both the meaning of rounds and the context in which rounds take place., Methods: We conducted a case study from January to August 2006 on a 22-bed general paediatric unit in an urban children's hospital and focused our observation on interns, senior residents and attending physicians. We observed the medical team during its normal activities on the study unit and conducted semi-structured interviews with a sample of attendings, interns and senior residents. We compiled a list of codes that emerged from patterns in the data and constructed a rich description of rounds according to the principles of inductive analysis., Results: Four themes emerged from the data: (i) attending rounds are a pervasive and routine part of clinical education; (ii) interns, senior residents and attending physicians hold assumptions about what should happen on rounds; (iii) tension exists between interns', senior residents' and attending physicians' assumptions about bedside teaching during rounds and the reality imposed by contextual factors, and (iv) bedside teaching during rounds is impacted, but not prohibited, by contextual factors., Conclusions: Our case study provides evidence that bedside teaching during rounds is a pedagogical ideal entrenched in medical education. Participants readily acknowledged teaching at the bedside during rounds as something they perceived should happen, although, in actuality, it was infrequently achieved. This study revealed a telling inconsistency in language and behaviour: 'bedside rounds' was embedded in the participants' ordinary language, but the activity was not necessarily part of their ordinary behaviour. We propose that the practice of bedside teaching is best explained as a ritual. Considering bedside teaching as a ritual helps to explain why rounds are sacrosanct and helps to develop more appropriate expectations for rounds., (© Blackwell Publishing Ltd 2010.)

Objective: To compare parental report of child body image with perceived healthy weight body image in preschoolers and describe weight-counseling preferences., Methods: Parents seeking well-child care were interviewed and asked to select images resembling: (a) their own child's current weight, (b) a healthy weight preschooler, and (c) friend and family report of a healthy weight preschooler. Those indicating that their overweight or obese child resembled a healthy weight image were considered to misclassify child weight. Logistic regression was used to identify predictors of misclassification and card-sorting exercises explored weight-counseling preferences., Results: Of the 150 preschoolers in our sample, 32.7% (n = 49) were overweight or obese with misclassification occurring in 71.4% of parents (n = 35). Absence of pediatrician comment on child weight strongly predicted misclassification (odds ratio, 12.3; 95% confidence interval, 1.74-87.2). Pediatricians were highly valued weight advisors., Conclusions: Weight-focused advice from pediatricians matters to parents and may promote parental identification of early childhood weight risks.

Objective: The aim of this study was to determine if an information sheet containing photographs and explanations of the training level of medical providers could enhance a parent's ability to identify their child's providers and whether this would impact parental attitudes toward trainee involvement and patient satisfaction., Methods: This was a prospective, mixed methods study of parent-child dyads admitted to an academic general pediatric inpatient service. The intervention group received a photo information sheet (Photographs of Academic Clinicians and Their Educational Status [PHACES] tool) consisting of passport-sized photos of the medical team along with information regarding their training. Parents were asked to name their child's providers, were surveyed about their attitudes toward trainees, participated in a brief, semistructured interview and completed the patient satisfaction questionnaire (ABIM-PSQ)., Results: Comparing intervention with control parents, 40 of 49 (82%) versus 19 of 51 (37%) were able to name at least one provider (adjusted odds ratio 8.0; P < .01). Parents who received the intervention were more likely to correctly match the face with the name of the medical student (67% vs 14%; P < .01) and attending (80% vs 24%; P < .01). Parents who received the intervention were more likely to report acceptance of the involvement of medical students and house staff as well as an improved understanding of their roles. Parents who received the intervention scored higher on the ABIM-PSQ (mean 48.3 vs 45.4; P = .008)., Conclusions: An information sheet containing the photographs of health care providers along with an explanation of their training improves recognition of the health care team members, improves acceptance of trainee involvement, and improves satisfaction with care delivered by physicians in training., (Copyright 2010 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Prior research has demonstrated that limited English proficiency in Hispanic patients is associated with adverse health outcomes. The authors sought to compare the perception of primary care in resident practices between Spanish-speaking and English-speaking parents using a previously validated tool, the Parents' Perception of Primary Care. Using survey results from 19 CORNET sites nationwide, they compared mean scores for each primary care domain and the full scale between the groups using Student's t test. Multiple linear regression models compared outcomes controlling for demographic variables. Of the 2122 analyzable surveys, 490 (23%) were completed in Spanish and 1632 (77%) in English. The mean scores for each domain and the total scale were not statistically different between the 2 groups. After adjustment, Spanish-speaking parents rated communication significantly higher. Resident clinics may use systems to provide high quality care to Spanish-speaking patients, which may help other sites improve care.

The objective of this study was to determine perceived benefits, detriments, and barriers to communication between pediatric providers and home visitors. The authors performed a cross-sectional, qualitative study consisting of 3 focus groups with paraprofessional home visitors (n=12), 6 with parents receiving home visiting (n=33), and 4 with pediatric providers whose patients received home visiting (n=19). Emerging themes were generated by an inductive analytic approach. Perceived benefits included home visitors assisting parents with communication, giving providers family information, and reinforcing providers' guidance. Detriments included parental concern of sharing confidential information and providers becoming aware of family issues for which they are unprepared to act. Barriers included parental consent, logistics of home visitor-provider communication, and providers' lack of knowledge about home visitor programs/roles. Greater coordination between home visitation programs and pediatric providers may strengthen home visiting services and reinforce advice and anticipatory guidance given by providers.

Context: Apprenticeship learning is common in medical education, but is often situated in theoretical frameworks which highlight its cognitive but not its social dimension., Methods: We conducted an ethnographic case study of paediatric residents' learning relationships with their preceptors in a community-based paediatric continuity site. It included 5 months (100 hours) of direct observation, and semi-structured interviews with 10 residents (before and after observation) and 10 primary care paediatricians who served as their continuity preceptors (after observation). Interview transcripts and notes from observations were inductively coded and analysed for major themes., Results: Our observations and reports of resident learning trajectories fit well with the concept of legitimate peripheral participation. Residents learned the everyday practice of primary care as they worked alongside experienced paediatricians in the continuity clinic. Although the direction of learning was towards central participation in patient care, residents learned during transient shifts to the periphery of practice. As a function of residents' increased participation, preceptors moved into more supportive roles. Residents were not only learners; at times they were teachers who facilitated preceptors' learning., Conclusions: Legitimate peripheral participation is a concept that helps to explain apprenticeship as a dynamic social relationship which shapes, and is shaped by, learning that takes place in clinical practice. Other concepts shed light on the bidirectional nature of apprenticeship learning.

Objectives: The continuity-structured clinical observation tool was developed and used to conduct a multiple-observer evaluation to assess residents in the core competency areas of patient care, interpersonal and communication skills, and professionalism. The objectives were to assess pediatric resident performance in a continuity clinic by using direct observation and to compare evaluations among preceptors, residents, and parents., Methods: Pediatric residents in a large continuity clinic participated between August and December 2005. The continuity-structured clinical tool included items in the following domains: opening the interview, history taking, relationship skills, personal manner, negotiation or management, and physical examination. Each resident was directly observed during 1 entire patient encounter. Parents, preceptors, and residents completed evaluations by selecting 1 of 4 possible responses for performance of each item. We dichotomized responses as "yes" versus "no/partial" and analyzed aggregate scores for individual items and domains among the 3 evaluators by McNemar test, percentage agreement, and interoberserver agreement (kappa)., Results: Fifty-four of 57 eligible residents had all 3 evaluations completed. Parents rated residents the highest and showed least variability (only 2 items for which parents indicated the task was completed in <90% of the encounters). Residents rated themselves the lowest (35 items with <90%). In comparing the residents and preceptors, the domains that had the lowest percentage of agreement were history taking (range: 61%-91%) and negotiation or management (range: 51%-88%). All of the evaluators scored residents the lowest in the domain of negotiation or management, with the following lowest-score items: probe for decision-makers, assess willingness and barriers, and use of visual aids., Conclusions: Compared with parents, residents and preceptors demonstrated greater variability in resident performance evaluations. All of the evaluators scored residents lowest in the domain of negotiation or management during continuity-clinic visits. Residency programs should strongly consider emphasizing skill development in this area.

Objective: The objective of this study was to document the frequency of pediatric resident experiences with end-of-life care for children and the educational context for these experiences, as well as to determine whether residents deem their preparatory training adequate., Methods: An Internet-based survey was distributed to all categorical pediatric residents at the Johns Hopkins Children's Center. Survey items asked residents to (1) quantify their experiences with specific responsibilities associated with the death of a pediatric patient, (2) identify their educational experiences, and (3) respond to Likert scale statements of, "I feel adequately trained to... ." The responsibilities were discussion of withdrawal/limitation of life-sustaining therapy, symptom management, declaration of death, discussion of autopsy, completion of a death certificate, seeking self-support, and follow-up with families., Results: Forty (50%) of 80 residents completed the survey. Residents had been present for a mean (+/- SD) of 4.7 (+/- 3.0) patient deaths. More than 50% of residents had participated in discussions of withdrawal/limitation of life-sustaining therapy, symptom management, completing a death certificate, and seeking personal support; however, <50% of residents had been taught how to hold discussions of withdrawal/limitation of life-sustaining therapy, declare death, discuss autopsy, complete a death certificate, and have follow-up with families. Residents did not feel adequately trained in any of these areas., Conclusion: Pediatric residents have limited experience with pediatric end-of-life care and highly varied educational experiences and do not feel adequately trained to fulfill the responsibilities associated with providing end-of-life care for children. Overall, this perception does not improve with increased level of training. This study identifies several target areas for curricular intervention that may ultimately improve the end-of-life experience for our pediatric patients and their families and the young physicians who care for them.

Objectives: Pediatric resident continuity practices provide care to more than one fifth of the socioeconomically disadvantaged population of the United States. With the structural challenges of resident training, there may be concerns about a lower quality of care received by patients. The objectives of this study were to measure parental perception of resident primary care, to determine the characteristics associated with better care, and to compare perception with a previously published community standard., Methods: A cross-sectional survey using the Parents' Perception of Primary Care was conducted of patients enrolled at 19 national academically affiliated resident continuity practices from the Continuity Research Network. Outcome measures included mean total scale score for the Parents' Perception of Primary Care and mean scores for each primary care domain. Comparisons were made between the subset of resident patients who were older than 5 years and a previously published community survey of parents of school-age children., Results: A total of 2572 patients were enrolled with a final sample size of 2211 analyzable surveys. The sample was 37% black and 40% Hispanic; 81% of the children had Medicaid insurance; and 20% of the parents had less than a high school education. Parents rated the care that they received in resident continuity with high total scores and subscale scores, with an overall mean total scale score of 74.0. Higher scores were associated with number of visits to the provider and being able to name the resident as the primary care provider, whereas minority status was associated with lower access and communication scores. The resident sample over age 5 had higher mean scores for the total scale and every domain as compared with the community sample., Conclusions: Parents of patients at resident continuity sites rated residents as providers of high-quality care to a socioeconomically disadvantaged population as compared with a previously published community sample. Efforts to improve resident continuity and identification may help improve care delivered in resident practices.

Objective: Little is known about what residents learn from "everyday" physician role models, who, in the course of their ordinary work, serve as real-life examples of residents' future roles. The purpose of this research was to analyze what and how pediatric residents learn through role modeling during their continuity experience., Design: We conducted a case study of 10 third-year pediatric residents and their 10 continuity clinic preceptors (CCP) in a community-based continuity clinic. Data were derived from 5 months (100 hours) of direct observation in clinic; semistructured interviews with residents before and after observation; and semistructured interviews with CCPs after resident data were collected. Interview transcripts and notes from observation were inductively coded and thematically analyzed., Results: From the residents' perspective, role modeling was an implicit and intentional learning strategy that was linked to routine clinical practice in continuity clinic. Residents learned, through modeling their CCPs, "how to talk" and "how to think things through." Residents did not directly report modeling professional behavior. For residents, learning through modeling was not contingent on CCPs' awareness of being a role model., Conclusions: Role modeling is a nuanced, deliberate learning strategy that provides pediatric residents with templates for interpersonal communication and clinical decision making that have both immediate and long-term relevance. Understanding residents' perspective on role modeling, and how it aligns with their CCPs' perspective, presents opportunities for improving residents' learning experiences, faculty development, and future research.

Objectives: The goal was to compare visit data from Continuity Research Network practices with data for a nationally representative sample of pediatric visits in practice settings from the National Ambulatory Medical Care Survey., Methods: A cross-sectional study comparing data for Continuity Research Network practice visits during a 1-week period in 2002 with data from the 2000 National Ambulatory Medical Care Survey was performed. Continuity Research Network and National Ambulatory Medical Care Survey data were derived from 30 patient visits per practice site for patients < 22 years of age, with the primary care providers being residents and practicing pediatricians, respectively., Results: Eighteen Continuity Research Network practices reported on 540 visits, compared with 32 National Ambulatory Medical Care Survey physicians reporting on 792 visits. Continuity Research Network patients were more likely to be black non-Hispanic or Hispanic/Latino and to have public insurance. The top 5 reasons for visits were the same for Continuity Research Network and National Ambulatory Medical Care Survey visits, although the orders varied slightly. These 5 reasons accounted for 58% of Continuity Research Network visits and 49% of National Ambulatory Medical Care Survey visits. Continuity Research Network visits were more likely to result in patient instructions to return at a specific time (78% vs 52%)., Conclusions: Residents in Continuity Research Network practices provide care to more underserved patients but evaluate problems that are similar to those observed in office practices; the Continuity Research Network practices thus provide important training experiences for residents who will serve both minority and nonminority children.

Background: The American Academy of Pediatrics (AAP) statement on Pediatric Palliative Care has emphasized the importance of identifying barriers and facilitators to effective palliative care., Objectives: To survey pediatric residents about their personal and professional experiences concerning death and determine factors associated with guilt (a potential barrier) and attendance at patient funerals (a potential facilitator)., Design/methods: PL-2 residents were surveyed midway through pediatric residency. Both personal and professional attitudes and experiences about death were solicited., Results: Seventy-nine (90%) PL-2 residents completed the survey from 1997-2000. While 91% reported that a close family member or friend had died, 75% recalled that their family had not openly discussed issues of death. Thus far in their career, residents reported encountering a mean of 9.4 patients who had died (+/-6.4; range, 0-30 deaths) and 39% expressed guilt about a death. Those who felt guilt about a death were more likely to state they felt responsible (p<0.01) but less likely to think about their own death (p<0.01). While 23% had attended a patient's funeral, 42% expressed fear of attending. The mean number of times a resident informed a family of a patient's death was slightly higher in those who attended a patient's funeral, and approached statistical significance., Conclusions: By midresidency, these pediatric residents have had many personal and professional experiences with death. Residency training programs must provide venues for residents to address bereavement, facilitate the integration of these experiences, and provide time to attend funerals.

We tested a kiosk-based tailoring intervention with a sample of 144 parents of young children using a two-group randomized controlled design to evaluate the kiosk. Intervention group parents (n = 70) answered 50 questions at a practice-based kiosk and they and their child's physician received immediate feedback reports of their injury prevention needs. Four weeks later, both control (n = 74) and intervention parents completed a telephone interview. Safety knowledge, beliefs, and practices were compared at follow-up. Compared to control group parents, intervention group parents were more knowledgeable about the inappropriateness of young children riding in the front seat of a car (16% versus 5%, p < 0.05), less likely to believe that teaching a child to mind you is the best way to prevent injuries (64% versus 86%, p < 0.05), and more likely to report that they "have syrup of ipecac" (34% versus 9%, p < 0.001) and "know how to use" it (24% versus 4%, p < 0.002). This study provides further support for the use of tailored communication to address the prevention of injuries to young children but calls for continued investigation in the area.

Objective: To determine how pediatric residents' perceptions of continuity clinic experiences vary by level of training, after controlling for the effect of continuity setting., Method: Cross-sectional survey of pediatric and combined pediatric trainees in US residency programs., Results: Survey responses were received from 1355 residents in 36 training programs. Residents' continuity experiences were in hospital-based and community settings. Numbers of patients seen increased between PGY-1 and PGY-3 years, but not in the PGY-4 and PGY-5 years. Compared to PGY-1 residents, PGY-2 and PGY-3 residents were more likely to report more encounters with established patients, but were not more likely to feel like the primary care provider. There were no significant differences by training level in terms of involvement in panel patients' laboratory results, hospitalizations, or telephone calls, although nursery involvement decreased with increasing training level. Autonomy was directly related to training level. The perception of having the appropriate amount of exposure to practice management issues was low for all respondents., Conclusions: Residents perceived that they had greater autonomy and continuity with patients as they become more senior, yet they were not more likely to feel like the primary care provider. Lack of increased involvement in key patient care and office responsibilities across training years may reflect a need for changes in resident education. These data may be helpful in formulating recommendations to program directors with regard to determining which Accreditation Council for Graduate Medical Education competencies should be emphasized and evaluated in the continuity experience.

Objective: To identify factors associated with resident satisfaction concerning residents' continuity experience., Design and Methods: Continuity directors distributed questionnaires to residents at their respective institutions. Resident satisfaction was defined as satisfied or very satisfied on a Likert scale. The independent variables included 60 characteristics of the continuity experience from 7 domains: 1) patient attributes, 2) continuity and longitudinal issues, 3) responsibility as primary care provider, 4) preceptor characteristics, 5) educational opportunities, 6) exposure to practice management, and 7) interaction with other clinic and practice staff. A stepwise logistic regression model and the Generalized Estimating Equations approach were used., Results: Thirty-six programs participated. Of 1155 residents (71%) who provided complete data, 67% (n = 775) stated satisfaction with their continuity experience. The following characteristics (adjusted odds ratio [OR] and 95% confidence interval [CI]) were found to be most significant: preceptor as good role model, OR = 7.28 ( CI = 4.2, 12.5); appropriate amount of teaching, OR = 3.25 (CI = 2.1, 5.1); involvement during hospitalization, OR = 2.61 (CI = 1.3, 5.2); exposure to practice management, OR = 2.39 (CI = 1.5, 3.8); good balance of general pediatric patients, OR = 2.34 (CI = 1.5, 3.6); resident as patient advocate, OR = 1.74 (CI = 1.2, 2.4); and appropriate amount of nursing support, OR = 1.65 (CI = 1.1, 2.6). Future career choice, type of continuity site, and level of training were not found to be statistically significant., Conclusions: Pediatric resident satisfaction was significantly associated with 7 variables, the most important of which were the ability of the preceptor to serve as a role model and teacher. The type of continuity site was not significant. Residency programs may use these data to develop interventions to enhance resident satisfaction, which may lead to enhanced work performance and patient satisfaction.

The American Academy of Pediatrics' statement on palliative care for children emphasizes the need to identify and address barriers to effective palliative care. The authors describe a seminar for pediatrics residents on death and bereavement that addresses these issues. The day-long seminar for second-year residents has been offered annually since 1996. The seminar is conducted offsite so that residents can concentrate without distraction. The seminar uses an intense and comprehensive multidisciplinary approach to accomplish seven goals: (1) to have residents gain expertise in talking with parents about the death of their child; (2) to have residents practice and experience how it feels to be in emotionally charged situations; (3) to train residents to become more knowledgeable concerning autopsy and organ donation, and to learn strategies to approach these topics with a child's parents; (4) to have residents gain an understanding of the role of the ministry for families who are grieving; (5) to provide residents with multidisciplinary strategies to support a family after a child has died; (6) to help residents gain insight into the impact of death on their own emotions and the importance of addressing their own emotions to cope with stress and potential burnout; (7) and to help residents better understand the parents' perceptions of the medical care providers and their dying child. In their evaluation comments, the residents report value from a seminar designed to help them address issues of patient death and bereavement. This type of educational intervention should be considered for the curriculum by other residency programs.

The use of standardized patients (SPs) is an emerging strategy in palliative care education. We have used this strategy to provide pediatric residents with a structured educational experience focused on effectively communicating bad news and concurrently understanding the emotions that they and the parents may experience. This article describes the importance of and process for realistic SP case development explicitly designed to address predetermined educational goals and objectives. Topics addressed include the types of potential SPs that can be utilized, their potential strengths and weaknesses, training issues which include giving constructive feedback, implementation strategies for the case scenarios and evaluation strategies.

Objective: To present the results of an intervention trial to enhance parents' home-safety practices through pediatric safety counseling, home visits, and an on-site children's safety center where parents receive personalized education and can purchase reduced-cost products., Design: Pediatricians were randomized to a standard- or an enhanced-intervention group. Parents of their patients were enrolled when the patient was 6 months or younger and observed until 12 to 18 months of age., Setting: A hospital-based pediatric resident continuity clinic that serves families living in low-income, inner-city neighborhoods., Participants: First- and second-year pediatric residents and their patient-parent dyads., Interventions: Parents in the standard-intervention group received safety counseling and referral to the children's safety center from their pediatrician. Parents in the enhanced-intervention group received the standard services plus a home-safety visit by a community health worker., Outcomes: Home observers assessed the following safety practices: reduction of hot-water temperature, poison storage, and presence of smoke alarms, safety gates for stairs, and ipecac syrup., Results: The prevalence of safety practices ranged from 11% of parents who stored poisons safely to 82% who had a working smoke alarm. No significant differences in safety practices were found between study groups. However, families who visited the children's safety center compared with those who did not had a significantly greater number of safety practices (34% vs 17% had > or 3)., Conclusions: Home visiting was not effective in improving parents' safety practices. Counseling coupled with convenient access to reduced-cost products appears to be an effective strategy for promoting children's home safety.

Objectives: To survey a large group of residents from different institutions to delineate whether there are significant perceptive differences pertaining to the clinical and educational strengths and weaknesses of their continuity experiences by the 3 types of continuity sites., Background: The residency review committee requires a 3-year continuity experience for pediatric residents. Residents receive this experience at a variety of practice sites: hospital-based sites (HBS), community health centers (CHC), and private practices (PP)/health maintenance organizations (HMOs)., Design/methods: Continuity clinic directors who attended the Ambulatory Pediatric Association Continuity Clinic Special Interest Group at the 1999 annual Pediatric Academic Societies Meeting were invited to participate in this cross-sectional study. Thirty-six agreed and distributed a 60-item questionnaire to their residents at the end of the academic year. The questionnaire addressed quality and quantity of the educational and patient care experiences, overall satisfaction, and future career plans., Results: Of the 1167 categorical residents (71%) who returned the questionnaire, 28% were postgraduate level (PL)-1s, 34% were PL-2s, and 37% were PL-3s. Ninety-four percent of the 36 programs had residents in HBS (n = 807 residents), 58% in CHC (n = 106), and 69% in PP/HMO (n = 254). Compared with other groups, residents in HBS were more likely to report having seen patients more than once, being involved during patients' hospitalizations, taking phone calls from patients, and perceiving that the parents identified them as the primary care provider. HBS and CHC residents felt more autonomous and were more likely to believe that they were advocates for their patients, compared with PP/HMO residents. The number of patients seen per session was greater in PP/HMO, whereas residents in PP/HMO were more likely to perceive that they had received the right amount of exposure to practice management and billing issues and the appropriate amount of nursing and office support. Although numbers of newborn visits were reported as adequate across sites, residents in HBS and CHC believed that they did not see enough adolescents. The majority of residents at all sites agreed that their preceptor was a good role model, was available for questions, and delivered the appropriate amount of teaching and feedback. Approximately two thirds of residents from all sites were satisfied with their experience and believed that it was preparing them for their future career., Conclusions: All 3 types of continuity sites have both strengths and weaknesses. No single type of continuity site met all expectations for clinical care or training. Most residents at all 3 types of sites reported overall satisfaction and believed that their continuity experience helped to prepare them for future career goals. The residency review committee, in collaboration with pediatric continuity educators, needs to prioritize what constitutes the essential experiences in resident continuity practices and to reemphasize that the ongoing relationship is an important component of the continuity experience.

Objective: To develop and evaluate an injury prevention anticipatory guidance training program for pediatric residents., Design: Thirty-one residents were randomly assigned to an intervention or control group. Both groups attended a 1-hour seminar about injury prevention and the American Academy of Pediatrics TIPP (The Injury Prevention Program) materials. The intervention group also received 5 hours of experiential instruction on injury prevention content and counseling skills (SAFE Counseling Framework). Families with infants from birth to age 6 months were enrolled in the study (N = 196); they were followed up until the child was aged 12 to 18 months. Data were collected by means of baseline and follow-up interviews, audiotapes of medical visits, parent exit surveys, and home observations., Setting: A hospital-based continuity clinic that serves families living in low-income, inner-city neighborhoods., Outcomes: Physician counseling and parent satisfaction, knowledge, beliefs, and behaviors., Results: Parents seen by physicians in the intervention group received significantly more injury prevention counseling for 5 of the 6 safety practices, and they were significantly more satisfied with the help their physicians provided on safety topics. They were no less satisfied with their physicians' counseling on other anticipatory guidance topics. Parents' knowledge, beliefs, and home safety behaviors did not differ between the 2 groups., Conclusions: The frequency and impact of pediatric counseling can be enhanced by experiential training that targets specific injury hazards. Because low-income families face many barriers to carrying out the recommended safety practices, supplemental strategies are needed to ensure safer homes.

Background: When residents complete their pediatric training, patients from their continuity practices in academic settings must be reassigned to either a known resident of their selection or an unknown, incoming intern., Objectives: To determine what antecedent factors were associated with patient reassignment to a known resident of their selection, whether such reassignment was associated with increased health care use, and what factors were associated with continuity with the new resident provider., Design: Nonconcurrent cohort study., Setting: Hospital-based resident continuity clinic practice., Participants: Patients of residents graduating in June 1993., Results: Seven hundred fifty-eight patients of 18 graduating residents required reassignment: 86 patients (11%) were assigned to a resident colleague, defined as the study group. From the remaining 673 patients who were assigned to unknown, incoming interns, a control group was randomly selected (n = 160), with approximately 2 patients for each study group subject. Looking at antecedent factors, study group patients were more likely to have chronic medical problems and to have seen their graduating resident more often and more recently. Univariate analysis explored the consequent factors of health care use and found that study group patients were more likely to return for a visit and to make more visits with the new provider. Multiple logistic regression analysis demonstrated that being in the study group, younger age at the original encounter with the graduating resident, and a shorter interval since the last visit with the graduating resident were all associated with increased continuity with the new resident., Conclusions: The method of patient reassignment at a continuity clinic was associated with chronic disease of the patient and regularity of visits with the graduating resident. Increased continuity with a new resident, as determined by multivariate analysis, was associated with the method of reassignment, a younger age at first encounter with the graduating resident, and a shorter interval since the last visit with the graduating resident. This study has implications at ambulatory sites where transitions occur.