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PROBLEM The U.S. primary care workforce remains inadequate to meet the health needs of the U.S. population. Effective programs are needed to provide workforce development for rural and other underserved areas. APPROACH At the University of North Carolina (UNC) School of Medicine (SOM), between November 2014 and July 2015, the authors developed and implemented the Fully Integrated Readiness for Service Training (FIRST) Program, an accelerated curriculum focused on rural and underserved care that links 3 years of medical school with a conditional acceptance into UNC's 3-year family medicine residency, followed by 3 years of practice support post-graduation. Students are recruited to the FIRST Program during the fall of their first year of medical school. The FIRST Program promotes close faculty mentorship and familiarity with the health care system, includes a longitudinal quality improvement project with an assigned patient panel, includes early integration into the clinic, and fosters a close cohort of fellow students. OUTCOMES As of March 2020, the FIRST Program had successfully recruited 5 classes of medical students, and 3 of those classes had matched into residency. In total, as of March 2020, 18 students had participated in the FIRST Program. NEXT STEPS The FIRST Program will be expanded to additional clinical sites across North Carolina and to specialties beyond family medicine, including pediatrics, general surgery, and psychiatry.

In the 10 years since the Lancet Commission on Education of Health Professionals for the 21st Century suggested the changes necessary to transform medical education, the United States remains plagued by shortages of physicians and maldistribution of the physician workforce. Minoritized and rural communities usually suffer the most, with widely documented health disparities across the United States by race, ethnicity, gender identity, education, and zip code. Medical schools can respond by recruiting students more likely to practice in these settings and training them to address the community needs. In 2013, the American Medical Association launched an initiative to trigger transformation in medical education and formed a consortium of schools representing a diversity of U.S. institutions. Consortium member schools highlighted in this article share lessons learned in their efforts to strengthen social accountability and develop needed sectors of the physician workforce. Development of the physician workforce involves recruiting and widening pathways of entry for diverse groups, providing training settings and competencies aligned with community needs, and explicit programming in retention, inclusion and well-being to mitigate against workforce losses.

In the last two decades, prompted by the anticipated arrival of the 21st Century and on the centenary of the publication of the Flexner Report, many in medical education called for change to address the expanding chasm between the requirements of the health care system and the educational systems producing the health care workforce. Calls were uniform. Curricular content was missing. There was a mismatch in where people trained and where they were needed to practice, legacy approaches to pedagogical methods that needed to be challenged, an imbalance in diversity of trainees, and a lack of research on educational outcomes, resulting in a workforce that was described as ill-equipped to provide health care in the current and future environment. The Lancet Commission on Education of Health Professionals for the 21st Century published a widely acclaimed report in 2010 that called for a complete and authoritative re-examination of health professional education. This paper describes the innovations of the American Medical Association Accelerating Change in Medical Education Consortium schools as they relate to the recommendations of the Lancet Commission. We outline the successes, challenges, and lessons learned in working to deeply reform medical education.

The transition from medical school to residency in the United States consumes large amounts of time for students and educators in undergraduate and graduate medical education (UME, GME), and it is costly for both students and institutions. Attempts to improve the residency application and Match processes have been insufficient to counteract the very large number of applications to programs. To address these challenges, the Coalition for Physician Accountability (CoPA) charged the Undergraduate to Graduate Review Committee (UGRC) with crafting recommendations to improve the system for the UME-GME transition. To guide this work, the UGRC defined and sought stakeholder input on a "blue-skies" ideal state of this transition. The ideal state views the transition as a system to support a continuum of professional development and learning, thus serving learners, educators, and the public, and engendering trust among them. It also supports the well-being of learners and educators, promotes diversity, and minimizes bias. This manuscript uses polarity thinking to analyze 3 persistent key tensions in the system that require ongoing management. First, the formative purpose of assessment for learning and growth is at odds with the use of assessment data for ranking and sorting candidates. Second, the function of residents as learners can conflict with their role as workers contributing service to health care systems. Third, the current residency Match process can position the desire for individual choice-among students and their programs-against the workforce needs of the profession and the public. This Scholarly Perspective presents strategies to balance the upsides and downsides inherent to these tensions. By articulating the ideal state of the UME-GME transition and anticipating tensions, educators and educational organizations can be better positioned to implement UGRC recommendations to improve the transition system.

Phenomenon: While part-time clinical work options are popular for physicians, part-time residency training is uncommon. Some residency training programs have offered trainees the option to complete their training on a modified schedule in the past. These part-time tracks often involved extending training in order to complete equivalent hours on a part-time basis. Having experience with trainees in such programs, we sought to explore the impact of completing residency training part-time on the professional and private lives of physicians.

Pediatric primary health care (PPHC) is of principal importance to the health and development of all children, helping them reach their true potential. Pediatricians, as the clinicians most intensively trained and experienced in child health, are the natural leaders of PPHC within the context of the medical home. Given the rapidly evolving models of pediatric health care delivery, including the explosion of telehealth in the wake of the COVID-19 pandemic, pediatricians, together with their representative national organizations such as the American Academy of Pediatrics (AAP), are the most capable clinicians to guide policy innovations on both the local and national stage.

Many challenges could occur that result in the need to handle an increase in the number of medical student clinical placements, such as curricular transformations or viral pandemics, such as COVID 19. Here, we describe four different institutions’ approaches to addressing the impact of curricular transformation on clerkships using an implementation science lens. Specifically, we explore four different approaches to managing the ‘bulge’ as classes overlap in clerkships Curriculum leaders at four medical schools report on managing the bulge of core clinical placements resulting from reducing the duration of the foundational sciences curriculum and calendar shifts for the respective clerkship curriculum. These changes, which occurred between 2014 and 2018, led to more students being enrolled in core clinical rotations at the same time than occurred previously. Schools provided respective metrics used to evaluate the effectiveness of their bulge management technique. These data typically included number of students affected in each phase of their curricular transformation, performance on standardized examinations, and student and faculty feedback. Not all data were available from all schools, as some schools are still working through their ‘bulge’ or are affected by COVID-19. There is much to be learned about managing curricular transformations. Working on such endeavors in a learning collaborative such as the AMA Accelerating Change in Medical Education Initiative provided support and insights about how to survive, thrive and identifying lessons learned during curricular transformation.

Phenomenon: Physicians are under intense pressure to improve clinical productivity. High clinical load, limited availability, and decreased clinical efficiency are well-documented barriers to precepting medical students and threaten clinical productivity. In an era of increasing medical student enrollment, these barriers have already led to a decreased availability of clinical teachers and training sites across the United States. Improved preceptor satisfaction could have a great impact on recruitment and retention of medical student preceptors and is likely linked to changes in productivity. Curriculum structure could impact both preceptor productivity and satisfaction. Comparing productivity and satisfaction of physician preceptors teaching in longitudinal integrated clerkships (LICs) to those teaching in traditional block rotations (TBRs), or in both settings (LIC-TBR), could lead to a better understanding of the impact of curriculum structure on preceptor productivity and satisfaction. Approach: Data were collected through a quantitative cross-sectional survey of outpatient physician preceptors in North Carolina in 2017. Preceptor satisfaction and student influence on productivity-related aspects of practice were analyzed with bivariate chi-square statistics and multivariate logistic regression. Findings: Analyses included 338 physician preceptors: 79 LIC (23%), 50 LIC-TBR (15%), and 209 TBR preceptors (62%). LIC preceptors were more likely to indicate being "very satisfied" with precepting than either their LIC-TBR or TBR counterparts. There were no differences in perceived productivity-related aspects of practice across the different curricula, such as patient flow, income, or physician working hours. Logistic regressions controlling for potential confounding variables suggested that those teaching in LICs were almost 3 times more likely to be "very satisfied" relative to those teaching in LIC-TBR and TBR settings and that the negative influence of students on patient flow and physician working hours had an adverse effect on preceptor satisfaction. Insights: Preceptor satisfaction was high overall, though satisfaction was significantly higher among preceptors who teach in LICs. The perceived impact of students on clinical productivity was stable across the different curricula. In an era of increasing need for physician preceptors, the higher satisfaction of those who teach in LICs should be considered in curricular design and for preceptor recruitment and retention.

Background The number of learners in clinical settings is increasing as health professions schools increase enrollment in order to develop the future workforce. Too many learners in clinics and hospital wards could create overcrowded conditions and diminish patient and learner experiences. Based on data gathered from a literature review, we identified challenges and solutions to address the increasing numbers of learners in clinical settings. Results Health care provider workload, physical environment and clinical culture were challenges identified from the literature review. These identified constraints were corroborated by learner and expert reflections on their experiences. Conclusion As the need for more health care providers increases, the number of learners in clinical settings poses a challenge. Innovative models to deliver care, an increasing role for learners, strategic patient scheduling and redesigning workspaces may mitigate problems. The recommendations suggested from this review may offer solutions that individual preceptors and organisations can implement.

Health outcomes in North Carolina are less than optimal. To drive improvement, we must prepare a health care workforce adequate in number, optimally distributed geographically, skilled with forward-looking expertise, and empowered to practice in interprofessional teams at the highest extent of their license. This issue of the North Carolina Medical Journal outlines how North Carolina's health profession education institutions are working to open new programs and innovate curricula to produce the workforce that our state needs.

Within the Match process, current residency interview practices are inefficient for both applicants and programs. Problems include disorganized interview offers and scheduling, excessive numbers of applicant interviews, unclear postinterview communication policies, and the significant expenses entailed. To address these issues, the authors propose applying a quality improvement approach to create a high-value interview process that would decrease investments of time, money, and energy and improve the quality of the Match experience for both applicants and programs. They propose establishing an interview offer week to streamline and systematize the interview offer and scheduling process; placing an evidence-based cap on the number of interviews that applicants are allowed to schedule; and enforcing a moratorium on postinterview communication that would apply to both applicants and programs. Implementing these proposals would decrease expenses, improve the efficiency of this process for all involved, and demonstrate that quality improvement methods used to improve patient care can also be applied to improving medical student and physician experiences.

Background Over the past 40 years, the physician supply of North Carolina (NC) grew faster than the total population. However, the distribution of physicians between urban and rural areas increased, with many more physicians in urban areas. In rural counties, access to care and health disparities remain concerning. As a result, the medical school implemented pipeline programs to recruit more rural students. This study investigates the results of these recruitment efforts. Methodology Descriptive analyses were conducted to compare the number and percentage of rural and urban students from NC who applied, interviewed, and were accepted to the University of North Carolina's School of Medicine (UNC SOM). The likely pool of rural applicants was based on the number of college-educated 18-34-year-olds by county. Results Roughly 10.9% of NC's population of college-educated 18-34-year-olds live in rural counties. Between 2017 and 2019, 9.3% (n = 225) of UNC SOM applicants were from a rural county. An increase of just 14 additional rural applicants annually would bring the proportion of rural UNC SOM applicants in alignment with the potential applicant pool in rural NC counties. Conclusions Our model of analysis successfully calculated the impact of recruitment efforts to achieve proportional parity in the medical school class with the rural population of the state. Addressing rural physician workforce needs will require multiple strategies that affect different parts of the medical education and healthcare systems, including boosting college completion rates in rural areas. This model of analysis can also be applied to other pipeline programs to document the success of the recruitment efforts.

Interprofessional education (IPE) brings educators and learners from two or more health professions together in a collaborative learning environment, specifically assuring that learners function as a team to provide patient-centered care, with each team member contributing a unique perspective. The Liaison Committee on Medical Education, the Accreditation Council for Graduate Medical Education, and the American Board of Radiology have endorsed interprofessional and team communication as essential core competencies. Radiology educators must understand, include, and optimize IPE in their pedagogy; as a specialty, radiology must innovate more interprofessional experiences for medical students, residents and other allied health professions.

Background Over the past 40 years, North Carolina’s physician supply grew faster than the total population, but the maldistribution of physicians between urban and rural areas increased. In rural counties, access-to-care and health disparities remain concerning. Method Descriptive analyses were conducted to compare the number and percentage of rural and urban students from North Carolina (NC) who applied, interviewed, and were accepted to the University of North Carolina’s School of Medicine. The likely pool of rural applicants was based on the number of college-educated 18-34-year-olds by county. Results Roughly 10.9% of NC’s population of college-educated 18-34-year-olds live in rural counties. Between 2017–2019, 9.3% (n = 225) of UNC SOM applicants were from a rural county. Conclusion An increase of just 14 additional rural applicants annually would bring the proportion of rural UNC SOM applicants in alignment with the potential applicant pool in rural NC counties. Addressing NC’s rural physician workforce needs will require multiple strategies that affect different parts of the medical education and health care systems, including boosting college completion rates in rural areas.

Background: There is an ongoing call for leadership development in academic health care and medical students desire more training in this area. Although many schools offer combined MD/MBA programs or leadership training in targeted areas, these programs do not often align with medical school leadership competencies and are limited in reaching a large number of students. Methods: The Leadership Initiative (LI) was a program created by a partnership between a School of Medicine (SOM) and Business School with a learning model that emphasized the progression from principles to practice, and the competencies of self-awareness, communication, and collaboration/teamwork. Through offerings across a medical school curriculum, the LI introduced leadership principles and provided an opportunity to apply them in an interactive activity or simulation. We utilized the existing SOM evaluation platform to collect data on program outcomes that included satisfaction, fidelity to the learning model, and impact. Results: From 2017 to 2020, over 70% of first-year medical students participated in LI course offerings while a smaller percentage of fourth-year students engaged in the curriculum. Most students had no prior awareness of LI course material and were equivocal about their ability to apply lessons learned to their medical school experience. Students reported that the LI offerings provided opportunities to practice the skills and competencies of self-awareness, communication, and collaboration/teamwork. Discussion: Adding new activities to an already crowded medical curriculum was the greatest logistical challenge. The LI was successful in introducing leadership principles but faced obstacles in having participants apply and practice these principles. Most students reported that the LI offerings were aligned with the foundational competencies.

Background: Given increasing class sizes and desires to keep costs down, many medical schools are developing regional clinical campuses. We found our regional campus system to be very successful in allowing class size expansion, inspiring a workforce for the state, and concurrently allowing our students to individualize their experience. We desire to articulate our experience, with a review of the relevant evidence, with the goal of assisting other medical schools in their efforts to develop regional medical campuses. Methods: We conducted a narrative literature review to identify considerations for developing regional campuses, taking into consideration our experiences in the process. A medical librarian undertook a literature search for the purposes of this narrative review. Results: Of the 61 articles identified, 14 were included for full-text review. Five facets on branch campus development were identified: relationships, infrastructure, curriculum, recruitment, and accreditation. Within each of these facets we provide further details based on findings from the literature complemented by our experience. Conclusions: Launching a regional campus requires building relationships with clinical partners, ensuring an infrastructure that supports student need and accreditation, comparable curriculum with the same objectives and assessment measures, and aspects of the experience that inspire a student desire to learn in that setting. We share our experience in building successful branch campuses, which have added significantly to our large public school of medicine and its service to our state.

The purpose of this paper is to describe the impact of an interprofessional (IP) population health course and accompanying clinical immersion experience. Outcomes related to IP learning, team-based communication, and clinical practice outcomes are discussed. Graduate students in medicine, nursing, pharmacy, public health and social work participated in a blended learning didactic course followed by a clinical immersion experience in primacy care. Students worked in interprofessional teams to complete a needs assessment, and design and implement quality improvement projects with primary care partners. Student assessment included evaluation of teamwork and collaboration and reflective practice. Overall impact of the course was measured by course outcomes, the impact of the quality improvement project at the practice site, and clinical satisfaction working with the student teams. This model demonstrates a clear need to continue to develop educational curricula aimed at building collaborations between health professionals and communities to provide care to populations that is cost effective and quality and outcomes based.

Problem: A large state university in the southeastern United States and state Area Health Education Centers (AHEC) collaborated to establish branch campuses to increase clinical capacity for medica...

Medical students are potential resources for ambulatory primary care practices if learning goals can align with clinical needs. The authors introduced a quality improvement (QI) curriculum in the ambulatory clinical rotation that matched student learning expectations with practice needs. In 2016-2017, 128 students were assigned to academic, university affiliated, community health, and private practices. Student project measures were matched with appropriate outcome measures on monthly practice dashboards. Binomial mixed effects models were used to model QI measures. For university collaborative practices with student involvement, the estimated odds of a patient being screened for breast cancer in March 2017 was approximately 2 times greater than in 2016. This odds ratio was 36.2% greater than the comparable odds ratio for collaborative practices without student involvement (95% confidence interval = 22.7% to 51.2% greater). When student curriculum and assignments align with practice needs, practice metrics improve and students contribute to improvements in real-world settings.

To measure community-based preceptors' overall satisfaction and motivations, the influence of students on preceptors' practices, and compare with 2005 and 2011 studies.North Carolina primary care preceptors across disciplines (physicians, pharmacists, advanced practice nurses, physician assistants) received survey invitations via e-mail, fax, postcard, and/or full paper survey. Most questions in 2017 were the same as questions used in prior years, including satisfaction with precepting, likelihood to continue precepting, perceived influence of teaching students in their practice, and incentives for precepting. A brief survey or phone interview was conducted with 62 nonresponders. Chi-square tests were used to examine differences across discipline groups and to compare group responses over time.Of the 2,786 preceptors contacted, 893 (32.1%) completed questionnaires. Satisfaction (816/890; 91.7%) and likelihood of continuing to precept (778/890; 87.4%) remained unchanged from 2005 and 2011. However, more preceptors reported a negative influence for patient flow (422/888; 47.5%) in 2017 than in 2011 (452/1,266; 35.7%) and 2005 (496/1,379; 36.0%) (P.0001), and work hours (392/889; 44.1%) in 2017 than in 2011 (416/1,268; 32.8%) and 2005 (463/1,392; 33.3%) (P.0001). Importance of receiving payment for teaching increased from 32.2% (371/1,152) in 2011 to 46.4% (366/789) in 2017 (P.0001).This 2017 survey suggests preceptor satisfaction and likelihood to continue precepting have remained unchanged from prior years. However, increased reporting of negative influence of students on practice and growing value of receiving payment highlight growing concerns about preceptors' time and finances and present a call to action.

The practice of medicine occurs primarily in the ambulatory environment where providers have many competing demands, including health record documentation and patient volume expectations. Subsequently, medical student education has not been a priority for providers, health systems, or community practices. Yet, accrediting and professional organizations, such as the Association of American Medical Colleges, American Academy of Family Physicians, Ambulatory Pediatric Association, Society of General Internal Medicine, and the Liaison Committee on Medical Education, recommend education in ambulatory settings.

BACKGROUND: Recruiting and retaining community-based pediatricians for teaching medical students has been explored through the lens of preceptors and educational leaders. The purpose of this study was to explore the perspective of pediatric department chairs, a key stakeholder group charged with maintaining teaching capacity among a faculty. METHODS: In 2015, members of the Association of Medical School Pediatric Department Chairs and Council on Medical Student Education in Pediatrics joint task force disseminated a 20-item survey to pediatric department chairs in the United States and Canada. Topics included demographics, incentives offered to community pediatricians, and the perceived value and feasibility of such incentives. Data were analyzed using descriptive statistics and χ2 to compare categorical variables. RESULTS: Pediatric department chairs from 92 of 145 (63% response rate) medical schools returned the survey. Sixty-seven percent reported difficulty recruiting or retaining preceptors, and 51% reported high-reliance on preceptors for the ambulatory portion of the pediatrics clerkship. Almost all (92%) cited competition from other programs for the services of community preceptors. The provision of incentives was correlated with perceived feasibility (R2 = 0.65) but not their perceived value (R2 = 0.12). Few (21%) chairs reported providing financial compensation to preceptors. The provision of compensation was not related to reliance but did vary significantly by geographical region (P < .001). CONCLUSIONS: Pediatric departments rely heavily on community-based pediatricians but face competition from internal and external training programs. The perspective of department chairs is valuable in weighing interventions to facilitate continued recruitment and retention of community preceptors.

As U.S. medical educators know, it has been exceedingly difficult over the past decade to train medical students to document in the electronic health record (EHR) yet remain compliant with Centers for Medicare and Medicaid Services (CMS) guidelines. Indeed, some institutions have interpreted the guidelines to prohibit all medical student documentation in the EHR. This has been particularly challenging since the Association of American Medical Colleges has recommended that all medical school graduates be entrusted with 13 specific professional activities, two of which directly require student use of the EHR. Furthermore, critical efforts by clerkship directors to recruit community physicians as preceptors of medical students have been significantly hampered by the medical students' inability to document encounters. Therefore, the CMS policy transmittal Pub 100-04 Medicare Claims Processing Manual, released on February 2, 2018, which now explicitly allows appropriately supervised student documentation to be submitted for billing, is a welcome policy change. U.S. medical educators need to seize this opportunity, encourage their health systems to revise their internal precepting practices, and widely advertise to community preceptors that students can now add value in the clinical setting by assisting with documentation in the EHR.

Pulmonary alveolar proteinosis (PAP) is an under-reported and under-diagnosed condition, with a high percentage of cases found on autopsy or late stage disease. The etiology of PAP includes genetic, primary (anti-granulocyte-macrophage colony-stimulating factor antibodies) and secondary (oncologic, rheumatologic, infectious, chemical and immunologic) causes. Here, we present the first reported pediatric case of endogenous lipoid pneumonia and non-specific interstitial pneumonitis preceding the development of PAP.

Background Fluid and electrolyte therapy is an important component in the care of the hospitalized child. Previous pediatric guidelines have followed the Holliday-Segar method of calculating and delivering maintenance IV fluids, using hypotonic fluids in maintenance therapy. However, research demonstrates that hypotonic fluids can lead to iatrogenic hyponatremia and that isotonic fluid is a safer alternative. Objective To provide the ideal approach to intravenous (IV) fluid use in the hospitalized child and determine the safety and effectiveness of isotonic maintenance fluid therapy. Method We searched PubMed, Medline, Cochrane Controlled Clinical Trials Register, and Clinical- Trials.gov for potentially relevant publications from the last five years (2011 to July 2016) with an emphasis on randomized control trials (RCTs) and contemporary evidence-based treatment guidelines. Results For maintenance IV fluids, isotonic solutions decreased risk of hyponatremia and did not increase risk of hypernatremia. Some studies demonstrate increased ADH production or hyponatremia on admission for hospitalized patients. Conclusion While there is no ideal composition of maintenance IV fluids for all children, isotonic fluids are safer than hypotonic fluids for use as maintenance in hospitalized children due to the decreased risk of iatrogenic hyponatremia. This article also provides recommendations for other types of fluid management in the inpatient pediatric population.

Case: A 9-month-old girl is brought by her mother because she is having difficulty breathing. Her mother states that the child is somewhat sleepy this morning after coughing all day yesterday and last night. She will no longer play or take a bottle and has not had a wet diaper this morning. You see a sleepy baby with obvious tachypnea, suprasternal and subcostal retractions, and nasal flaring. Difficulty breathing is a frequent complaint in the office setting with a broad differential and a wide range of severity. When addressing respiratory distress in children, it is important to define the location of pathology along the respiratory tract. The most common complaint involves congestion of the nose and upper respiratory tract. There is no effective means to address this complaint in babies other than mechanical suctioning of the upper airway after the application of saline drops. Reassurance and education is the role of the provider in this setting. When the pathology is found lower in the respiratory tract it can be more concerning.

The Pediatrics Primary Care Residency Program at the University of North Carolina School of Medicine will graduate its first class in 2014. Funded by the Health Resources and Services Administration through the Patient Protection and Affordable Care Act, this innovative program has a unique curriculum that offers several benefits, but sustainability of the program remains a challenge.

Pulmonary alveolar proteinosis (PAP) is an under-reported and under-diagnosed condition, with a high percentage of cases found on autopsy or late stage disease. The etiology of PAP includes genetic, primary (anti-granulocyte-macrophage colony-stimulating factor antibodies) and secondary (oncologic, rheumatologic, infectious, chemical and immunologic) causes. Here, we present the first reported pediatric case of endogenous lipoid pneumonia and non-specific interstitial pneumonitis preceding the development of PAP.

BACKGROUND: Resident physicians and patient families have not traditionally been involved in setting expectations for professional behavior by physicians. OBJECTIVE: To elicit and compare prioritized lists of attributes and behaviors of physician professionalism formulated by residents and patient families. METHODS/DESIGN: We used qualitative and quantitative methods to identify and compare prioritized perceptions of important attributes and behaviors of physician professionalism among residents and families of patients. We conducted 3 resident focus groups, 1 for residents in each resident-training year (postgraduate years 1, 2, and 3), and elicited attributes and behaviors the residents associated with physician professionalism by using free-listing and nominal-group techniques. Family perspectives of the attributes/behaviors of physician professionalism were elicited by using semistructured interviews of consecutive families with a child who was admitted to the hospital. All results were transcribed, and common themes were identified. RESULTS: Fifty-eight residents (78% of the total in the program) and 40 families participated. Similar themes arose from all 3 resident focus groups, which prioritized tactfulness, support of team members, respectfulness, good communication, and humanism. Residents also provided specific behavioral strategies to put these attributes into practice, such as avoiding jokes about patients and using patient names when addressing and discussing them. Patient families most frequently cited good communication, caring, knowledge, skill, honesty, and attitude. Communication and humanism were aspects consistently endorsed by both residents and patient families. CONCLUSIONS: There was important overlap in the attributes of professionalism generated and prioritized by resident physicians and patient families, although only residents identified ways that health care providers should interact with each other. This novel approach to identifying professionalism attributes provides opportunities for curriculum improvement.

Objective To perform a systematic review and meta-analysis to determine whether taking antiemetic drugs reduces vomiting and decreases the need for further intervention in children with gastroenteritis without causing significant adverse effects. Data Sources Computerized databases, reference lists, and expert recommendations. Study Selection Prospective controlled trials evaluating medication use in children with vomiting from gastroenteritis. Intervention Antiemetic drug therapy. Main Outcome Measures Emesis cessation, use of intravenous fluid for rehydration, hospital admission, return to care, and medication adverse effects. Results The 11 articles that met the inclusion criteria evaluated various antiemetic agents: ondansetron (n = 6), domperidone (n = 2), trimethobenzamide (n = 2), pyrilamine-pentobarbital (n = 2), metoclopramide (n = 2), dexamethasone (n = 1), and promethazine (n = 1). Meta-analysis of 6 randomized, double-masked, placebo-controlled trials of ondansetron demonstrated decreased risk of further vomiting (5 studies; relative risk [RR], 0.45; 95% confidence interval [CI], 0.33-0.62; number needed to treat [NNT] = 5), reduced need for intravenous fluid (4 studies; RR, 0.41; 95% CI, 0.28-0.62; NNT = 5), and decreased risk of immediate hospital admission (5 studies; RR, 0.52; 95% CI, 0.27-0.95; NNT = 14). Diarrheal episodes increased in ondansetron-treated patients in 3 studies. Ondansetron use did not significantly affect return to care (5 studies; RR, 1.34; 95% CI, 0.77-2.35). Conclusions Ondansetron therapy decreases the risk of persistent vomiting, the use of intravenous fluid, and hospital admissions in children with vomiting due to gastroenteritis. Future treatment guidelines should incorporate ondansetron therapy for select children with gastroenteritis.

ContextEvaluation of abdominal pain in children can be difficult. Rapid, accurate diagnosis of appendicitis in children reduces the morbidity of this common cause of pediatric abdominal pain. Clinical evaluation may help identify (1) which children with abdominal pain and a likely diagnosis of appendicitis should undergo immediate surgical consultation for potential appendectomy and (2) which children with equivocal presentations of appendicitis should undergo further diagnostic evaluation.ObjectiveTo systematically assess the precision and accuracy of symptoms, signs, and basic laboratory test results for evaluating children with possible appendicitis.Data SourcesWe searched English-language articles in MEDLINE (January 1966–March 2007) and the Cochrane Database, as well as physical examination textbooks and bibliographies of retrieved articles, yielding 2521 potentially relevant articles.Study SelectionStudies were included if they (1) provided primary data on children aged 18 years or younger in whom the diagnosis of appendicitis was considered; (2) presented medical history data, physical examination findings, or basic laboratory data; and (3) confirmed or excluded appendicitis by surgical pathologic findings, clinical observation, or follow-up. Of 256 full-text articles examined, 42 met inclusion criteria.Data ExtractionTwenty-five of 42 studies were assigned a quality level of 3 or better. Data from these studies were independently extracted by 2 reviewers.ResultsIn children with abdominal pain, fever was the single most useful sign associated with appendicitis; a fever increases the likelihood of appendicitis (likelihood ratio [LR], 3.4; 95% confidence interval [CI], 2.4-4.8) and conversely, its absence decreases the chance of appendicitis (LR, 0.32; 95% CI, 0.16-0.64). In select groups of children, in whom the diagnosis of appendicitis is suspected and evaluation undertaken, rebound tenderness triples the odds of appendicitis (summary LR, 3.0; 95% CI, 2.3-3.9), while its absence reduces the likelihood (summary LR, 0.28; 95% CI, 0.14-0.55). Midabdominal pain migrating to the right lower quadrant (LR range, 1.9-3.1) increases the risk of appendicitis more than right lower quadrant pain itself (summary LR, 1.2; 95% CI, 1.0-1.5). A white blood cell count of less than 10 000/μL decreases the likelihood of appendicitis (summary LR, 0.22; 95% CI, 0.17-0.30), as does an absolute neutrophil count of 6750/μL or lower (LR, 0.06; 95% CI, 0.03-0.16). Symptoms and signs are most useful in combination, particularly for identifying children who do not require further evaluation or intervention.ConclusionsAlthough the clinical examination does not establish a diagnosis of appendicitis with certainty, it is useful in determining which children with abdominal pain warrant immediate surgical evaluation for consideration of appendectomy and which children may warrant further diagnostic evaluation. More child-specific, age-stratified data are needed to improve the utility of the clinical examination for diagnosing appendicitis in children.

OBJECTIVE: To characterize the clinical presentation and clinical course of shaken baby syndrome (SBS) with normal cranial computerized tomography (CT) on admission and to suggest further diagnostic procedures in such circumstances. METHODS: Using a worldwide listserv designed to facilitate discussion in the field of child abuse and neglect, we solicited case information for children hospitalized in different medical centers, who were diagnosed with SBS and had a normal CT scan on admission. RESULTS: Nine cases were identified. While all children had an abnormal neurologic examination on admission, eight had a normal CT, and one had "widening of cranial sutures." In four cases, subdural hemorrhage was diagnosed on magnetic resonance imaging (MRI) 3 to 7 days after admission. Five children had bone fractures. The neurological outcome was normal in four of nine cases. Five children had long-term neurologic damage. The diagnosis of SBS was supported by either perpetrator confession, characteristic evolution of brain abnormalities on CT or MRI, inconsistent or absent explanatory history, and/or other social risk factors. CONCLUSION: The diagnosis of SBS can be established even when brain CT is normal on admission. The documentation of retinal hemorrhages is of primary importance in establishing the diagnosis of SBS in these cases. Language: en

To the Editor .— Wathen et al1 studied the use of serum electrolyte panels (SEPs) for children needing intravenous fluid (IVF) for gastroenteritis. All children enrolled had obligatory SEPs drawn, and the results were presented to the attending physician. They then documented evaluation, management, and disposition plans. Because the SEPs changed decisions about clinical care and disposition, the authors concluded that SEPs are useful in all children receiving IVFs for gastroenteritis. We feel that the results are overstated because of a limited study design. Two of the study …

ContextThe ability to assess the degree of dehydration quickly and accurately in infants and young children often determines patient treatment and disposition.ObjectiveTo systematically review the precision and accuracy of symptoms, signs, and basic laboratory tests for evaluating dehydration in infants and children.Data SourcesWe identified 1561 potential articles by multiple search strategies of the MEDLINE database through PubMed. Searches of bibliographies of retrieved articles, the Cochrane Library, textbooks, and private collections of experts in the field yielded an additional 42 articles.Study SelectionTwenty-six of 1603 reviewed studies contained original data on the precision or accuracy of findings for the diagnosis of dehydration in young children (1 month to 5 years).Data ExtractionTwo of the 3 authors independently reviewed and abstracted data for estimating the likelihood ratios (LRs) of diagnostic tests. We eliminated 13 of the 26 studies because of the lack of an accepted diagnostic standard or other limitation in study design. The other 13 studies were included in the review.Data SynthesisThe most useful individual signs for predicting 5% dehydration in children are an abnormal capillary refill time (LR, 4.1; 95% confidence interval [CI], 1.7-9.8), abnormal skin turgor (LR, 2.5; 95% CI, 1.5-4.2), and abnormal respiratory pattern (LR, 2.0; 95% CI, 1.5-2.7). Combinations of examination signs perform markedly better than any individual sign in predicting dehydration. Historical points and laboratory tests have only modest utility for assessing dehydration.ConclusionsThe initial assessment of dehydration in young children should focus on estimating capillary refill time, skin turgor, and respiratory pattern and using combinations of other signs. The relative imprecision and inaccuracy of available tests limit the ability of clinicians to estimate the exact degree of dehydration.