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This study investigated the patterns of parental bereavement in 20 parents who have lost a child to cancer, congenital heart disease, meningitis, or drowning in the last 19 months, using semi-structured interviews and standardized questionnaires of depression and grief. Qualitative content analysis of interviews identified three bereavement patterns: The majority of parents (65%) presented uncomplicated, Integrated Grief, five mothers were Consumed by Grief, and one mother and one father expressed Minimal Grief. Quotes from parents exemplified these patterns. Parental gender, symptoms of depression, and pre-death relationship between parents and their deceased child differentially related to these patterns. Having surviving children, social support, and being active appeared to help to integrate grief into daily life. These findings illustrate differential patterns of parental bereavement and related factors, information that has important implications for identifying at-risk parents for complicated bereavement. [ABSTRACT FROM AUTHOR]

OBJECTIVE: There are no accepted and practical measures of the relative clinical and educational activities of pediatricians who work in an academic health science center. Such measures are necessary for justification of existing and future human resource plans and evaluation of the activities and performance of physicians. The limited literature on the measurement of physician workload usually focuses on a specific subspecialty group and does not account for such issues as indirect patient care, such as telephone calls or e-mail consultations; variables that affect the delivery of clinical care, including patient acuity and complexity; and the presence of students during the patient care activities. After completing a pilot study that assessed the educational workload of faculty members, we adapted existing personal digital assistant technology and software to document clinical and educational activities. METHODS: Twenty full-time physicians from 4 subspecialty pediatric divisions participated in a 2-week evaluation project in May through June 2005. Clinical activities, with and without trainees, and educational activities were collected with the use of personal digital assistants. Software allowed an individualized division-specific drop-down menu. Information that was collected included clinical (location of activity, diagnosis, and time requirement) and educational activities. After completion of a 2-week data collection period, each physician was asked to complete a 5-question evaluation form. RESULTS: The project was completed successfully with capture of additional clinical and educational activities. A 5-question evaluation form was completed by 70% of the participants at the end of the 2-week data collection. Data on clinical and educational activities were analyzed qualitatively and graphed. CONCLUSIONS: This method of workload data collection added significant information in capturing activities that are not measured in traditional workload evaluations for either clinical activities, such as e-mail, telephone, and patient information review, or educational endeavors, including mentoring and educational lectures and presentations. [ABSTRACT FROM AUTHOR]

Health systems currently underutilize systematic reviews. Here, we describe a proof of concept project designed to augment the standard systematic review process by presenting qualitative information as a companion to a review on deprescribing interventions. We conducted a thematic analysis of semi-structured interviews with Veterans Health Administration clinicians and Veterans to describe first-hand experiences of engaging in the deprescribing process. Qualitative findings were incorporated into an interactive, web-based product designed to supplement the systematic review report. Preliminary evaluation suggests that integration of narratives as a companion to systematic reviews is of interest to frontline clinicians, researchers, and health system administrators., (© The Association for Clinical and Translational Science 2021.)

Theoretical models of technology acceptance are critical to scope projects, select interventions, and measure adoption. We describe use of the Effective Technology Use (ETU) model in the design and deployment of software supporting electronic consult management. We applied the model to four project phases: (1) needs assessment; (2) software design; (3) deployment; and (4) uptake assessment. In this paper, we describe how we used the ETU to plan stakeholder meetings, conduct usability simulations, and organize findings from a qualitative analysis to identify implementation facilitators and barriers.

Objective : To aid the implementation of a medication reconciliation process within a hybrid primary-specialty care setting by using qualitative techniques to describe the climate of implementation and provide guidance for future projects. Methods : Guided by McMullen et al's Rapid Assessment Process 1 , we performed semi-structured interviews prior to and iteratively throughout the implementation. Interviews were coded and analyzed using grounded theory 2 and cross-examined for validity. Results : We identified five barriers and five facilitators that impacted the implementation. Facilitators identified were process alignment with user values, and motivation and clinical champions fostered by the implementation team rather than the administration. Barriers included a perceived limited capacity for change, diverging priorities, and inconsistencies in process standards and role definitions. Discussion : A more complete, qualitative understanding of existing barriers and facilitators helps to guide critical decisions on the design and implementation of a successful medication reconciliation process.

Background: The Veterans Affairs Portland Healthcare System developed a medication history collection software that displays prescription names and medication images., Objective: This article measures the frequency of medication discrepancy reporting using the medication history collection software and compares with the frequency of reporting using a paper-based process. This article also determines the accuracy of each method by comparing both strategies to a best possible medication history., Study Design: Randomized, controlled, single-blind trial., Setting: Three community-based primary care clinics associated with the Veterans Affairs Portland Healthcare System: a 300-bed teaching facility and ambulatory care network serving Veteran soldiers in the Pacific Northwest United States., Participants: Of 212 patients with primary care appointments, 209 patients fulfilled the study requirements., Intervention: Patients randomized to a software-directed medication history or a paper-based medication history. Randomization and allocation to treatment groups were performed using a computer-based random number generator. Assignments were placed in a sealed envelope and opened after participant consent. The research coordinator did not know or have access to the treatment assignment until the time of presentation., Main Outcome Measures: The primary analysis compared the discrepancy detection rates between groups with respect to the health record and a best possible medication history., Results: Of 3,500 medications reviewed, we detected 1,435 discrepancies. Forty-six percent of those discrepancies were potentially high risk for causing an adverse drug event. There was no difference in detection rates between treatment arms. Software sensitivity was 83% and specificity was 91%; paper sensitivity was 81% and specificity was 94%. No participants were lost to follow-up., Conclusion: The medication history collection software is an efficient and scalable method for gathering a medication history and detecting high-risk discrepancies. Although it included medication images, the technology did not improve accuracy over a paper list when compared with a best possible medication history., Trial Registration: ClinicalTrials.gov Identifier: NCT02135731., Competing Interests: The authors report no conflicts of interest in the research; there are no plans to commercialize the software., (Schattauer GmbH Stuttgart.)

Medication history errors are common at admission, but can be mitigated through the implementation of medication reconciliation (MR). We designed multi-media software to assist clinicians with collection of an admission history. This manuscript describes a naturalistic usability study conducted on the hospital wards. Our goals were to 1) estimate the impact of our workflow upon departmental productivity and 2) determine the ability of our software to detect discrepancies. We furnished clinical pharmacists with our application on a tablet PC and asked them to collect a bedside history. We used 1) time-motion analysis to estimate cycle-time and 2) chart reviews to estimate error detection rates. Our intervention detected an average of 7.7 discrepancies per admission (11.7 per pharmacy-shift). A panel rated 67% of these discrepancies as 'high' or 'very high' risk. The cycle-time per admission was slightly longer than usual care processes (20.5 min vs. 17.9 min), but included a bedside interview. In general, pharmacists agreed that the technology improved the completeness and accuracy of a medication history. However, workflow leveling strategies are important to implementing a durable process. In conclusion, a pharmacist-mediated, patient-centered technology holds promise for improving the quality of MR and overall clinical performance.

Internationally, major efforts are underway to improve medication safety and reduce medication errors during transitions of care. One strategy that has emerged to improve data accuracy and close information gaps is the introduction of software applications and workflow models that allow patients to review, enter, and modify their own patient data (e.g. information about medications they are taking). Evaluating the quality and effectiveness of such patient-facing healthcare applications is critical, especially when this approach is applied to high-stakes clinical tasks such as medication reconciliation. In this paper we describe an approach that has been used to assess the usability of a patient-facing medication reconciliation and allergy review (MRAR) kiosk. The phases involved are described along with implications and challenges of carrying out this work.

Objective: Our objectives were to (1) develop an in-depth understanding of the workflow and information flow in medication reconciliation, and (2) design medication reconciliation support technology using a combination of rapid-cycle prototyping and human-centered design., Background: Although medication reconciliation is a national patient safety goal, limitations both of physical environment and in workflow can make it challenging to implement durable systems. We used several human factors techniques to gather requirements and develop a new process to collect a medication history at hospital admission., Methods: We completed an ethnography and time and motion analysis of pharmacists in order to illustrate the processes used to reconcile medications. We then used the requirements to design prototype multimedia software for collecting a bedside medication history. We observed how pharmacists incorporated the technology into their physical environment and documented usability issues., Results: Admissions occurred in three phases: (1) list compilation, (2) order processing, and (3) team coordination. Current medication reconciliation processes at the hospital average 19 minutes to complete and do not include a bedside interview. Use of our technology during a bedside interview required an average of 29 minutes. The software represents a viable proof-of-concept to automate parts of history collection and enhance patient communication. However, we discovered several usability issues that require attention., Conclusions: We designed a patient-centered technology to enhance how clinicians collect a patient's medication history. By using multiple human factors methods, our research team identified system themes and design constraints that influence the quality of the medication reconciliation process and implementation effectiveness of new technology., Keywords: Evidence-based design, human factors, patient-centered care, safety, technology.

Purpose: Despite the importance of leadership in interprofessional health care teams, little is understood about how it is enacted. The literature emphasizes a collaborative approach of shared leadership, but this may be challenging for clinicians working within the traditionally hierarchical health care system., Method: Using case study methodology, the authors collected observation and interview data from five interprofessional health care teams working at teaching hospitals in urban Ontario, Canada. They interviewed 46 health care providers and conducted 139 hours of observation from January 2008 through June 2009., Results: Although the members of the interprofessional teams agreed about the importance of collaborative leadership and discussed ways in which their teams tried to achieve it, evidence indicated that the actual enactment of collaborative leadership was a challenge. The participating physicians indicated a belief that their teams functioned nonhierarchically, but reports from the nonphysician clinicians and the authors' observation data revealed that hierarchical behaviors persisted, even from those who most vehemently denied the presence of hierarchies on their teams., Conclusions: A collaborative approach to leadership may be challenging for interprofessional teams embedded in traditional health care, education, and medical-legal systems that reinforce the idea that physicians sit at the top of the hierarchy. By openly recognizing and discussing the tensions between traditional and interprofessional discourses of collaborative leadership, it may be possible to help interprofessional teams, physicians and clinicians alike, work together more effectively.

Purpose: Although experts advise disclosing medical errors to patients, individual physicians' different levels of knowledge and comfort suggest a gap between recommendations and practice. This study explored pediatric residents' knowledge and attitudes about disclosure., Method: In 2006, the authors of this single-center, mixed-methods study surveyed 64 pediatric residents at the University of Toronto and then held three focus groups with a total of 24 of those residents., Results: Thirty-seven (58%) residents completed questionnaires. Most agreed that medical errors are one of the most serious problems in health care, that errors should be disclosed, and that disclosure would be difficult. When shown a scenario involving a medical error, over 90% correctly identified the error, but only 40% would definitely disclose it. Most would apologize, but far fewer would acknowledge harm if it occurred or use the word "mistake." Most had witnessed or performed a disclosure, but only 40% reported receiving teaching on disclosure. Most reported experiencing negative effects of errors, including anxiety and reduced confidence. Data from the focus groups emphasized the extent to which residents consider contextual information when making decisions around disclosure. Themes included their or their team's degree of responsibility for the error versus others, quality of team relationships, training level, existence of social boundaries, and their position within a hierarchy., Conclusions: These findings add to the understanding of facilitators and inhibitors of error disclosure and reporting. The influence of social context warrants further study and should be considered in medical curriculum design and hospital guideline implementation.

Background: Teaching is an important professional role for most faculty members in academic health sciences centres. Careful delineation of educational workload is needed to foster and reward teaching efforts, and to facilitate equitable allocation of resources., Aims: To promote recognition in teaching and facilitate equitable resource allocation, we developed, piloted, and qualitatively assessed a tool for delineating the educational workload of pediatric faculty in an academic health sciences centre., Methods: A prototype educational workload measurement tool was developed. Between 2002 and 2004, three successive phases of pilot implementation were conducted to (1) assess the face validity of the tool, (2) assess its feasibility, and (3) develop and assess the feasibility of a PDA (Personal Digital Assistant) version. Participants were interviewed regarding strengths, weaknesses, and barriers to completion. Data were analyzed for recurrent themes., Results: Faculty found that the tool was usable and represented a broad range of educational activities. The PDA format was easier to use and better received. Technical support would be imperative for long-term implementation. The greatest barriers to implementation were skepticism about the purpose of the tool and concerns that it would promote quantity over quality of teaching., Conclusion: We developed a usable tool to capture data on the diverse educational workload of pediatric faculty. PDA technology can be used to facilitate collection of workload data. Faculty skepticism is an important barrier that should be addressed in future work.

Background and Objective: Advocacy is an integral part of a paediatrician's role. The Royal College of Physicians and Surgeons of Canada has identified advocacy as one of the essential Canadian Medical Education Directives for Specialists competencies, and participation in child advocacy work as an important component of paediatric residency training. The objective of the present paper was to describe the development, implementation and evaluation of the first four years of the child advocacy initiative at the University of Toronto (Toronto, Ontario)., Methodology: Ideas for community child advocacy projects were generated through a literature review, and a link to a local elementary school was identified. Teacher and parent focus groups were conducted to identify areas for resident involvement. Workshops were then developed, implemented and evaluated by paediatric residents., Results: Six child advocacy projects between 2001 and 2004 were conducted based on results from the focus groups. These included annual clothing drives, as well as workshops for parents and children about nutrition, safety, parenting, illness management and basic first aid. More than 95% of parents reported that the workshops were useful or very useful, more than 92% felt that they learned something new and more than 83% wanted the residents to return for further workshops. Teachers and residents gave positive informal feedback., Conclusions: Through the child advocacy initiative, paediatric residents had the opportunity to develop skills in advocacy, learn about the determinants of child health and become community partners in advocating for children. Such an initiative can be incorporated into the residency curriculum to help residents develop competency in advocacy.

Background: Increasing evidence suggests that communication plays a central role in effective clinical care. To facilitate effective instruction in this domain, this study seeks to understand how pediatric residents approach the challenge of cross-cultural communication., Methods: A convenience sample of 29 pediatric residents participated in five focus groups that were jointly facilitated by a clinical and a process expert. Discussion was stimulated using two video scenarios of pediatric cross-cultural communication challenges., Results: Seven dominant categories were evident in the discussions: characteristics of culture, beliefs about culture, attitudes towards culture, opinions about how to build expertise in communication, cultural conflict, insights regarding prejudice, and comments about interview technique. Residents tended to view culture and difference as residing in patients (not in themselves), reflecting their assumption that western medicine is acultural., Conclusions: Residents believe that lack of knowledge about other cultures causes their communication difficulties. Our findings suggest, however, that more basic issues may underlie their difficulties. Residents may recognize prejudice in the abstract but fail to see it in their environment, and they may spend minimal time reflecting on their professional culture and beliefs.

This report encourages clinicians to consider a diagnosis of Carney's triad in patients with multifocal gastric stromal sarcoma, extraadrenal paraganglioma (predominantly mediastinal), or pulmonary chondroma. The authors conducted a retrospective 20-year survey at the Hospital for Sick Children and identified two children with Carney's triad. One child, presenting atypically with papilledema and fundal hemorrhages from malignant hypertension and benign intracranial hypertension from chronic iron-deficiency anemia, is the second patient ever to date be described with the complete Carney's triad of neoplasms at diagnosis. Another child presented more typically with gastric stromal sarcoma and pulmonary chondroma without paraganglioma. Carney's triad is a rare differential diagnosis for "idiopathic" hypertension or iron-deficiency anemia from chronic gastrointestinal bleeding. If missed, patients with Carney's triad may have the debilitating physical and mental consequences of chronic iron deficiency and may die of untreated prolonged hypertension and metastatic leiomyosarcoma.

Background: The traditional remedies applied by medical schools to the perennial problem of teaching "caring competence" have been unsuccessful., Purpose: Our purpose was to design and evaluate a simple and effective method for helping students maintain affective contact with their patients., Methods: Third-year medical students and pediatric residents were given the opportunity to talk informally with parents of medically ill children and reflect on the value of this experience for their learning. Trainees' opinions of the experience were measured with focus groups and a questionnaire., Results: Trainees were delighted with the experience, particularly with the following aspects: the opportunity to hear a personally relevant story told in a sincere manner, the realization that they could have an authentic interaction "even" in a medical setting, and the usefulness of the information they derived from the conversation., Conclusions: We concluded that something unique to the conversational experience has educational value.

Purpose: This article discusses the importance of the process of evaluation of clinical teaching for the individual teacher and for the programme. Measurement principles, including validity, reliability, efficiency and feasibility, and methods to evaluate clinical teaching are reviewed., Context: Evaluation is usually carried out from the perspective of the learner. This article broadens the evaluation to include the perspectives of the teacher, the patient and the institutional administrators and payers in the health care system and recommends evaluation strategies., Results: Each perspective provides specific feedback on factors or attributes of the clinical teacher's performance in the domains of medical expert, professional, scholar, communicator, collaborator, patient advocate and manager. Teachers should be evaluated in all domains relevant to their teaching objectives; these include knowledge, clinical competence, teaching effectiveness and professional attributes., Conclusions and Implications: Using this model of evaluation, a connection can be made between teaching and learning about all the expected roles of a physician. This can form the basis for systematic investigation into the relationship between the quality of teaching and the desired outcomes, the improvement of student learning and the achievement of better health care practice. It is suggested that the extent of effort and resources devoted to evaluation should be commensurate with the value assigned to the evaluation process and its outcomes.

Objective: To evaluate the usefulness of an objective structured clinical examination (OSCE) for assessing and providing feedback to postgraduate residents in pediatrics., Design: A 5-station OSCE given in 1996, based on the educational objectives of a general pediatric training program. Each station assessed the residents' interviewing and history-taking skills with a standardized patient. The results were correlated with those of the in-training evaluation reports., Setting: The Department of Paediatrics, University of Toronto Faculty of Medicine, Toronto, Ontario., Participants: Forty-three of 61 pediatric residents: 14 first-year, 12 second-year, 8 third-year, and 9 fourth-year residents., Main Outcome Measures: Scores for each of the 5 stations were broken down into 15 points for the check-list, 5 for the global assessment, and 10 for the written postencounter question, for a total score of 150. The in-training evaluation report ratings were converted to a 5-point numerical scale, ranging from 1 (unsatisfactory) to 5 (outstanding)., Results: The mean OSCE score for the 43 pediatric residents was 104.9. Although the residents in their senior year scored higher, there was no statistically significant difference among the 4 years for the total OSCE score or for any of the 5 stations. The fourth-year residents' scores on the postencounter questions were significantly (P < .05) higher than the first-year residents' scores. Two residents scored less than 60%. The internal consistency of the 5-station OSCE was limited (r = 0.69). Residents received verbal feedback at the conclusion of the OSCE, and they received their scores when they were calculated. The mean overall in-training evaluation report score for all 61 pediatric residents was 3.9. There was a moderate, but statistically significant, correlation between the overall mean OSCE results and the overall mean in-training evaluation report scores (r = 0.45)., Conclusion: The OSCE can provide a useful formative evaluation of postgraduate residents, but the usefulness of the evaluation data and the feedback must be balanced with the logistic difficulties and expense.

The Royal College of Physicians and Surgeons of Canada has stated that residency programs "must provide opportunities for residents to gain an understanding of the basic principles of biomedical ethics as it relates to the specialty." This article presents the steps taken to develop a curriculum for teaching and learning biomedical ethics in Canadian pediatric residency programs, and to provide a model for teaching ethics in this context. Using literature reviews, and opinion surveys of departmental chairpersons, pediatric residents, and practising pediatricians across Canada, we have developed a teachers' handbook to help faculty members in teaching ethics. It can also be used as a tool to enhance faculty development in ethics. The manual is to be distributed to all pediatric training programs throughout Canada in 1997, and its use will be evaluated over the subsequent year. It offers a prototype that is adaptable to Royal College programs other than pediatrics.

Bereavement programs for children and parents are becoming popular since there are more and more neonatal intensive care programs, pediatric oncology programs and pediatric intensive care programs offering these services. This paper addresses the following question: Do bereavement programs work? An overview of the literature dating back to 1964 was undertaken. Only papers dealing with treatment were reviewed. Randomized controlled trials were selected as presenting the best evidence for or against program effectiveness. Methodologic features such as description of the sample, comparability of treatment and control groups, description of the intervention, use of objective, valid, reproducible and blinded outcome measures, sample size calculations, thoroughness of follow-up and attention to clinical as well as statistical significance were assessed. Four randomized controlled trials were found in the literature search. Two of the studies showed benefit, two did not. All four suffered significant methodologic flaws. At this time it is unclear as to whether or not bereavement programs help families. Given the high costs of health care, it is important that studies be done to determine which families are likely to benefit from bereavement programs and what type of program is effective.

We studied 27 infants admitted to the hospital with acute diarrhea caused by human rotavirus (HRV) and obtained additional data on fecal excretion from ten outpatients with the same infection. The disease was characterized by watery diarrhea with fever and vomiting at the onset, isotonic dehydration, compensated metabolic acidosis, and increased concentrations of sodium and chloride but low concentrations of sugar in stools. Diarrhea usually ceased in three to four days when oral feedings were reduced or stopped but recurred mildly in four patients. Of 57 household contacts, 12 were symptomatic, 6 had HRV in their stools, and 19 had significantly increased serum HRV antibody titers. These features of the disease accord with available information on the pathogenesis of HRV infection. Knowledge of the clinical pattern of this newly diagnosable infection should help physicians to recognize and treat quickly this highly infectious, potentially dangerous illness.

The effectiveness of oxybutynin in the treatment of primary enuresis was evaluated in a double-blind study. A total of 30 children (25 boys, five girls), at least 6 years of age, with primary enuresis and no daytime incontinence or history of other urinary tract problems were selected at random from an enuresis clinic population. The study was explained to the families and they were told how to keep records of nocturnal bed-wetting episodes and side effects. The patients were treated with a 10 mg of oxybutynin at suppertime for 28 days. Before or after the treatment period, all children received an identical placebo for 4 weeks. Two-sided paired t tests were used to compare frequency of nocturnal enuresis. Frequency during the drug regimen did not differ significantly from that during the placebo study. There were no differences in findings between boys and girls or between children who had previously taken imipramine and those who had not. The study showed no evidence that oxybutynin is effective in treating primary enuresis.