Supported by a grant from The Maternal and Child Health Bureau. These materials may be freely rep... more Supported by a grant from The Maternal and Child Health Bureau. These materials may be freely reproduced and used, but may not be modified without written consent of the authors. Case Authors: Case Advisor:
The Center for Pediatric Integrative Medical Education and Boston Healing Landscape Project repre... more The Center for Pediatric Integrative Medical Education and Boston Healing Landscape Project represent diverse approaches to integrative medicine and its practice. The relationship and collegial collaboration between the two programs illustrates the extent to which they complement one another. Both recognize the importance of curriculum geared to different levels of learners and of interventions introduced across the full curriculum. Both use case-based learning, although each focuses on different kinds of CAM and different case models. The Center for Pediatric Integrative Medical Education promotes interactive didactics with hands-on, direct experiential learning. The BHLP applies active-learning pedagogy, through experiential learning and its teaching case model. Both programs understand that, given the ongoing interaction among medical students, residents, fellows, and faculty, each group's training in CAM must reinforce the others for a larger system to change.
OBJECTIVE: Adolescent idiopathic scoliosis (AIS) is a relatively common reason for referral to or... more OBJECTIVE: Adolescent idiopathic scoliosis (AIS) is a relatively common reason for referral to orthopedic surgery, but most referred patients do not require bracing or surgery. We developed a quality improvement (QI) program within the Pediatric Physicians’ Organization at Children’s, an independent practice association affiliated with Boston Children’s Hospital, to reduce unnecessary specialty referrals for AIS. METHODS: The QI program consisted of physician education, decision support tools available at the point of care, and longitudinal feedback of data on physician referrals for AIS. Referral patterns in the 2-year postintervention period were tracked and compared with those of the 2-year preintervention period. Clinical characteristics of referred patients were compared through claims analysis and chart review. RESULTS: Initial visits to orthopedic surgery for AIS declined from 5.1 to 4.1 per 1000 adolescents per year, a reduction of 20.4% (P = .01). Process control chart anal...
Journal of Continuing Education in the Health Professions, 2011
Mentoring is increasingly recognized as central to career development. Less attention has been pa... more Mentoring is increasingly recognized as central to career development. Less attention has been paid, however, to how mentoring relationships evolve over time. To provide a more complete picture of these complex relationships, the authors explored mentoring from a mentee's perspective within the context of a three-year faculty development program in which the mentor provided specific expertise to assist the mentee in completing a scholarly educational project. Methods: Using an evolving focus group design, the authors interviewed mentee groups in 2007-2009 inclusive. Transcripts were coded inductively; codes were revised as data patterns became more apparent. Preliminary assertions about the answers to guiding questions were made; the trustworthiness of the assertions was assessed via member check. Results: Mentees offered a variety of reasons for choosing their project mentor, including proximity, familiarity, and mentor expertise. There was a dyadic relationship with the project mentor in year 1, a broader collaboration with multiple senior mentors in year 2, and mentoring among program peers in year 3. Mentees benefitted from mentors' supportive behaviors and, to a lesser extent, mentors' challenging behaviors. Conclusion: Mentoring relationships, in the context of this faculty development program, tended not to be an exclusive dyadic connection but rather a constellation of relationships that evolved over time and included peer mentoring. The complex reality of these relationships challenges the application of traditional mentoring models and suggests unique considerations in developing mentoring programs designed to meet the needs of faculty in academic medicine.
The growing evidence on the benefits and risks of complementary and alternative medicine (CAM) an... more The growing evidence on the benefits and risks of complementary and alternative medicine (CAM) and its high rate of use (69% of Australians) – particularly for chronic or recurrent conditions – means increasing attention on CAM. However, few people disclose CAM use to their GP, and health professionals tend to inadequately discuss CAM-related issues with their patients, partly due to insufficient knowledge. As clinical and non-clinical chronic condition management guidelines are a means to educate primary health care practitioners, we undertook a content analysis of guidelines relevant to two common chronic conditions – cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM) – to assess their provision of CAM-related information. Ten current Australian guidelines were reviewed, revealing scant CAM content. When available, the CAM-relevant information was brief, in some cases unclear, inconclusive and lacking in direction to the GP or health care provider. Although we focus ...
Background: Patients across North America are using complementary and alternative medicine (CAM) ... more Background: Patients across North America are using complementary and alternative medicine (CAM) with increasing frequency as part of their management of many different health conditions. The objective of this study was to develop a guide for academic health sciences centers that may wish to consider starting an integrative medicine program. Methods: We queried North American leaders in the field of integrative medicine to identify initial sites. Key stakeholders at each of the initial sites visited were then asked to identify additional potential study sites (snowball sampling), until no new sites were identified. We conducted structured interviews to identify critical factors associated with success and failure in each of four domains: research, education, clinical care, and administration. During the interviews, field notes were recorded independently by at least two investigators. Team meetings were held after each visit to reach consensus on the information recorded and to ensure that it was as complete as possible. Content analysis techniques were used to identify key themes that emerged from the field notes. Results: We identified ten leading North American integrative medical centers, and visited nine during 2002-2003. The centers visited suggested that the initiation of an integrative medicine program requires a significant initial outlay of funding and a motivated "champion". The centers had important information to share regarding credentialing, medico-legal issues and billing for clinical programs; identifying researchers and research projects for a successful research program; and strategies for implementing flexible educational initiatives and establishing a functional administrative structure. Conclusion: Important lessons can be learned from academic integrative programs already in existence. Such initiatives are timely and feasible in a variety of different ways and in a variety of settings.
OBJECTIVES. The purpose of this study was to examine the feasibility and effectiveness of impleme... more OBJECTIVES. The purpose of this study was to examine the feasibility and effectiveness of implementation of validated developmental screening by using the Parents' Evaluation of Developmental Status in 2 urban pediatric practices. DESIGN AND METHODS. We implemented the Parents' Evaluation of Developmental Status at Boston Children's Hospital Primary Care Center and at Joseph Smith Community Health Center as quality improvement initiatives. Each practice offered screening to all of the patients attending well-child care visits between 6 months and 8 years of age. The implementation process was investigated by using preimplementation and postimplementation surveys and a focus group of pediatric primary care providers. To assess outcomes, such as changes in identification rates and referrals for developmental and behavioral concerns, we reviewed medical charts of all of the 2- and 3-year-olds present at Children's Hospital Primary Care Center well-child care visits in t...
Pediatricians are required to perform quality improvement for board recertification. We developed... more Pediatricians are required to perform quality improvement for board recertification. We developed an asthma project within the Pediatric Physicians' Organization at Children's, an independent practice association affiliated with Boston Children's Hospital, designed to meet recertification requirements and improve asthma care. The program was based on the learning collaborative model. We developed practice-based registries of children 5 to 17 years of age with persistent asthma and helped physicians improve processes of asthma care through education, data feedback, and sharing of best practices. Fifty-six physicians participated in 3 cohorts; 594 patients were included in the project. In all cohorts, improvements occurred in the use of asthma action plans (62.4%-76.8% cohort 1, 50.6%-88.4% cohort 2, 53.0%-79.6% cohort 3) and Asthma Control Tests (4.6%-55.2% cohort 1, 9.0%-67.8% cohort 2, 15.2%-61.4% cohort 3). Less consistent improvements were observed in seasonal influen...
Objective.-To design, implement, and evaluate an experiential child advocacy curriculum for pedia... more Objective.-To design, implement, and evaluate an experiential child advocacy curriculum for pediatric residents. Design.-Pilot study including before-after 2-group trial of an educational intervention and a qualitative component. Setting.-A large, hospital-based, urban resident continuity clinic. Participants.-General pediatrics residents (N Ï 29 [PGY: 1-4]). Intervention.-Residents and faculty designed a longitudinal curriculum in child advocacy for the continuity clinic, which included community-based and legislative experiences for individual residents as well as clinic-based group activities. Residents reported their experiences to their clinic group at weekly preclinic conferences. In addition, residents presented posters at their year-end residency retreat and wrote grants to fund community projects based on their original findings.
Pediatricians are required to perform quality improvement for board recertification. We developed... more Pediatricians are required to perform quality improvement for board recertification. We developed an asthma project within the Pediatric Physicians' Organization at Children's, an independent practice association affiliated with Boston Children's Hospital, designed to meet recertification requirements and improve asthma care. The program was based on the learning collaborative model. We developed practice-based registries of children 5 to 17 years of age with persistent asthma and helped physicians improve processes of asthma care through education, data feedback, and sharing of best practices. Fifty-six physicians participated in 3 cohorts; 594 patients were included in the project. In all cohorts, improvements occurred in the use of asthma action plans (62.4%-76.8% cohort 1, 50.6%-88.4% cohort 2, 53.0%-79.6% cohort 3) and Asthma Control Tests (4.6%-55.2% cohort 1, 9.0%-67.8% cohort 2, 15.2%-61.4% cohort 3). Less consistent improvements were observed in seasonal influen...
Objectives-To describe the characteristics of hospitalizations for patients who utilize clinical ... more Objectives-To describe the characteristics of hospitalizations for patients who utilize clinical programs that provide care coordination for children with multiple, chronic medical conditions. Study design-Retrospective analysis of 1,083 patients hospitalized between June 2006 and July 2008 who utilize a structured, pediatric complex-care clinical program within four children's hospitals. Chronic diagnosis prevalence (technology assistance, neurologic impairment and other complex chronic conditions), inpatient resource utilization (length of stay, 30-day readmission), and reasons for hospitalization were assessed across the programs.
The Journal of Alternative and Complementary Medicine, 2005
To describe the establishment of a multidisciplinary team of complementary and alternative medici... more To describe the establishment of a multidisciplinary team of complementary and alternative medicine (CAM) providers and educators in an urban pediatric hospital and affiliated medical school.
Objective. To determine patterns of subspecialty utilization within a pediatric primary care netw... more Objective. To determine patterns of subspecialty utilization within a pediatric primary care network. Data Sources/Study Setting. Paid claims from a large not-for-profit health plan for patients of The Pediatric Physicians' Organization at Children's, a network of private pediatric practices affiliated with Children's Hospital Boston. Principal Findings. The subspecialty visit rate was 1.01 visits per subject-year. In 2007, 56.8 percent of subjects had no subspecialty visits, whereas 4.2 percent had 5 visits; the corresponding figures in 2008 were 54.1 and 4.5 percent, respectively. The most frequently visited subspecialties were Ophthalmology, Orthopedics, Dermatology, Otorhinolaryngology, and Allergy/Immunology. Visit rates varied sevenfold by practice. Conclusions. Wide practice variability in pediatric subspecialty utilization suggests an opportunity for reducing unnecessary visits. Better integration between primary care and the most commonly used subspecialties will be needed to meaningfully reduce unnecessary visits and enhance value.
Setting We conducted this survey in a large urban teaching hospital's primary care clinic th... more Setting We conducted this survey in a large urban teaching hospital's primary care clinic that serves more than 12 500 pediatric patients and delivers approximately 39 000 visits per year. Most of the patients served by this clinic live in surrounding urban neighborhoods ...
Supported by a grant from The Maternal and Child Health Bureau. These materials may be freely rep... more Supported by a grant from The Maternal and Child Health Bureau. These materials may be freely reproduced and used, but may not be modified without written consent of the authors. Case Authors: Case Advisor:
The Center for Pediatric Integrative Medical Education and Boston Healing Landscape Project repre... more The Center for Pediatric Integrative Medical Education and Boston Healing Landscape Project represent diverse approaches to integrative medicine and its practice. The relationship and collegial collaboration between the two programs illustrates the extent to which they complement one another. Both recognize the importance of curriculum geared to different levels of learners and of interventions introduced across the full curriculum. Both use case-based learning, although each focuses on different kinds of CAM and different case models. The Center for Pediatric Integrative Medical Education promotes interactive didactics with hands-on, direct experiential learning. The BHLP applies active-learning pedagogy, through experiential learning and its teaching case model. Both programs understand that, given the ongoing interaction among medical students, residents, fellows, and faculty, each group's training in CAM must reinforce the others for a larger system to change.
OBJECTIVE: Adolescent idiopathic scoliosis (AIS) is a relatively common reason for referral to or... more OBJECTIVE: Adolescent idiopathic scoliosis (AIS) is a relatively common reason for referral to orthopedic surgery, but most referred patients do not require bracing or surgery. We developed a quality improvement (QI) program within the Pediatric Physicians’ Organization at Children’s, an independent practice association affiliated with Boston Children’s Hospital, to reduce unnecessary specialty referrals for AIS. METHODS: The QI program consisted of physician education, decision support tools available at the point of care, and longitudinal feedback of data on physician referrals for AIS. Referral patterns in the 2-year postintervention period were tracked and compared with those of the 2-year preintervention period. Clinical characteristics of referred patients were compared through claims analysis and chart review. RESULTS: Initial visits to orthopedic surgery for AIS declined from 5.1 to 4.1 per 1000 adolescents per year, a reduction of 20.4% (P = .01). Process control chart anal...
Journal of Continuing Education in the Health Professions, 2011
Mentoring is increasingly recognized as central to career development. Less attention has been pa... more Mentoring is increasingly recognized as central to career development. Less attention has been paid, however, to how mentoring relationships evolve over time. To provide a more complete picture of these complex relationships, the authors explored mentoring from a mentee's perspective within the context of a three-year faculty development program in which the mentor provided specific expertise to assist the mentee in completing a scholarly educational project. Methods: Using an evolving focus group design, the authors interviewed mentee groups in 2007-2009 inclusive. Transcripts were coded inductively; codes were revised as data patterns became more apparent. Preliminary assertions about the answers to guiding questions were made; the trustworthiness of the assertions was assessed via member check. Results: Mentees offered a variety of reasons for choosing their project mentor, including proximity, familiarity, and mentor expertise. There was a dyadic relationship with the project mentor in year 1, a broader collaboration with multiple senior mentors in year 2, and mentoring among program peers in year 3. Mentees benefitted from mentors' supportive behaviors and, to a lesser extent, mentors' challenging behaviors. Conclusion: Mentoring relationships, in the context of this faculty development program, tended not to be an exclusive dyadic connection but rather a constellation of relationships that evolved over time and included peer mentoring. The complex reality of these relationships challenges the application of traditional mentoring models and suggests unique considerations in developing mentoring programs designed to meet the needs of faculty in academic medicine.
The growing evidence on the benefits and risks of complementary and alternative medicine (CAM) an... more The growing evidence on the benefits and risks of complementary and alternative medicine (CAM) and its high rate of use (69% of Australians) – particularly for chronic or recurrent conditions – means increasing attention on CAM. However, few people disclose CAM use to their GP, and health professionals tend to inadequately discuss CAM-related issues with their patients, partly due to insufficient knowledge. As clinical and non-clinical chronic condition management guidelines are a means to educate primary health care practitioners, we undertook a content analysis of guidelines relevant to two common chronic conditions – cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM) – to assess their provision of CAM-related information. Ten current Australian guidelines were reviewed, revealing scant CAM content. When available, the CAM-relevant information was brief, in some cases unclear, inconclusive and lacking in direction to the GP or health care provider. Although we focus ...
Background: Patients across North America are using complementary and alternative medicine (CAM) ... more Background: Patients across North America are using complementary and alternative medicine (CAM) with increasing frequency as part of their management of many different health conditions. The objective of this study was to develop a guide for academic health sciences centers that may wish to consider starting an integrative medicine program. Methods: We queried North American leaders in the field of integrative medicine to identify initial sites. Key stakeholders at each of the initial sites visited were then asked to identify additional potential study sites (snowball sampling), until no new sites were identified. We conducted structured interviews to identify critical factors associated with success and failure in each of four domains: research, education, clinical care, and administration. During the interviews, field notes were recorded independently by at least two investigators. Team meetings were held after each visit to reach consensus on the information recorded and to ensure that it was as complete as possible. Content analysis techniques were used to identify key themes that emerged from the field notes. Results: We identified ten leading North American integrative medical centers, and visited nine during 2002-2003. The centers visited suggested that the initiation of an integrative medicine program requires a significant initial outlay of funding and a motivated "champion". The centers had important information to share regarding credentialing, medico-legal issues and billing for clinical programs; identifying researchers and research projects for a successful research program; and strategies for implementing flexible educational initiatives and establishing a functional administrative structure. Conclusion: Important lessons can be learned from academic integrative programs already in existence. Such initiatives are timely and feasible in a variety of different ways and in a variety of settings.
OBJECTIVES. The purpose of this study was to examine the feasibility and effectiveness of impleme... more OBJECTIVES. The purpose of this study was to examine the feasibility and effectiveness of implementation of validated developmental screening by using the Parents' Evaluation of Developmental Status in 2 urban pediatric practices. DESIGN AND METHODS. We implemented the Parents' Evaluation of Developmental Status at Boston Children's Hospital Primary Care Center and at Joseph Smith Community Health Center as quality improvement initiatives. Each practice offered screening to all of the patients attending well-child care visits between 6 months and 8 years of age. The implementation process was investigated by using preimplementation and postimplementation surveys and a focus group of pediatric primary care providers. To assess outcomes, such as changes in identification rates and referrals for developmental and behavioral concerns, we reviewed medical charts of all of the 2- and 3-year-olds present at Children's Hospital Primary Care Center well-child care visits in t...
Pediatricians are required to perform quality improvement for board recertification. We developed... more Pediatricians are required to perform quality improvement for board recertification. We developed an asthma project within the Pediatric Physicians' Organization at Children's, an independent practice association affiliated with Boston Children's Hospital, designed to meet recertification requirements and improve asthma care. The program was based on the learning collaborative model. We developed practice-based registries of children 5 to 17 years of age with persistent asthma and helped physicians improve processes of asthma care through education, data feedback, and sharing of best practices. Fifty-six physicians participated in 3 cohorts; 594 patients were included in the project. In all cohorts, improvements occurred in the use of asthma action plans (62.4%-76.8% cohort 1, 50.6%-88.4% cohort 2, 53.0%-79.6% cohort 3) and Asthma Control Tests (4.6%-55.2% cohort 1, 9.0%-67.8% cohort 2, 15.2%-61.4% cohort 3). Less consistent improvements were observed in seasonal influen...
Objective.-To design, implement, and evaluate an experiential child advocacy curriculum for pedia... more Objective.-To design, implement, and evaluate an experiential child advocacy curriculum for pediatric residents. Design.-Pilot study including before-after 2-group trial of an educational intervention and a qualitative component. Setting.-A large, hospital-based, urban resident continuity clinic. Participants.-General pediatrics residents (N Ï 29 [PGY: 1-4]). Intervention.-Residents and faculty designed a longitudinal curriculum in child advocacy for the continuity clinic, which included community-based and legislative experiences for individual residents as well as clinic-based group activities. Residents reported their experiences to their clinic group at weekly preclinic conferences. In addition, residents presented posters at their year-end residency retreat and wrote grants to fund community projects based on their original findings.
Pediatricians are required to perform quality improvement for board recertification. We developed... more Pediatricians are required to perform quality improvement for board recertification. We developed an asthma project within the Pediatric Physicians' Organization at Children's, an independent practice association affiliated with Boston Children's Hospital, designed to meet recertification requirements and improve asthma care. The program was based on the learning collaborative model. We developed practice-based registries of children 5 to 17 years of age with persistent asthma and helped physicians improve processes of asthma care through education, data feedback, and sharing of best practices. Fifty-six physicians participated in 3 cohorts; 594 patients were included in the project. In all cohorts, improvements occurred in the use of asthma action plans (62.4%-76.8% cohort 1, 50.6%-88.4% cohort 2, 53.0%-79.6% cohort 3) and Asthma Control Tests (4.6%-55.2% cohort 1, 9.0%-67.8% cohort 2, 15.2%-61.4% cohort 3). Less consistent improvements were observed in seasonal influen...
Objectives-To describe the characteristics of hospitalizations for patients who utilize clinical ... more Objectives-To describe the characteristics of hospitalizations for patients who utilize clinical programs that provide care coordination for children with multiple, chronic medical conditions. Study design-Retrospective analysis of 1,083 patients hospitalized between June 2006 and July 2008 who utilize a structured, pediatric complex-care clinical program within four children's hospitals. Chronic diagnosis prevalence (technology assistance, neurologic impairment and other complex chronic conditions), inpatient resource utilization (length of stay, 30-day readmission), and reasons for hospitalization were assessed across the programs.
The Journal of Alternative and Complementary Medicine, 2005
To describe the establishment of a multidisciplinary team of complementary and alternative medici... more To describe the establishment of a multidisciplinary team of complementary and alternative medicine (CAM) providers and educators in an urban pediatric hospital and affiliated medical school.
Objective. To determine patterns of subspecialty utilization within a pediatric primary care netw... more Objective. To determine patterns of subspecialty utilization within a pediatric primary care network. Data Sources/Study Setting. Paid claims from a large not-for-profit health plan for patients of The Pediatric Physicians' Organization at Children's, a network of private pediatric practices affiliated with Children's Hospital Boston. Principal Findings. The subspecialty visit rate was 1.01 visits per subject-year. In 2007, 56.8 percent of subjects had no subspecialty visits, whereas 4.2 percent had 5 visits; the corresponding figures in 2008 were 54.1 and 4.5 percent, respectively. The most frequently visited subspecialties were Ophthalmology, Orthopedics, Dermatology, Otorhinolaryngology, and Allergy/Immunology. Visit rates varied sevenfold by practice. Conclusions. Wide practice variability in pediatric subspecialty utilization suggests an opportunity for reducing unnecessary visits. Better integration between primary care and the most commonly used subspecialties will be needed to meaningfully reduce unnecessary visits and enhance value.
Setting We conducted this survey in a large urban teaching hospital's primary care clinic th... more Setting We conducted this survey in a large urban teaching hospital's primary care clinic that serves more than 12 500 pediatric patients and delivers approximately 39 000 visits per year. Most of the patients served by this clinic live in surrounding urban neighborhoods ...
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