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APA Focus
The Official Newsletter of the Academic Pediatric Association

Volume 52, Issue 3 July 2015
PHM 2015
Communications Director's Message

Message from the Communications Director

It is my hope that this message finds everyone taking time to refresh their minds and spirits with some rest and relaxation time. The fall will be upon us before we know it. Back in October of 2014 I put out a call for members to help with the APA communication strategy. The Board has started those conversations and we are now moving to the action phase. On that note, I will be re-convening regular meetings of the APA Communications Committee starting in September 2015. The work of the committee will be to develop a communication strategic plan for the APA which will include but is not limited to plans for our social media strategy, website development, policies for working with the media as well as the potential development of a speakers' bureau for the organization. The task of the committee will be to work with the executive committee on the development and implementation of the strategic plan.

If you are interested, please send an email to connie@academicpeds.org.org by August 1st. We will then send out the schedule of conference calls to this group. If you know specific APA members with an interest in this area that might not reach the newsletter, please share this information with them. I look forward to working with you all.

Ivor Horn
Communications Director

Academic Pediatric Association
ivor.horn@seattlechildrens.org

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President's Message

Mark

Colleagues,
I am tremendously honored to begin serving as your president and wanted to take this opportunity to say "thank you" ---for your leadership and engagement in our programs and professional development opportunities, our committees, interest groups and regional activities; and for your commitment to our mission to improve the health of children and adolescents.

Although minutes for all of our board meetings are available on the members only section of the website, I wanted to take this opportunity to highlight some of the key decisions made at our April 2015 meeting.

In the fall of 2016 under Mary Ottolini's leadership, we will embark upon a process to update the APA strategic plan. In preparation for these important conversations, we will implement procedures this year to ensure we have important data about how our current programs and activities serve the needs of our membership and have an indication of the resource requirements to sustain and/or grow these programs. As such, we will include annual reports from our Special Interest Groups and will engage in an internal review process for our core programs (e.g. educational scholars program, young investigators award program, etc).

In alignment with our strategic goal to ensure inclusion and enhance diversity in the APA, the board voted unanimously to change two of our current board positions. In the next election, you will have the opportunity to select colleagues to serve as our Chair of Membership, Diversity and Inclusion and as our Chair of Regions and Special Interest Groups. While we are committed to diversity and inclusion in all of our activities and programs, the incorporation of this focus in a board level position reflects our commitment to this important issue at the highest level of governance for the organization. We also recognize that there are opportunities to share best practices and lessons learned across regional and special interest groups' activities. The new Chair position will ensure that we help to facilitate conversations that promote the adoption of efficient and successful approaches for our members in these important groups.

Thank you again for all do for the APA and in support of children and families. Please do not hesitate to contact with questions or thoughts about your experience as a valued member of our organization: maryellenegusic@gmail.com

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APA New Members

Welcome to all of the new APA Members!


Ara Balkian
Michael Cooper
Matthew Di Guglielmo
Tayseer El-Hassan
Abby Fleisch
Brooke Geyer
Albina Gogo
Mera Goodman
Marybeth Jones
Harsohena Kaur
Ruchi Kaushik

Sutapa Khatua
Brittany Massare
Kathy Mullens
Ross Newman
Judy Ross
Judy Schaechter
Padma Swamy
Toni Wakefield
Lauren walker
Traci Wolbrink

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Upcoming Conferences

APA Regional Meetings

APA Region I
March 13th 2016
Boston, MA (Children's Hospital)

APA Region II/III
March 11th 2016 (tentative date only)
New York University, NY, NY

APA Region IV
February 19th - February 20th 2016
Charlottesvile, VA (Omni)

APA Region V
March 11th - March 12th 2016
Peoria, IL

APA Region VI
September 25, 2015
Kansas City

APA Region VII/VIII
February 18th - February 20th 2016
New Orleans, LA

APA Region IX/X
January 30th - January 31st 2016
Monterey, CA

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Leadership Conference 2015
Leadership 2015

Leadership Conference 2015
July 22-23, 2015
Marriott Rivercenter
San Antonio, TX

Pediatric Hospital Medicine (PHM) 2015
PHM2015

Pediatric Hospital Medicine 2015
July 23-26, 2015
Marriott Rivercenter
San Antonio, TX


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Core Activities
CORNET
CORNET

This is an especially busy time of year for all of us, but also an exciting time as we say farewell to our senior residents and introduce new interns to their continuity experience. As CORNET moves forward, we are hoping to enhance involvement of residents in CORNET research projects.

Project Updates

Upcoming: Preventive Services Improvement Project - State Spread (PRESIPS 2)
A new quality improvement initiative to improve the preventive health outcomes of young children based on Bright Futures is underway. Continuity clinics (5) will be recruited by CORNET once AAP Chapter states are selected through an application process. Please share information about this initiative with your AAP Chapter leadership and encourage them to get involved! Measurement-based preventive services, implemented by faculty and residents in continuity clinics, are the key to the "future" of Bright Futures. If your state is selected, as a CORNET member, your site will be eligible for this collaborative project. Please see the Announcements Section of the APA newsletter for more information.

In Progress: National Immunization Partnership with the APA (NIPA)
This large-scale quality improvement project will coach programs through practice changes intended to increase adolescent HPV vaccination rates and prioritize HPV vaccination at every visit. Interest in this project was high and we are impressed with the number of sites who responded to recruitment! Luckily, we expect to implement two consecutive QI cycles, so there are opportunities for sites to participate in either Year 1 or Year 2 of the project.

Faculty who meet minimum participation requirements will receive MOC 4 credit, and we are excited that we will now be able to offer banked MOC credit for residents as well.

Thanks to all of you who responded to our recruitment, which included interest from 26 institutions. We are in the process of notifying sites for participation in Year 1 and plan to initiate orientation calls and IRB submissions in July.

Approaching Completion: National Partnership for Adolescent Immunization (NPAI)
All data collection activities from this project are expected to be complete by July, and we can begin the data analysis phase. This includes an assessment of resident involvement in NPAI to help us enhance the relevance of future CORNET projects to residents. We know the participants will be anxious to see the results of their efforts in this year-long QI project centered on HPV immunization.

Faculty who met the minimum participation requirements should make sure to send in their MOC attestation forms to Nui Dhepyasuwan ASAP: nui@academicpeds.org.

Thanks to participating sites and faculty:

  • University of Utah - Joni Hemond
  • University of South Florida - Tracy Burton, Sharon Dabrow
  • New York Medical College - Terry Hetzler, Vicki Iannoti
  • Baylor College of Medicine - Jan Drutz, Teresa Duryea
  • Dartmouth Hitchcock Medical Center - Kim Gifford, Sam Martin
  • Medical University of South Carolina - Kristina Gustafson, James Roberts
  • University of Oklahoma - Monique Naifeh, Mark Pogemiller
  • University of Southern California - Rukmani Vasan, Jennifer Saenz
  • University of Louisville - Melissa Hancock, Jeff Meyer
  • Helen DeVos Children's Hospital - William Stratbucker
  • Dayton Children's Medical Center - Maria Nanagas, Melissa King, Ilona Albrecht
  • University of Toledo - Mary Beth Wroblewski, Joyce Bevington
  • Duke University Medical Center - Melissa Deimling, Richard Chung

Region Chair Recruitment
We have had many transitions this year and are seeking APA CORNET members from Region II, Region V, Region VII, Region IX and Region X to serve as a member of the CORNET Executive Committee. As a member of this Committee, you will benefit by learning from others, making new friends and contacts, and having opportunities for collaborative research. PLEASE RESPOND BY AUGUST 15.

The CORNET Executive Committee will consider the materials from all interested applicants for this position.

The role of a CORNET Regional Research Chair is to:

Work with the Executive Committee to

  • Review submitted research proposals
  • Provide research proposal feedback to the submitters
  • Determine proposal acceptance
  • Attend the annual 1½ day national CORNET planning meeting following the PAS meeting. We have been able to provide 1 night's hotel accommodation for this purpose, however transportation must be available through the member's own institution.

Serve as the liaison between the CORNET institutions in your region and the Executive Committee

  • Maintain contact through periodic communication with regional residency training programs through communication with Continuity Directors
  • Represent CORNET and present updates at Regional APA meetings
  • Recruit additional institutions/practices within your region
  • Encourage institutions/practices in your region to participate in new CORNET studies
  • Solicit and help generate research study ideas from regional practices
  • Communicate with regional practices about upcoming CORNET research studies and recruit interested practice sites
  • Assist practices, if needed, in the implementation of CORNET research studies
  • Help maintain regional lists of pediatric residency programs and notify CORNET office of any changes
  • Advise on possible funding opportunities

To apply, please submit your name, CV and a brief summary describing your interest in serving on the CORNET Executive Committee as a Regional Research Chair. Please submit this information to the CORNET Research Coordinator, Nui Dhepyasuwan at nui@academicpeds.org by August 15th.

Do you know your Regional Research Chair?
Here is the current list of CORNET chairs by APA region. Please reach out to your local contact for any questions or research idea. They would be happy to provide you with guidance and suggestions.

Region I: Ron Samuels, ronald.samuels@childrens.harvard.edu
Region II: VACANT
Region III: Lynn Garfunkel, lynn.garfunkel@rochestergeneral.org
Region IV: Michael Steiner, msteiner@med.unc.edu
Region VI: Sue Heaney, Heaney@slu.edu
Region V: William Stratbucker, william.stratbucker@helendevoschildrens.org
Region VII: VACANT
Region VIII: Sharon Dabrow, sdabrow@health.usf.edu
Region IX: VACANT
Region X: VACANT

And lastly...
We have several projects in various stages of the "pipeline" (from developing ideas to looking-for-funding) so stay alert for new projects coming up later this year!

Submitted by
CORNET Steering Committee

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Educational Scholars Program

2015 Application Cycle: The Educational Scholars Program (ESP) will be recruiting a new cohort of 24 scholars this summer. Our recruitment flyer is attached here. Applications for a new ESP cohort will be accepted from July - October 2015. Last year, we accepted 24 new scholars into the program, including 12 general pediatricians, 7 hospitalists, and 5 subspecialists. We welcome pediatric faculty from all disciplines.

Cohort 8 will begin in May 2016. Briefly, our program includes three full-day teaching sessions, which scholars attend over 3 years at the PAS meetings, and 2 educational modules per year are completed between PAS meetings. All scholars develop an educator portfolio and receive expert feedback to help them plan their careers and maximize their chances for promotion. Finally, scholars plan and conduct a mentored, scholarly project in education. To receive a Certificate of Excellence in Educational Scholarship, each must provide evidence of a successfully peer reviewed publication or presentation related to the project. All program requirements have been selected with an eye to career advancement of young educators.

For more information on the ESP curriculum and other program activities, go to http://www.academicpeds.org/education/education_scholars_program.cfm. For more information, contact Connie Baldwin (Director): constance_baldwin@urmc.rochester.edu.

New faculty advisors for next group of scholars: We will be recruiting a number of new faculty advisors for our Cohort 8 scholars. Former scholars, members of the APA Education Committee or Faculty Development SIG and other persons committed to faculty development are invited to apply. Advisors serve for three years, advising two scholars on career development and scholarship. They are expected to attend the annual ESP Day on the Friday before PAS to participate in project mentoring sessions and faculty development sessions for advisors. Please contact Cohort 8 leader Hans Kersten at Hans.Kersten@DrexelMed.edu,for more information or with questions.

ESP application reviewers: We also need reviewers to help us select the new cohort of scholars. Application reviews will occur over a 2 week period between Oct 15 - Nov 15, 2015. Please contact Cohort 8 leader Hans Kersten at Hans.Kersten@DrexelMed.edu.

ESP at PAS: We had another busy day of teaching and networking at ESP Day at PAS, April 24 in San Diego. Graduation for Cohort 5 took place on April 26, followed by an ESP Reception for current and past members of the program.

Educational Scholarship Planning Forum: This new Forum was convened at PAS to broaden the ESP's impact on the careers of APA educators by promoting collaborative projects in educational research and evaluation. We had an excellent turnout for the Forum, and discussion groups considered a wide variety of potential research and evaluation projects.

The New ESP Portal: The ESP is the first APA program to use the new APA Portal, a learning management system powered by Moodle. ESP Portal Manager, Virginia Niebuhr, has been working very hard to build a platform for communications, assignments, directories, committee agendas, document repositories and other key functions. 

ESP's 10th Birthday! In 2016, the ESP will be celebrating its 10-year birthday at the PAS meeting in Baltimore. Two stellar ESP graduates, Barry Solomon (Hopkins) and Melissa Klein (Cincinnati), are leading the Planning Committee. More to come later!

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PRIS
PRIS Logo

PRIS News

Come See Us at PHM!

Members of the PRIS Executive Council will be attending the 2015 Pediatric Hospital Medicine Meeting in San Antonio, Texas. If you will be there, be sure to check out the workshops we'll be involved with.

July 24-
  • Research 301: Writing a Manuscript for Publication with Drs. Samir Shah and Raj Srivastava
  • Making it Measurable: Evidence-Based Advocacy for the Practicing Pediatric Hospitalist with Dr. Karen Wilson
  • Learn How to Systematically, Safely and Successfully Discharge Hospitalized Children with Medical Complexity with Dr. Jay Berry
July 25-
  • Abstract Writing for Scientific Meetings with Dr. Samir Shah
  • PHM Division Chief Group Therapy with Dr. Samir Shah
  • Research 101: Understanding the Research Process and Avoiding Common Pitfalls with Dr. Samir Shah
July 26-
  • Beyond Little League: Professional Coaching for Career Success with Dr. Karen Wilson

PHIS+
Augmenting the Pediatric Health Information System (PHIS) with Clinical Data

The PHIS+ project links clinical data from six hospitals to a common administrative database to conduct comparative effectiveness research (CER) studies.

The PHIS+ project has collected and mapped 5 years of clinical data from 6 PRIS member children's hospitals. This data includes lab tests, radiology results and microbiology results. The PHIS+ team has been using this collected data to conduct 4 separate comparative effectiveness research projects on osteomyelitis, gastroesophageal reflux in neurologically impaired children, appendicitis and pneumonia.

The abstract titled "Management of Gastroesophageal Reflux Risk in Children with Neurologic Impairment and Gastrostomy Feeding: A Comparative Effectiveness PHIS+ Study" was presented at the 2015 PAS Annual Research Meeting. Manuscript for this and the other CER studies were submitted in June 2015.

Comparative effectiveness of narrow vs. broad spectrum beta-lactam antibiotic therapy in children hospitalized with community-acquired pneumonia

Results: 28,834 were originally identified using inclusion criteria; 8,886 patients remained after applying exclusion criteria. The median age was 3.3 years (IQR: 1.5-6.6 years); 71.6% of children were 1-5 years of age. 52.9% were male sex. 11.7% were Hispanic, 27.1% were non-hispanic black, and 54.9% were non-hispanic white, and 4.0% were Asian, the remaining were other race. 70.6% had government insurance. The median LOS was 2 days (IQR: 1-3 days). Narrow spectrum prescribing ranged from 8.6% to 62.3% across hospitals.

Management of Gastroesophageal Reflux Risk in Children with Neurologic Impairment and Gastrostomy Feeding: a Comparative Effectiveness PHIS+ Study

Results: Of 1,797,420 discharges, we identified 1178 children with NI, refractory GER, and a GT who underwent initial fundoplication, and 163 who underwent GJ tube placement with matched sampling of 114 patients/group. RRH IRR (GJ/fundoplication) was 1.24 (0.90 to 1.70; p=0.19). Secondary outcomes were rare. Incidence of death was similar between groups. Failure to thrive, repeat of the initial intervention, and crossover to the opposite intervention were all more likely in the GJ group. Early and late procedural complications were rare and similar in the groups. Persistent vomiting, gastrostomy infection, and mechanical complication of gastrostomy were more common in the GJ group.

Influence of peripherally inserted central catheters on revisit rates and hospital cost in children with complicated appendicitis

Results: Of the 733 patients that met inclusion criteria, 93 (12.7%) received a PICC line. Seventy-one patients were propensity matched into each treatment group and no differences were found on the basis of demographic characteristics or disease severity post-matching. Following adjustment for covariates, no differences were found between groups in overall treatment-related cost during the index admission, although significantly higher pharmacy and diagnostic imaging-related costs were found for the PICC group. No differences were found in ED or inpatient revisit rates, cost associated with revisit encounters, nor in overall cumulative cost between groups when revisit encounters were factored in with the index admission.

Comparative effectiveness of empiric antibiotics among hospitalized children with acute osteomyelitis in the era of MRSA.

1265 hospitalized children, ages 2 through 18 years, were initially identified among the participating PHIS + hospitals with a primary diagnosis of osteomyelitis. After all inclusion and exclusion criteria were applied, 547 children were included for analysis with a mean age of 9 years (SD 4). 61% were male, 65% were non-Hispanic White, 15% were non-Hispanic Black, 8% were Hispanic, 2% were Asian and the remaining 10% were other race. 32% had government insurance, 59% had private insurance and 9% had other insurance. The mean LOS was 5 days (SD 4). 249 (46%) of patients had no bacterial growth from culture. 213 patients (39%) grew MSSA from culture, 44 (8%) grew MRSA and 41 (7%) grew a non-staph aureus organism. From radiography data review 24% of patients had an abscess diagnosed by MRI, 11% had an operative procedure referenced by radiographic report and 10% had reference to growth plate involvement. 21% of patients had repeat imaging with concern for disease progression. The most commonly used antibiotics for empiric treatment of osteomyelitis were (in order of frequency) Clindamycin, Vancomycin, Nafcillin and Cefazolin. Patients empirically treated with MSSA antibiotics had a greater 72-hour improvement rate in WBC count when compared to those treated with MRSA antibiotics (16% vs. 4% respectively, p=0.02).  The rates of improvement in CRP, platelet count and ESR were not significantly different between MSSA and MRSA treatment groups.

I-PASS
The I-PASS Executive Council is pleased to report the following updates:

1. On April 15-16, Drs. Christopher Landrigan, Nancy Spector and Theodore Sectish represented the I-PASS Institute at the Forum on Health Care Innovation hosted by Harvard Business School and Harvard Medical School. The I-PASS Institute is a HBS-HMS Health Acceleration Challenge finalist (one of 4 selected from a pool of 478 applications). At the forum, Dr. Landrigan accepted the Cox Prize on behalf of the I-PASS Institute.

2. Drs. Glenn Rosenbluth, James Bale, Amy Starmer, Nancy Spector, Rajendu Srivastava, Daniel West, Theodore Sectish, Christopher Landrigan and the I-PASS Study Education Executive Committee published an article titled "Variation in Printed Handoff Documents: Results and Recommendations from a Multicenter Needs Assessment" in the May 2015 edition of Journal of Hospital Medicine.

3. Drs. Jennifer K O'Toole, Zia Bismilla, and Jennifer L Everhart published an article titled "The I-PASS Handoff Program: A Standardized Approach to Transitions of Care that Improves Patient Safety" in the Spring 2015 edition of Alliance for Academic Internal Medicine Insight.

4. Dr. Daniel West presented a platform presentation titled "Assessment of Resident Patient Handoff Skills: Validity Evidence Supporting the Use of a Structured Clinical Observation Tool to Make Competency and Entrustment Decisions" on behalf of the I-Pass Study group at the Annual Spring meeting of the Association of Pediatric Program Directors on March 26, 2015 in San Diego, California.

5. Drs. Lauren Destino, Melissa Valentine, Amy Starmer and Chris Landrigan delivered a platform presentation titled "Variation in resident time spent with patient and families: a closer look at the motion data from the I-PASS study" at the Pediatric Academic Societies annual meeting on April 26, 2015 in San Diego, California.

6. Drs. Amy Starmer, Jennifer O'Toole, Jennifer Hepps, Sharon Calaman, Zia Bismilla, Lauren Destino, Maitreya Coffey and Glenn Rosenbluth presented "The I-PASS handoff bundle: implementing, adapting and evaluation a standardized approach to transitions of care" as a workshop presentation at the 2015 Pediatric Academic Societies annual meeting on April 26, 2015 in San Diego, California.

7. On May 13, 2015 Drs. Chris Landrigan and Clifton Yu presented a webinar titled "Integrating High Quality Handoffs into TeamSTEPPS and Hospital Care" hosted by AHRQ.

8. On May 28, 2015, Drs. Chris Landrigan and Nancy Spector presented a webinar titled, "I-PASS: Better Handoffs. Safer Care" as part of the Consumers Advancing Patient Safety (CAPS) Signature Series. Dr. Theodore Sectish presented "The I-PASS Handoff Program for Better Handoffs and Safer Care" at the Flying Physicians Association annual meeting on May 30, 2015 in Hanover, New Hampshire.

9. On June 2, 2015, Dr. Amy Starmer presented "The I-PASS Handoff Program, a PerfectServe sponsored webinar". Available from: http://perfectserv.com/connect/video/i-pass-handoff-program-perfectserve-sponsored-webinar

10. Dr. Amy Starmer presented "Avoiding Handoff Fumbles: Implementing I-PASS to Improve Patient Safety" at GME grand rounds at the University of Minnesota on June 2, 2015.

11. Members of the I-PASS consultation group continue active engagements to facilitate the implementation of the I-PASS Program at Mass General Hospital, New York Presbyterian Hospital and MD Anderson.

12. Members of the I-PASS Institute also continue work on a project funded by the Agency for Healthcare Research and Quality (AHRQ) partnering with Society of Hospital Medicine to provide mentored implementation of the I-PASS Program in 32 institutions (16 adult and 16 pediatric). In addition, they continue their work on a project titled "Bringing I-PASS to the Bedside: A Communication Bundle to Improve Patient Safety and Experience". This project is funded by a grant from the Patient Centered Outcomes Research Institute (PCORI).

PIVVOT
Comparative Effectiveness of Intravenous v. Oral Antibiotic Therapy for Serious Bacterial Infections

The aim of this project is to compare the effectiveness of oral antibiotics vs. intravenous antibiotics delivered via a PICC.

The PIVVOT Study published its first manuscript in JAMA Pediatrics and hosted a "Tweet Chat" Journal Club on it. The manuscript can be found on the JAMA Pediatrics website or by following this link.
http://archpedi.jamanetwork.com/article.aspx?articleid=2022276

PRIMES
Pediatric Illness Inpatient Measurement System

PRIMES is a previously developed quality measurement tool that assesses the quality of care provided for respiratory illnesses commonly encountered in the hospital setting:

  • Asthma (41 PRIMES quality indicators)
  • Bronchiolitis (21 PRIMES quality indicators)
  • Croup (17 PRIMES quality indicators)
  • Community Acquired Pneumonia (18 PRIMES quality indicators)
  • Cystic Fibrosis Acute Pulmonary Exacerbation (28 PRIMES quality indicators)

Stage 2 of this work in conjunction with PRIS seeks to answer the question: Does better performance on these quality indicators lead to better health and health care outcomes?

Progress to date:

PRIMES is currently enrolling children to participate in this study. A total of 1,232 children have been enrolled from five sites- Children's Hospital of Philadelphia, Children's Hospital of Colorado, Texas Children's Hospital at Baylor, Seattle Children's Hospital and Vanderbilt.

The majority of children have an admitting diagnosis of bronchiolitis (55%), followed by asthma (49%), pneumonia (42%) and croup (19%).

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Task Forces
Global Health

AAP Endorses Faculty Competencies for Global Health

The American Academy of Pediatrics (AAP) has announced its endorsement of the APA Global Health Task Force consensus statement on faculty competencies for global health. The statement was produced by APA Global Health Task Force members from the APA, the Association of Pediatric Program Directors, the AAP, the Canadian Paediatric Society, and the Programme for Global Pediatric Research. The Faculty Competencies for Global Health also received endorsement from the APA Board of Directors, the Canadian Paediatric Society, and the Programme for Global Pediatric Research. The competencies are available at Click Here.

Contributed by
Ruth A. Etzel, Chair

APA Global Health Task Force
retzel@earthlink.net

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Regions
Region II/III

We are excited to welcome Nicole Hackman, MD from Penn State Medical Center as our new region Co-Chair. We are already planning for our 2016 regional meeting, which will take place in NYC in March---details will be forthcoming. We are open to suggestions from our members for speakers and workshops for this meeting. Have a wonderful summer!

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Region V

Greetings Region V. Hope everyone is enjoying the summer and staying dry. My goodness, the rain has been quite something! My garden and lawn loves the results, but I'm definitely not enjoying having to cut the grass so much! The new academic year has arrived with new bright, shining faces both in the residency and faculty ranks. PAS San Diego seems like a distant memory but it was great to connect with many of you at the meeting. I just want to fill you in on some of the plans for the upcoming year for our region.

We are planning to hold our fall regional webinar in September. There were many great ideas tossed out at the Regional breakfast at PAS and Chris and I hope to have details out to you all within the next month on topic and time to be placed onto your calendars. We are hoping to select a topic more geared towards our trainees in the fall and hopefully involve them in a combined lunch webinar similar to last year. Our second webinar will take place in early 2016.

We have decided on a date and location for the Annual Region V Meeting. This year's meeting will take place in Peoria, Illinois on March 11-12, 2016. In the fall we will be sending out a call for trainee abstracts, as well as volunteers to review the abstracts. We are excited to hopefully offer cash prizes for the top abstracts for both categories of research/quality improvement abstracts and case report abstracts to trainees and encourage you to spread the word to your programs about this wonderful opportunity. This is a great opportunity for young trainees to showcase their research work, network, and learn about the APA. Please let us know if you would be interested in presenting, or if you know of topics and speakers that you think would be good for the Regional Meeting.

So Chris and I are in search for a new APA Region V Co-Chair. Can you recommend anyone in your institution who would be a good candidate that Chris and I could approach? It is a three year cycle. Our APA Region V consists of Ohio, Indiana, Illinois and Michigan. Chris is in Cincinnati and I am in Peoria. Being a Region Co-Chair is a great way to get involved in the APA, network, and build leadership skills. The APA Board is currently in the process of writing letters to our Chairs recognizing us for our work as Co-Chairs. It is a great tool to go into your promotion portfolio. The time commitment is not huge. We plan 2 hourly webinars per year, write APA newsletter updates on Region activities (such as this), send welcome emails to new APA Region V members, and plan/host the Region Breakfast at PAS each year. The biggest activity is the Region Meeting. We would love for you to join us as a Co-Chair and would be happy to set up a time to talk via phone if you would like to get more information.

Finally, please contact us with any questions about the Region or upcoming activities (including any suggestions for future topics at our events).

Region V Co-Chairs:
M. Jawad Javed
jawadj@uic.edu

Chris Peltier
Chris.Peltier@cchmc.org

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Region VI

It was great to see everyone at PAS in April. With 35 members in attendance, we had a very successful Region VI Breakfast. After the business portion of the meeting, Donna D'Alessandro, from the University of Iowa, was thanked for her tremendous leadership over the past three years as Region VI Co-Chair. We also welcomed Mitzi Scotten from the University of Kansas Medical Center, who is the new Region VI Co-Chair. Six APA SIG leaders from our region then spoke to us about their respective SIG's current initiatives and ways to become involved. Overall, it was a great time to network and discuss regional events.

Save the Date
Region VI's Fall Meeting will be on Friday September 25th at the Beller Conference Center at the University of Kansas Medical Center in Kansas City. Goals of the program will be academic development, networking, collaboration and working to build our region. The meeting will start with a special Grand Rounds presentation by Maryellen Gusic, the current APA President. This will be followed with workshops conducted by Keith Mann of the University of Missouri on "Leadership and Quality Improvement," by Michelle Kilo of the University of Missouri on "Mindfullness," as well as a special workshop by Maryellen Gusic on "Mentoring." A leadership panel and a poster session are also planned. All faculty and trainees can register for the meeting at the following link: https://www.academicpeds.org/secure/meeting/region6meeting.

The submission deadline for the poster session was July 1st. Awards will be given out for the top trainee posters. We are also planning a social event the evening before on Thursday, September 24th. Remember, there are no fees to register and APA membership is not required to attend. Negotiated hotel rates are available at $120 plus tax under APA Region VI Fall Meeting at Holiday Inn Express and Suites Kansas City, located next to the Beller Center, Phone: 913-236-8700. http://www.ihg.com/holidayinnexpress/hotels/us/en/kansas-city/mkckc/hoteldetail A few rooms will be reserved at this rate until August 24, 2015. Please register, reserve a room and plan to visit Kansas City in September.

Initiatives
1. Institutional liaisons- We are still in the process of establishing institutional liaisons. The goal of this initiative is to increase information exchange and member involvement. These individuals would agree to represent their institution through regular interactions with Region VI Co-chairs. We already have quite a few institutions represented. We are still in need of liaisons from Wisconsin, North Dakota and Minnesota. If you are interested in fulfilling this vital role, please email Anita Moonjely at anita-moonjely@uiowa.edu

2. Promotion Reviewer List-Tim Fete has developed a promotion reviewer list. This is a list of Associate and Full Professors within our region that are willing to serve as references for faculty members from other institutions within our region. This list is only available to our region members. If you are willing to serve in this capacity or would like a copy of the list, please email one of the Region VI Co-Chairs.

The Region Spotlight
Dr. George Phillips will be the new Director of the Division of General Pediatrics at Children's Mercy Hospital in Kansas City, MO as well as Director of the Division of General Pediatrics at Kansas University Medical Center in Kansas City, KS. George will be leaving the University of Iowa after 13 years. Congratulations to George on his new position.

COMSEP (council on medical student education in pediatrics) meeting will be in St. Louis. April 6-9. Click here for more information . You don't have to be a COMSEP member to attend!

Dr. Robert M Jacobson received the Faculty of the Year award from the Mayo Clinic School of Continuous Professional Development. The Mayo School of Continuous Professional Development conducts more than 200 educational activities offered annually throughout the world. The award was based on ratings received from attendees of courses he taught at Pediatric Days in Chicago and Clinical Reviews in Rochester in 2014. Congratulations to Bob on this prestigious award!

Other Important Information
Newsletter items including Region Spotlight items can be submitted to the national office or the region co-chairs at any time.

Nominations for region co-chair - nominate yourself or someone else by contacting the region co-chairs.

Region Co-Chairs:
Matthew Broom
broomma@slu.edu

Grace Brouillette
gbrouillette@kumc.edu

Anita Moonjely

anita-moonjely@uiowa.edu

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Region VIII

The 2015 Pediatric Academic Societies' annual meeting in San Diego, CA, featured many important events. Through the APA's four committees (Health Care Delivery, Education, Public Policy & Advocacy, and Research) we learned about the imminent addition of the Quality Scholars Program and the development of a Health Policy Scholars Program. These will complement the already existing Education Scholars and Research Scholars Programs. A call to the leadership was made encouraging all Academic General Pediatric Fellowships to become accredited by the APA and participate in the MATCH program. As in years past as part of the APA business meeting, our APA President, Dr. Mark Schuster, oversaw an impassioned debate centered on the resolve, “It's time to take the pediatrician out of primary care pediatrics." APA Special Interest Groups and Committees were also active, with reminders to watch for Young Investigator Award and Research Scholar program applications later this summer. A special thank you also goes out to our region members who mentored trainees at the poster sessions, a popular service among mentees now in its fourth year.

Finally, we welcomed our new Region VIII co-chair, Amy Elizabeth Pattishall, MD. Dr. Pattishall is an Assistant Professor in the Department of Pediatrics at Emory University School of Medicine. She received her Medical Doctorate from Pennsylvania State University College of Medicine and completed residency at St. Christopher's Hospital for Children. While in Philadelphia, Dr. Pattishall served as a chief resident and hospitalist at St. Chris as well as clinical instructor at Drexel University College of Medicine. She has been faculty at Emory University for the past 7 years. Along with her APA membership, Dr. Pattishall is also a member of the AAP and the Georgia Chapter of the AAP. Welcome Dr. Pattishall!

Looking forward, remember to put our combined Region VII and VIII Southern Regional Meeting on your calendar (New Orleans, LA - February 18-20, 2016). The call for workshops will be sent in the next few weeks, and the abstract deadline will be October 9, 2015. More information will be coming soon. Please do not hesitate to contact us with questions about involvement in any APA activity.

Kind regards,

Region VIII Co-Chairs:
Kristina Gustafson, MD MSCR
gustafs@musc.edu

Deborah Winders Davis, PhD
deborah.davis@louisville.edu

Amy Pattishall, MD
apattis@emory.edu

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Special Interest Groups
Advocacy Training

This year, our Advocacy Training SIG and Teaching in Community Settings SIG joined forces and had a fun and lively presentation at PAS. Our focus was on successful community partnerships and how to train residents with a wide variety of time and resources. We heard from experts Dr. Lisa Chamberlain and Dr. Ben Hoffman on their successes, lessons learned, and educational theories to use in creating community experiences. Next, faculty from varied programs large and small gave examples of how to make this happen! Finally our resident oral presentations and posters stole the show! We continue to be amazed at what our up and coming pediatric leaders are doing to affect child health in their communities. We heard about resident-led Pediatricians at the Capitol, ED visits with Adolescent mental health screening, how residents in Toronto are running a free clinic for uninsured children, and many other incredible examples of advocacy in action! We were energized to have over 50 attendees, many of whom were trainees and new faces. If you are interested in joining our SIG and hearing more about advocacy efforts please email us and we will get you connected!

Your Advocacy Training SIG Co-chairs:
Nancy Kelly
Marny Dunlap
Marjorie Rosenthal
Sara Bode

Culture, Ethnicity, and Healthcare

The Co-chairs of the Culture, Ethnicity and Healthcare SIG would like to announce the addition of a new co-chair. Dr. K. Casey Lion is Assistant Professor of Pediatrics at the University of Washington and at the Seattle Children's Research Institute. Dr. Lion provides clinical care at Seattle Children's Hospital, and conducts research on the interventions to improve health care quality for children from low-income, minority, and limited English proficient families.

This year at the annual PAS meeting in San Diego we had a combined meeting of the Culture, Ethnicity, and Healthcare SIG and the Serving the Underserved SIG. The combined session focused on how pediatricians can implement screening and intervention for social determinants of health into practice. The session included a screening of parts of The Raising of America documentary. Dr. Renee Boynton-Jarrett provided an overview of the impact of adverse childhood experiences on child health and development and Dr. Jeffrey Colvin discussed methods to screen for, and intervene on, social determinants of health in the inpatient setting, as well as a primer on medical-legal partnerships. Dr. Lisa Simpson provided information on the Academy Health and Child and Measurement Health Initiative on the development of a research and action agenda to address adverse childhood experiences (ACEs) in our changing health care landscape, and elicited feedback from attendees on the topic. Slides from the presentations have been posted on the APA Culture, Ethnicity and Healthcare SIG Wiki page.




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Child Abuse

The Child Abuse Special Interest Group meeting was held at the 2015 Pediatric Academic Societies Meeting on April 26, 2015 in San Diego, California. This thought provoking session, entitled "Shades of Grey: Uncertainty in the Diagnosis of Child Abuse," was attended by almost 40 members. This topic was explored from different perspectives by four excellent speakers: Richard Krugman, MD, former dean of the University of Colorado School of Medicine and former director of the Kempe National Center for the Prevention and Treatment of Child Abuse and Neglect; Heather Keenan, MD, PhD a researcher and Critical Care specialist from the University of Utah, Salt Lake City, Utah; John Lantos, MD, a bioethicist from Children's Mercy Hospital in Kansas City, Missouri; and Cindy Christian, MD, endowed chair of child abuse prevention at the Children's Hospital of Philadelphia and Medical Director of Philadelphia's Department of Human Services.

Dr. Krugman opened the session with an historical perspective on the issue of misplaced medical certainty. He reviewed the evolution of medical knowledge in the field of child abuse pediatrics with a cautionary tale of how the more we learn the less we know. Dr. Keenan informed us about the risks of bias in the setting of medical uncertainty, in part based on her own research, and offered strategies to help reduce biased decision-making in times of uncertainty. Dr. Lantos presented ethical principles relevant in cases of medical uncertainty and highlighted the ethics of decision-making in uncertain cases. Finally, Dr. Christian shared personal experiences with uncertainty in the practice of child abuse pediatrics. She acknowledged how uncertainty in difficult decisions can have personal repercussions and emphasized the importance of self-care for professionals involved in child abuse medicine.

The last segment of the meeting involved a panel discussion. Panelists encouraged attendees to identify and adopt strategies to deal with uncertain cases personally and professionally. We also identified practices that lead to successful patient outcomes.

From a personal perspective, suggestions emerging from this discussion included:

  • Recognize that most abusive parents love their children, but are just not doing it well.
  • Recognize that most abused children love their parents, they just want the abuse to stop.
  • Define clear boundaries that establish your level of expertise and comfort in practice.
  • Slow down before each patient interaction, and take time before engaging a caregiver in a difficult conversation. Some advised washing hands slowly before going into a room.
  • Identify settings in which bias may occur and recognize methods of reducing this.
  • Talk to someone about how you feel about your work---family, friends, therapist.
  • Accept the fact that we can't solve everything; we don't know everything.

From a professional perspective, suggestions included:

  • Keep pursuing the case, yet accept that some cases remain uncertain.
  • Collaborate with colleagues around uncertain cases to identify gaps in logic, bias in decision-making, or missing information
  • Develop and maintain strong professional relationships, especially if working solo.
  • Improve communication of uncertainty to families and to other professionals---learn to convey appropriate concern and uncertainty simultaneously.
  • Participate in multidisciplinary teams, working with professionals who can protect and support a child even if details of a case remain uncertain
  • Follow up on cases, and feel validated when there are good outcomes.

We enjoyed the workshop very much and appreciate the input of our panelists and the attendees for a rich and rewarding session.

Cindy DeLago
Kris Campbell
Child Abuse SIG Chairs




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Division Directors

The Division Directors SIG (a forum for academic division and section directors in the APA to meet and share information regarding issues such as academic development and promotion, financial constraints, and educational and research priorities) and the Faculty Development SIG (a professional home for pediatric medical educators interested in faculty development with a focus on the members' roles as faculty developers, not merely the members' own personal faculty development) got together on April 25th, 2015 at the PAS meeting to present "The QI Hat-trick: Patient Care, Residency Education, & MOC."

After introductions and updates, a fun and interactive quality exercise, which will be made available on our website, was done by John Harrington. The "pig drawing exercise," worked as a metaphor for highlighting uniformity in patient care. Laura Noonan, the Director of Quality Improvement & Center for Advancing Pediatric Excellence at the Levine Children’s Hospital, Charlotte, NC provided background on the important aspects of implementing a QI program and how to engage and motivate the residents, faculty, and staff. We concluded with some interesting updates from our guest speaker, Ginny Moyer, the current Vice President for MOC and Quality at The American Board of Pediatrics, on the part IV section of the MOC.

During our debriefing at the end of the meeting we realized that many of the current division directors were actually previous chief residents. We decided to do a quick survey of the 100 APA division directors on our SIG and got 43 respondents. The percentage of chief residents in this sample was approximately 40%. Therefore, we would like to invite chief residents, as mentees, to our SIG meeting at the 2016 PAS meeting and may make this an annual event.

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E-Learning

e-learning_sig

This year's SIG meeting in San Diego introduced cutting edge technology as well as performance based curricular tools. Following opening remarks about this year's agenda, attendees were presented with two engaging presentations as well as a hands on workshop about curriculum dissection.

Drs. Lewis and Hathaway with colleagues stationed at Children's Mercy Hospital introduced a cutting edge telepresence platform called SighDeck (SID). The presentation demonstrated Children's Mercy Hospital's current pilot project with SID sharing examples of telepresence meetings. Participants also experienced synchronous telepresence meeting by talking to the co-presenters from Kansas City.

Dr. Michal Cidon described her work with e-portfolios using Ning technology to promote student- centered learning about pediatric rheumatology with trainees.

Drs. Kadriye Lewis and Douglas Blowey provided strategies on how to design a performance based curriculum for pediatric nephrology fellowship training.

Changes in e-Learning SIG in Medical Education
We are pleased to welcome a new Co-Chair to our SIG. Traci Wolbrink, MD MPH is a pediatric intensivist at Boston Children's Hospital and Associate Director of OPENPediatrics, an open-access, online social learning platform currently used in 125 countries (www.openpediatrics.org). OPENPediatrics aims to connect the pediatric community of clinicians worldwide, allowing them to share best practices from all resource settings through innovative collaboration and digital learning technologies. Traci leads the development of the platform's content, coordinates the development team, and working closely with technical collaborators to design site functionality and develop digital applications. Traci's academic interests including developing and researching optimal strategies for video-based learning and serious gaming.
After two years as Co-Chair, Dr. Erik Black is stepping down. Dr. Black will remain an integral part of our group, advising us and contributing his knowledge and experience in medical education. We thank him for the leadership and dedication that he has provided to our group.

Upcoming Conferences and Workshops - 2015

  • AAMC Medical Education Meeting, Baltimore, Maryland. Nov 10-12, 2015

https://www.aamc.org/meetings/421328/2015medicaleducationmeeting.html

  • 21st Annual Online learning Consortium at Orlando, Florida. Oct 14-16, 2015

http://olc.onlinelearningconsortium.org/conference/2015/aln/welcome

To learn further about educational technology and related education conferences, please visit http://www.elearnhub.org/elearning-conferences-june-to-december-2015-and-beyond/

Invitation for Contribution to e-Learning SIG Newsletters and Webinar Proposals
We sincerely invite all of the APA members to contribute to our newsletters with topics that might be of interest to our e-Learning SIG members. Also, if you are looking for opportunities to present or deliver your e-learning initiatives, please send a brief outline and summary of your presentation topic. Feel free to contact Drs. Michal J. Cidon or Traci Wolbrink via the information below to discuss your ideas.

Co-Chairs:
Michal J. Cidon, MD mjcidon@stanford.edu
Traci Wolbrink, MD Traci.Wolbrink@childrens.harvard.edu

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Environmental Health and Developmental Behavioral

During this year's PAS meeting that was held in San Diego, the Environmental Health and Developmental Behavioral Pediatrics SIGs held a joint session. We capitalized on expertise available on the west coast to assemble an expert panel of speakers from the UC Davis MIND Institute on an environmental health topic of critical importance to children: environmental exposures and autism risk.

The first speaker, Dr. Irva Hertz-Picciotto, is an internationally renowned environmental epidemiologist who directs the Program in Environmental Epidemiology of Autism and Neurodevelopment. She discussed "Community and household environmental chemicals and risks for autism and other developmental delays: an assessment of the scientific evidence." Dr. Irva Hertz-Picciotto discussed the CHARGE Study, the first large, comprehensive population-based study that is assessing the role of environmental influences on autism, and the MARBLES Study (Markers of Autism Risk in Babies - Learning Early Signs), the first longitudinal study of autism to begin in pregnancy. Specifically, she focused on the role of air pollutants and pesticides on childhood autism risk.

The next speaker, Dr. Judy Van de Water's laboratory pursues research programs pertaining to autoimmune and clinical immune-based disorders including the biological aspects of autism spectrum disorders. Her work involves the dissection of immune anomalies noted in some individuals with autism, and in the differentiation of various autism behavioral phenotypes at a biological level. Dr. Van de Water discussed "The effects of in vitro exposure of persistent organic pollutants on immune function in children with ASD."

The final speaker was Dr. Schmidt, a molecular epidemiologist, who researches the role of gene-environment and nutrient-environment interactions in relation to autism risk. Dr. Schmidt is also investigating potential mechanisms behind these associations, including those relating to epigenetics, as this field provides groundbreaking framework for these intersections. She discussed "Folate Pathways for Autism Prevention: Interactions with Environmental Risk Factors".

Our SIG collaboration put on a successful joint session at PAS, drawing a broad audience composed of members from both interest groups. The three cutting-edge presentations described above stimulated rich dialogue among the 35 attendees, who reflected their enthusiasm for both the forum and topic through overwhelmingly positive reviews. Evaluations of the SIG meeting were completed by attendees immediately after the session; the summarized results are pending. This year's allotment of SIG funds were offered to our speakers as an honorarium.

SIG Co-Chairs:

Developmental-Behavioral SIG
Diane Langkamp, MD, MPH
dlangkamp@chmca.org

Environmental Health SIG
Heather Brumberg, MD, MPH

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Ethics

Dear Ethics SIG members,

We had a well-attended and very well received meeting in San Diego. We had four speakers from four different institutions tackling the ethical issues involving end of life (EOL) care. There was spirited debate between the different cultures and it helped highlight that ethical issues cannot be solved with a single approach.

Our session started with the announcement of the winners of our fourth Ethics SIG essay contest (please see the essays at the end of this letter). Dr. Jessica Brunkhorst, a neonatology Fellow at Children's Mercy Hospital, Kansas City, MO won the first place. In her essay titled "Two" Dr. Brunkhorst wonderfully used a personal case to describe EOL care and cultural differences.

Dr. Katharine Brock, fellow in Pediatric Hematology & Oncology, at Stanford University won second place. In her essay titled "A Christmas Present" she skillfully analyzed a situation where patient care and research created a conflict in physician duties.

The rest of the session was dedicated to EOL care/decision making and cultural differences.

Dr. Ryan Coleman was our first speaker. The title of his talk was "Time to Move on - Understanding Death and Distribution of Resources in an African Hospital". His excellent talk was eye opening to the global health issues and also the resiliency of people in resource poor settings.

Dr. Lama Charefeddine was our second speaker. The title of her talk was ""Closing the Loop in End-Of-Life Decisions: NICU Experience in a Multicultural Setting"". In her very informative talk Dr. Charafeddine walked us through the ethical challenges she and her team experienced in Lebanon, a very diverse cultural setting. We all learned how making personal connections could potentially make a difference in EOL decision making.

Dr. Michael S Schimmel's talk was titled "End of life" from the beginning: Experience of a multicultural, large NICU service in Jerusalem". In his talk Dr. Schimmel talked about the challenges of EOL decision making in Israeli setting.

Finally, Dr. Eduard Verhagen presented his talk titled "Pediatric euthanasia in Netherlands, how and why are the Dutch different?" His talk showed how EOL decision making could differ among cultures, even among Western cultures. We all learned how different the Dutch approach to death was and how physician patient relationships differ for that matter.

As we have already started to plan for next year we would love to hear any ideas/topics that you would like to be presented. In this way we can plan our next session according to your needs/wishes.

We would also like to announce our fifth annual ethics SIG ethics essay contest. Please find the official announcement in the announcement section of the newsletter.

We will keep in touch via our newsletter and we will continue to be a platform sharing our views and concerns about the impacts of ethics in our clinical work, research and teaching.

Warmest regards,
Ethics SIG Co-Chairs

Zeynep Salih, M.D., MA
Adrian Lavery, M.D., MPH

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Evidence-Based Pediatrics
  • The Evidence-Based Pediatrics Special Interest Group met Saturday, April 25, 2015 in San Diego, CA, from 2:45 - 4:45 with 32 in attendance. Four invited speakers presented on a variety of topics, some recommended and requested by our membership.

  • Martha Wright, MD, Med, Professor and Vice Chair for Education at Case Western Reserve University School of Medicine, and the Residency Training Program Director at Rainbow Babies and Children's Hospital, presented "Not Just MK-1: How Learning the Skills of EBM Relates to the Pediatrics Milestones." Dr. Wright summarized the evolution of EBM training in residency programs, through the competencies and the milestones, and looking ahead, to EPAs. Even those not directly involved with residency education found the presentation informative and relevant. Robert Johnson, MLIS, was our non-physician guest speaker. He is a Clinical Services Librarian at Norris Medical Library at the University of Southern California. All found his presentation on "Incorporating Information Resources in the Clinical Workflow" to be highly informative, useful and relevant, and many commented that they would partner with their own librarians in the future. Manish I. Shah, MD, Assistant Professor in the Department of Pediatrics at Texas Children's Hospital, presented his work on creating national guidelines for EMS, in a presentation titled, "Evidence-Based Protocols for Emergency Medical Services in the US." His work highlighted the important clinical application of evidence-based medicine in real time. Patricia G. McBurney, MD, MSCR, was our fourth speaker. Dr. McBurney, is an Associate Professor and the Co-Director of the Pediatric Clerkship at the Medical University of South Carolina. She shared her work, already published on MedEdPortal, in a presentation titled, "Evidence-Based Medicine: Our Experience Running an EBM Subcourse in our Pediatric Clerkship." All presentations generated questions and discussions on a variety of topics. All presentations are available on the EBP SIG webpage, as PDF files.

  • The presentations were followed by a brief business meeting. Rachel Boykan provided an update on a survey created through the SIG, by herself and the outgoing co-chair, Bob Jacobson. The survey will be sent to pediatric program directors to assess the role of medical librarians in pediatric residency training. Several SIG members helped in the creation of the survey by providing their feedback. (We thank them!) Monique Naifeh presented an update on the EBP SIG's submission for HPV Vaccination Small Grant RFA. While the SIG did not receive the grant, the submission generated interest and plans are underway to proceed with the project. We encouraged attendees to sign the sign-in sheet and provide in addition to their names, email addresses, and their institutions. We reminded everyone to complete the official PAS evaluation sheets and turn them in promptly. We thanked outgoing co-chair Robert M. Jacobson, M.D., Professor of Pediatrics, Mayo Clinic, for his service as co-chair of the EBP SIG from 2007 to 2015, and presented him with a plaque to express our gratitude. We welcomed incoming co-chair Kimberley Dilley, MD, MPH, attending physician in General Pediatrics and Academic Medicine at Advocate Children's Hospital in Chicago, elected April, 2015. She began her three year term at the conclusion of this meeting.

  • We adjourned the meeting with a reminder to use our list-serve, to continue to be involved in SIG projects and to consider topics and nominations for next year's Pediatric Academic Societies meeting April 30 - May 3, 2016, in Baltimore, MD.

  • 2015 Presentations


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Newborn Nursery

Our Newborn Nursery SIG was held on Sunday, April 26, 2015 and was well attended. Sorry to those of you who were not able to attend, and we are sorry that the General Pediatrics-Newborn Nursery Plenary was schedule at the same time!
Our Hot Topics speaker was Valerie Flaherman, MD, MPH, Assistant Professor of Pediatrics at the University of California, San Francisco. Dr. Flaherman spoke about patterns in normal newborn weight loss for breastfed babies and demonstrated the use of weight loss nomograms for babies, comparing babies born via vaginal delivery and via C-section. She reviewed the NEWT website http://www.newbornweight.org with a calculator to help determine excess weightloss for babies over the first three days of life. She then discussed the ELF (Early Limited Formula) Study in which babies are offered small volumes of formula if weight loss is over 5% in first day of life. The group discussed the controversy surrounding these recommendations in light of the Baby Friendly Hospital Initiative and the exclusive breastfeeding requirements in our nurseries. Our Quality Improvement speaker was Carrie Anne Phillipi, MD, PhD, Associate Professor of Pediatrics at Oregon Health and Science University, who spoke about the challenges that physicians face related to refusal of universal practices (such as erythromycin eye ointment, hepatitis B vaccine and Vitamin K) in the newborn nursery. She started with an exercise that divided the participants into two halves of the room and got everyone involved in making a decision regarding the early discharge of a newborn. She then discussed shared decision making strategies and approaches to the discussion regarding refusal of recommended routine practices. She introduced many of us to the option grids that are used to explain options for circumcision, but also can be used for many other topics with parents.

Copies of the speakers' slides are now available on the wiki. The business meeting included discussion of how the SIG can best serve its members. A suggestion was made by Dr. Beth Simpson that SIG members be available to one another for review of academic promotion packages. This suggestion was well received. We discussed the communication about newborn nursery topics through our well used list serve and the not-so-frequently-used APA wiki. It was discussed and recommended that if a question is posed on the list serve, then the person who poses the question should collate the results and upload the information to the wiki.

The idea of a SIG-specific newsletter was discussed, and there was a consensus was that the Co-Chairs should try to send at least four newsletter/updates per year to our list serve and that it will include the following sections:

  • New and exciting articles in the care of newborns
  • Educational materials
  • Hot topics summarized by members of the SIG

Japreet Loyal, gave an update on the ethics paper being written by Drs. Jaspreet Loyal, Mary Ann LoFrumento and Gary Emmett. The focus was to be on the ethics of a hospitalist or employed physician in Nursery being forced to accept all patients and to violate their own ethics regarding the routine use of vitamin K. However, in a follow up e-mail, Dr. Carrie Phillipi revealed that she and a colleague had already submitted an ethics piece to Pediatrics regarding the choice to offer oral vitamin K. After some discussion, Jaspreet and Mary Ann LoFrumento decided to postpone our paper at this time.

New business included the idea of researching a cultural guide to newborn care. We also noted that Dr. Esther K. Chung will be finishing her 3-year term as SIG Co-Chair after PAS 2016, and suggested that others consider running for Co-Chair. During the break, research posters were available for viewing and discussion. Topics ranged from refusal of vitamin K prophylaxis to treatment of neonatal abstinence syndrome. Thank you to all presenters and attendees!!

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Nutrition

Recent successes in the prevention and treatment of obesity suggest a reconsideration of how nutrition is addressed in our pediatric residencies. Approximately 10% of questions in the American Board of Pediatrics (ABP) certifying examinations are nutrition-related, and many parents insist that their pediatrician have a clinical competence in nutrition, considered in its entirety. To remedy this deficiency, we propose convening a one-day session in one APA Region to consider planning and implementing a nutrition curriculum that fulfills the ABP's nutrition competencies and considers resident needs for clinical practice. This pilot project would have an expected time-line of three years and require the direction of one faculty member:

  1. Over the course of the first year, a) assess current allocation of time for nutrition topics within the pediatric   departments in the Region, and b) re-allocate those times to fulfill the ABP objectives.
  2. In the second year, implement the curricular redesign.
  3. In the third year, a) evaluate its effectiveness and b) present outcomes to others.

The emphasis here is to provide a redesigned curriculum that makes no additional time demands on clinicians. We will support a yearly lunch for attendees at the institution in the Region that acts as host.

It is necessary for one colleague to serve as convener for the Region and one as coordinator at each participating department.  We suggest that chief residents be   engaged in the project.  Chair support and resident participation are essential for success.

Outcomes from such a project will vary but one can reasonably assume that both resident scores on nutrition questions and the nutritional knowledge of the pediatricians our departments produce will be better than what we achieve presently.

If you have any questions or would like more information, please contact me at Robert.karp@downstate.edu.

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Patient and Family Centered Care

We had another great SIG session at PAS this year! "PFCC - Strengthen the Center" highlighted ways to promote participation in PFCC across organizations by showcasing programs that focused on patient, family, and provider development. The session included a presentation from Chrissie Blackburn, a parent on staff at UH Hospitals-Rainbow Babies and Children's Hospital. She shared a structure for engaging patients and families across an organization, including strategies for engagement and education at the bedside and a reporting model for hired parents on staff.

We also had an exciting panel of physician discussants and Family/Parent Faculty with experience in family engagement and group exercises that helped participants develop or improve reporting structure of Family Faculty. We provided examples of orientation, teaching tools, and resources to actively train both families and providers in PFCC and PFCR. Finally, we hosted a poster session to network with others who are interested in PFCC. Thank you to all who attended the PFCC SIG session.

We are looking for a new co-chair. If you are interested in being considered, send us your CV and a paragraph explaining your interest, background, experience, and anything you think is important to know for our team. We will then invite an interested member to serve a 3-year term as co-chair.

If you have any feedback or ideas for future PAS PFCC topics, please feel free to email Michelle Kelly (mkelly@pediatrics.wisc.edu) or Kristin Voos (kristin.voos@uhhospitals.org). We look forward to seeing you next year at PAS in Baltimore!

SIG Co-chairs
Kristin Voos, Nena Osorio, Heather Toth, Mike Weisgerber, & Michelle Kelly

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Announcements
Call for Systematic Reviews

The APA journal, Academic Pediatrics, now regularly publishes systematic reviews and is calling for submissions of systematic reviews concerning health care delivery, public policy, education & professional development, or research methodology.

We expect submissions to be highly structured investigations that follow the latest methodology for systematic reviews. Of course, such submissions will undergo the same level of rigorous peer-review as do other submissions to the journal. Nonetheless, junior investigators can master the methods of systematic review and use such an investigation to launch their efforts in a direction of inquiry.

Those interested in pursuing such an investigation with the intention to publish in Academic Pediatrics may contact the section editor, for more information.--Robert M Jacobson, MD, Mayo Clinic, Desk Ba3b, 200 First St SW, Rochester, MN 55905-0001, ph: 507-538-1642, fax: 507-284-9744, email: jacobson.robert@mayo.edu.

APA Board Position Description Changes

The APA Board has approved a shift in the responsibilities of two of the Board positions. The Chair of Membership and Regions will now be the Chair of Regions and SIGs and the Chair of SIGs and New Century Scholars will now be the Chair of Membership, Diversity and Inclusion. This change will occur in May of 2016 when the new Board members take office.

Bright Futures

Maternal Child Health Bureau at Health Resources and Services Administration.

Elizabeth Edgerton, MD, MPH: eedgerton@hrsa.gov

HRSA funds the American Academy of Pediatrics to support the development and ongoing dissemination and implementation of the Bright Futures Guidelines. This serves as the primary reference for the anticipatory guidance visit throughout the infant, child and adolescent's life. Recommendations are based on an evidence-guided process that seeks input across professional fields and provider types. The companion periodicity chart serves as a guide to the clinical preventive services that are covered by the Affordable Care Act. We are glad to announce that pubic review is now open for the Bright Futures Guidelines, 4th Edition.

This document represents the combined efforts of four Age/Stage Expert Panels comprised of pediatricians, family physicians, nurse practitioners, nutritionists, mental health specialists, pediatric dentists and families. This is a review for accuracy, completeness, citation updates and consistency with policy. Bright Futures is soliciting suggestions for content (general comments can no longer be integrated). The Bright Futures Guidelines co-Chairs and Expert Panel members will take them into consideration in the final product.

The review is organized in the following manner:

  • 12 health promotion themes
  • 32 health supervision visits (prenatal and 31 age-specific visits)

This review is Web-based only. All comments must be received by July 29, 2015 11:59 PM EDT.
Direct Link:
http://review.aap.org/BrightFutures/Guidelines/(or via the home page of the Bright Futures Web site)

In addition, the American Academy of Pediatrics Bright Futures Initiative is pleased to announce the launch of an exciting Quality Improvement Initiative. The Bright Futures Preventive Services Improvement State Spread Project (PreSIPS2) is a groundbreaking learning collaboration to create sustainable, state-to-local system infrastructure improvement impacting preventive health outcomes for young children/families based on the Bright Futures Guidelines. AAP Chapters will work with their state level partners (eg; public health, Medicaid/ACOs/payers, academic pediatrics), families, and 10-15 pediatric practices (including 1 residency continuity clinic), to identify practical strategies that really work at the state and practice level to support implementation of preventive services guidelines for early childhood. The application deadline is August 10, 2015. Go to brightfutures.aap.org for more details about the project and upcoming informational Webinars.
Funded in part by the Health Resources and Services Administration, Maternal and Child Health Bureau, under a cooperative agreement to the American Academy of Pediatrics (#U04MC07853), and by the Friends of Children, a Charitable Fund of the American Academy of Pediatrics.

Announcement: Ethics Essay Contest at Ethics SIG

Announcement: Ethics Essay Contest at Ethics SIG

Dear Pediatric Residents and Fellows of all Subspecialties in Pediatrics,

We are pleased to announce the fifth APA Ethics Special Interest Group (SIG) Essay Contest.

The contest is open to all pediatric residents and pediatric subspecialty fellows (including pediatric surgical fellows). Essays should focus on the ethical issues that residents and fellows face while caring for patients. Topics may include but are not limited to personal narratives of ethical dilemmas faced in training or practice or scholarly presentations of issues related to organizational, interprofessional or global health ethics.

Essays should be between 800 to 1600 words. Essays longer than 1700 words will be disqualified without review. Essays must be original and unpublished works. If multiple authors, the award will be shared. All co-authors should provide demographic information (training status) and role in manuscript preparation.

Two awards will be offered. Awards can be used as travel awards to attend the PAS meeting.

1st Place - $200
2nd Place - $100

The winning essays will be read at the PAS meeting in Baltimore, MD and will be published on the  APA website as part of Ethics SIG newsletter in July 2016. If the resident or fellow will be attending PAS in Baltimore they may present their paper themselves.

Deadline: March 10, 2016
Submit essays to: zsalih@iupui.edu

We wish you all the best in your writings in ethics!
Zeynep Salih, M.D., MA
Indiana University School of Medicine
Riley Hospital for Children
zsalih@iupui.edu
Adrian Lavery, MD, MPH
Loma Linda University
Children's Hospital
ALavery@llu.edu

 

Winning Essays for Ethics SIG Ethics Essay contest-2015

First Prize winner:
Jessica Brunkhorst, MD
Neonatology Fellow
Children's Mercy Hospital
Kansas City, MO

TWO

Two tiny, pink and blue stripped hats. Two stacks of carefully folded, hospital receiving blankets. Two preheated radiant warmers. Two heart shaped, temperature probe stickers. Two stethoscopes. Two 3.0 sized endotracheal tubes. Two laryngoscopes with functioning lights. Two oxygen saturation probes. Two interns anxiously awaiting the arrival of our patients. Two babies living side-by-side, in a cozy uterus, for the past 30 weeks. Two more minutes until all of the similarities would come to an end.

The delivery room was packed to the brim with various health care providers. The neonatal team consisted of the neonatal attending, myself- a first year neonatology fellow, a nurse practioner, the senior resident, two interns, the charge nurse, a delivery nurse and two resource nurses. Add five providers from anesthesia, eight obstetric personal plus both parents and the total in the room was somewhere around twenty-five. Nonetheless, the feeling of heaviness in the room took up a far greater amount of space. For every last person already knew, once they were born, one baby would live and the other would die.

Prenatally, Twin B was diagnosed with a complex form of hypoplastic left heart syndrome. His parents had been counseled extensively from multiple disciplines, including cardiovascular surgery, cardiology, neonatology, the palliative care team and social work. A three stage surgical palliation was offered, but ultimately, the parents felt that comfort care, with no aggressive resuscitative measures, was in their son's best interest. Additionally, citing cultural reasons, the parents did not wish to hold or see their son at the time of delivery.

The mother had developed severe pre-eclampsia necessitating a caesarean delivery at 30 weeks gestation. I had previously heard of the case, but did not anticipate being the one on call at the time of the delivery. As we assembled our team and supplies, I tried to mentally prepare myself for the events ahead. I had a pit deep within my stomach, the kind that can only be associated with moral distress. I had varied past experience with hypoplastic left heart syndrome. I had seen babies spend the first nine months of their life in the hospital, only to die gruesome CPR ridden deaths. I had seen babies emergently cannulated for ECMO shortly after surgery. But, I had also seen curly haired, blonde, five year olds, who you would have never known something was wrong if not for the scar on their chest. What would I do if this was my child?

";Uterine,"; announced the OB, interrupting my thoughts. Our team braced for delivery. Both babies entered the world vigorous and crying. Twin A stabilized nicely on CPAP, with minimal oxygen requirement. Twin B was substantially more cyanotic, easily declaring himself as the infant with congenital heart disease. As we transferred to the NICU, the infants were placed on opposite sides of the unit, to assist in facilitating the parents' request to not see their son. The residents began to set up for umbilical lines on Twin A.

I paused for a moment by the bedside of Twin B. His oxygen saturations had already fallen into the 40's and his heart rate had dropped to the 70's. I had to suppress the voice in my head saying, ";do something... call a code... start Prostins... do something."; It was the first time in my career that I had been in this position. I had the skills, knowledge and resources available to me to ";save"; this baby and yet, contrary to my instincts, I was doing nothing. In other neonatal deaths, I realized that I had found solace in telling the parents ";we did everything we could."; Somehow doing ";everything"; was much easier to stomach than doing nothing. But would resuscitation be in this baby's best interest?

The sound of the father's voice startled me. ";We just started thinking, what kind of life would that be for our son? All that time in the hospital. All that pain. And what if they made fun of him for his scar,"; he said half to me, half to himself, a fair distance away from the bedside as he avoid looking at his son. His eyes were welling up with tears. If he was trying to justify his decision to me, it was unnecessary. I didn't judge him for choosing comfort care. I couldn't imagine being in his shoes. I wish I could say that I responded in a perfectly eloquent and compassionate manner, but truth be told, I cannot remember what I said. I know at some point, I touched him softly on the shoulder and offered my condolences, just before the code pager went off for a different patient.

I wasn't there when little twin B died. I hope that someone was. I hope that someone took the time to hold him. The thought of a baby dying all alone haunts me.

Sometime after the fact, I attempted to reflect upon the events from an ethical standpoint. Was the parents' decision ethically permissible? If the best interest standard is applied, I believe that the parents' decision of comfort care for complex hypoplastic left heart syndrome is justifiable. It is generally accepted that parents are the best surrogate decision makers for infants, who obviously can't speak for themselves. Based on the counseling and education the parents received, they deemed that their son's future quality of life would be unacceptable if surgical palliation was chosen. It was their perception that comfort care was in his best interest.

In a 2012 article in Pediatric Cardiology, Dr. Alexander Kon and colleagues published the choices physicians would make if their own infant had hypoplastic left heart syndrome. They found that only 45% of the cardiologist and cardiac surgeons surveyed would choose a surgical option. Interestingly, these numbers remained consistent over an eight year time span, in spite of improved mortality rates for hypoplastic left heart syndrome. These specialists have by far the greatest knowledge and perspective of what children with hypoplastic left heart syndrome endure. If less than half would choose the surgical option for their own child, it reaffirms that the parents' decision for twin B was ethically permissible.

I struggle a much more with the parents' decision not to bond with their son. Perhaps this is a reflection of my own ignorance of their culture. But is there really a culture that supports abandoning your own child? (That's harsh. I know.) Were they afraid that they would change their mind? Did they feel it would increase their own grief and suffering? With the recent progress in neonatal palliative care and the careful attention typically paid to parental requests and support during neonatal end of life care, the circumstances of this case felt so foreign to me.

In my attempts at a literature search, I did not find any publications that provided cultural support for the parents' decision to distance themselves from their son. In the article ";Understanding Cultural Difference in Caring for Dying Patients,"; Dr. Barbara Koenig and Dr. Jan Gates-Williams review various cultural norms and differences in handling death. They mention that in some Native American societies, a ";naming ceremony"; for an infant often does not occur until after one month of age. If the infant dies prior this, they are not officially a part of the social group, therefore not fully alive and do not require a funeral. The authors also describe infant loss in impoverished areas of Brazil, where the death of a child is thought to be inevitable and mourning lasts only a few days. Certainly cultural variation and diversity exists. The article concludes by saying ";The challenge for clinical practice is to allow ethical pluralism---a true engagement with and respect for diverse perspectives---without falling into the trap of absolute ethical relativism. I've tried to keep my mind open. Two years later, I'm still working on it.

One pink, flowery car seat. One ";It's a Girl"; balloon. One fuzzy, fleece blanket. One diaper bag. One premature infant going home with her parents. One little girl who will never get to meet the brother she once had.

References:

Koenig BA, Gates-Williams J. Understanding cultural difference in caring for dying patients, In Caring for Patients at the End of Life [Special Issue]. West J Med 1995; 163:244-249

Kon AA, Prsa M, Rohlicek CV. Choices Doctors Would Make if Their Infant Had Hypoplastic Left Heart Syndrome: Comparison of Survey Data from 1999 and 2007. Pediar Cardiol 2013;34(2)345-353

 

2nd Prize winner:
Katharine Brock, MD
Fellow, Pediatric Hematology & Oncology
Rathmann Family Foundation Fellow
Stanford University

A Christmas Present

I had been feeling good about my work in pediatric oncology, the care for my patient with a relapsed solid tumor and the tough decisions that the family and I made to prioritize quality of life and palliation of symptoms. That was the case until I was called into my attending's office.

Only three weeks earlier, I had the conversation I absolutely dread as an oncologist. My adorable, sassy nine-year-old patient with Stage 4 cancer, who had just finished therapy two months ago, had relapsed everywhere. The disease had come back with a vengeance causing fever and extreme pain. I knew the statistics; she would be lucky to be alive in a year. I was crushed, so I could not even begin to imagine the devastation her parents felt as I gave them the worst news imaginable. I had practiced this conversation many times; it's even the topic of my research. But as the parents heard the words ";Incurable... I'm so sorry,"; their unbearable grief was palpable, and soon we were all in tears. In those moments, I wanted so badly to offer a chemotherapy regimen, an experimental therapy that would cure her, but it would have been a lie. So despite the profound sense of failure, I offered what I could - compassion, a shoulder on which to cry, and an admission for pain and symptom control.

The following day, the family and I talked again about the goals of care. We decided on the ";best"; of a few dreadful options - Phase I therapy. But we agreed to be thinking about doing for her versus doing to her. As an oncology fellow and future palliative care fellow, it was a small victory for quality of life.

Sadly, therapy caused nausea, a drug rash, and neutropenia. Fever and neutropenia triggered an automatic stay in the hospital the week of Christmas - what was likely to be her last Christmas. The family asked to negotiate with us. They knew the rules - ANC over 500, no fever, negative blood cultures. ";Even in light of her prognosis?"; her parents pleaded. So, despite persistent neutropenia and pain, the inpatient team worked hard to get her out of the hospital, adjusting her dose of oxycodone, arranging home antibiotics and IV fluids. And she made it home in time to set out carrots for the reindeer, take family pictures, and get presents from Santa - because she had been ";good this year.";

Despite the happy parents, pain-free holiday and lack of readmission, I was sitting in front of my attending for a difficult discussion, listening as she told me about the downsides of the decision. ";This isn't standard care...Other relapsed patients wouldn't be allowed to go home...She is still neutropenic...She could get very sick. Is the family prepared for that? ...We gave her the therapy so we're obligated to support her through that...She's not DNR yet.";

So despite my respect for my attending, her work-ethic, medical decision making, and care for patients, I feebly tried to state my case. ";I've called and emailed to check on the family...They'll come back for new fevers or ill-appearance...But the family is so happy at home...It's what they wanted.";

I left that meeting feeling conflicted. My gut told me that I had been right. But it got me thinking: when is the right time to involve parents in the decision making for their children? Was enrolling her on a Phase I study the best option? Am I obligated to support her through the down side of chemo, even if the family does not want this? Does she need to be DNR to let her go home for Christmas?

We tout ourselves on shared decision making and family-centered care. But as oncologists, we normally tell parents what chemo agents their child will get, on what days, for how many cycles. There isn't much choice there. When the goal is cure, we push therapy through every holiday, including Christmas. But when their child is no longer curable, this all changes. There is now room for more negotiation: we will involve families in every decision, ask parents what their goals are, and whether they want to prioritize quantity or quality of life. It seems then, that the time to involve parents is now.

After this meeting, I started to wonder: why enroll children on a Phase I trial if a main goal is quality of life? Maybe it was time pressure, or not being ready to give up on quantity of time. But the largest contributor in enrollment, was that when asked ";What do you recommend?"; - we recommended it. Although we were ";clear"; about the risks and goals of Phase I therapy - extra blood draws, scans, and clinic visits with less flexibility, all to find the dose-limiting toxicity - we slipped back into the usual oncology banter: the combination of chemotherapy and novel agents might palliate her symptoms, and extend survival. As an oncologist, we accept the rigid rules of experimental therapy to help the larger pediatric cancer community. It is possible though, that these strict rules burden the family. Was a Phase I the right decision? In a setting where there is no good choice, I would like to think that, as an oncologist, we can do it all - obtain unbiased trial results and help the family achieve their goals. But we can't pretend there is no conflict of interest between being a researcher and being the patient's doctor.

Partly because of her trial enrollment, I heard from my oncology colleagues, ";We are obligated to support the patient through the downsides of therapy."; In discussing this with our palliative care team, I heard the counter-argument, ";Only if that's what the family wants you to do."; This gets back to shared decision making. Are we saying we'll listen in those good times, but tell the family what to do during the bad? No, I don't think so. When the prognosis is so poor that giving no cancer-directed therapy is a viable option, (knowing that her life may be shortened by many months) then why isn't it an option now, after the chemo has already gone in? I tend to agree with my palliative care team; we made a choice and the family was aware of the risks. As much as we don't want the chemotherapy to be what causes her death, we may have to learn to live with ourselves if it is.

Of course my patient wasn't DNR yet. It had only been three weeks since the family learned of her relapse. I knew the cards I was holding; I had analyzed the data and knew that at our institution, Hematology/ Oncology patients were made DNR a median of only nine days prior to death. For her tumor type, only 57% were made DNR, and when they were, it was a median of three days before death. I never worked up the courage to say this out loud to my attending. So I privately thought, ";If I waited until she was DNR to allow the family to pursue their goals of care, it would be too late."; She would be too ill, missing out on the holidays at home, precious time with her family, and a Winter Adventure trip. If I waited to focus on quality of life, in the most important time of this family's life, I would have failed them.

Perhaps by divine intervention, at home her fevers suddenly stopped. She never got septic. She stayed at home spending quality time with her parents. I've been told, ";You can't judge your actions at the time based on the outcome."; So I don't know if it was the right decision, but I'd make the same choice again tomorrow.