2. Takagishi et al
Methods
Setting
The study was based out of two
different pediatric residency pro-
grams located at the Medical Uni-
versity of Ohio in Toledo and the
University of South Florida in
Tampa. Residents participate in
this required, 1-month block com-
munity pediatrics rotation during
their second or third year of resi-
dency. The visited sites were se-
lected by the rotation supervisors
as facilities utilized by children
and families to improve their
lives, thus exposing the residents
to relevant community resources.
During the rotation, residents
spend ;^ to 2 days at each of a vari-
ety of sites. The agencies visited in
Ohio are a residence for persons
infected with human immunode-
ficiency virus (HfV) and acquired
immunodeficiency syndrome
(AIDS) resource center, early in-
tervention site, administrative of-
fice of the mentally retarded/de-
velopmentally delayed, domestic
violence shelter. Women Infant
and Children's (WIC) offices and
their sponsored Breastfeeding
Support Croup, child protection
team centers, day care for med-
ically fragile children, and
schools for children with special
needs. In Florida, the residents
visit a domestic violence shelter,
homeless shelter, WIC office,
lead inspection team, develop-
mental day care, hospice pro-
gram, various public schools,
child protection team, and coor-
dination team for children with
complex medical needs. There is
no didactic component.
Study Design
A set of 9 questions, closed-
and open-ended, were developed
by the investigators to survey pe-
diatric residents' perceptions of
the community sites visited, im-
pressions the sites left upon the
residents, and of the rotation
overall (Table 1). At an introduc-
tory meeting at the beginning of
the community pediatrics rota-
tion, the authors reviewed these
questions with residents. From
July 2001 to July 2002, the resi-
dents completed journal entries
pre and post visits at all of the
above-mentioned sites using these
questions as a guide, although
they were given latitude to express
themselves more freely. These
same questions were asked at the
exit interview for the rotation,
conducted by one of the authors
(JT or SD in Florida; JC in Ohio).
The interviews lasted 30 to 60
minutes per resident. No en-
trance interview was conducted to
allow for comparison.
To best portray the richness of
the responses to both journal en-
tries and exit interviews, we used a
qualitative methodology as de-
scribed by Creswell.'o All of the
journal entries and interview
Tabte t
RESIDENT ADVOCACY QUESTIONNAIRE
1. What health-related physical, mental, or psychosocial Issues did you identify at the site and/or affect children and
families who attend the site?
2. How do you screen for kids who may benefit from attending the site?
3. In your future general subspecialty practice what could you do to address the needs of children who may
attend the site?
4. Did your perceptions of the identified problem change as a result of the experience there?
5. Best part of the experience?
6. Worst part?
7. How can you improve future residents experiences at that site?
8. Do you have any ideas for projects or other services that pediatric residents could provide for that site?
9. Rank the value.
Excellent Very Good Good Fair Poor
240 CLINICAL PEDIATRICS APRIL 2006
3. Lessons Learned from Pediatric Residents
transcripts from both institutions
were hand transcribed and col-
lated into one document, with re-
sponses listed by question and
identified by a code number for
each resident. Three of the au-
thors (JT JC, and SD) read all the
transcripts looking for emerging
themes.
The Medical tJniversity of
Ohio and the University of South
Florida Institutional Review
Boards reviewed and approved
the research protocol for this
study. Consent to use the data for
research purposes was received
from all pediatric residents.
Results
Twelve residents from the Uni-
versity of South Florida and 7 res-
idents from the Medical College
of Ohio participated in the study.
No residents from either site re-
fused to participate. From
Florida, 7 residents were female,
and 5 male. Eleven of them were
second year residents; the other
was a third year (male). Upon
graduation, 50% of the residents
went into general pediatrics,
while the others began fellow-
ships. From Ohio, all residents
were third year—5 female, 2
male—and upon graduation, all
became general pediatricians.
The following sections summarize
the three themes elicited from
the residents' interviews and jour-
nals. Each theme will be de-
scribed further, with relevant quo-
tation from the residents
included. The comments and
themes noted did not differ be-
tween Florida and Ohio residents.
We identified three com-
mon themes present in resi-
dents' responses: enlighten-
ment and attitude change,
impact of direct participation,
and rotation challenges.
Enlightenment and
Attitude Change
In their journals and inter-
views, residents described their
previsit ideas of various sites, of-
ten making negative assumptions.
After visiting these locations, how-
ever, the residents were often sur-
prised by the quality and quantity
of services and facilities.
"I visualized a much smaller
place. I visualized a home
where people live who
need care, and that is a very
small part of it. I didn't re-
alize that they did as much
of the informational things,
references, coordination of
services" (re: HIV-infected
men's residence).
"I was completely unaware
of what to expect when I
walked into the WIC office
this morning. I expected
to see a cramped office
with a line of people wait-
ing to receive food or
coupons. My assumption
was that the services pro-
vided would be very re-
stricted and difficult to ob-
tain. I couldn't have been
more surprised. What I
learned today was worth
the whole month all by it-
self. . . . My perceptions of
the clients served by the
agency did change for the
better . . ." (re: WIC).
Some residents were not only
surprised by what they learned,
but seemed "enlightened" by the
experience. Not only was their
awareness of the resources in-
creased, hut they gained a new ap-
preciation for either the clients
served or the agency's offerings.
"I think the home visit really
opened my eyes. Getting to
talk with the family and the
patient" (re: hospice).
"What a wonderful experi-
ence this was. It opened
my eyes to so much moi"e
than I ever knew was avail-
able" (re: Wi.C).
A couple of residents even
wrote about moments for which
their own views were challenged
or changed by the experience.
"Used to see homeless peo-
ple as scruffy, dirty . . . but
now just saw people as out
of luck, can be anybody
out of luck" (re: homeless
persons in a shelter).
"It is going to take a lot of
effort on my part to take
care of kids like these
(children with behavioral
problems) in Vermont, lo
make sure I am doing it
well and not changing my
usual care because I have
problems with their behav-
ior. I know it will be tough
not to feel mad at them"
(re: children with severe
behavioral problems).
Further, residents realized
that awareness of local commu-
nity resources could help them
better access appropriate care for
their patients.
"Best part: listened in on
group meeting of social
workers. Learned about
the process, systems, pro-
grams" (re: domestic vio-
lence shelter).
"Found out how to use the
school system to help out
the kids" (re: school with
migrant workers' children).
APRIL 2006 CLINICAL PEDIATIUCS 241
4. Importantly, they also discov-
ered problems within the systems
created for children and their
families to obtain care. This
awareness is integral to the resi-
dent's development as child advo-
cate, a central goal of this rotation.
"... I just wish there was
some way as physicians that
we could speak up for
these people (with HIV)
and against the insurance
companies because it is
not fair what they do to
these people who have
huge medical costs . . ."
(re: HIV-infected men's
residence).
Impact of Direct Participation
In addition to acquiring
knowledge about community re-
sources, residents were also re-
quired to give talks, formally or in-
formally, at several of the locations.
Many found that teaching others
enhanced their experience.
"The best part was answer-
ing questions for the
moms and hopefully mak-
ing a difference for their
children" (re: domestic
violence shelter).
"The best part was the
night I came back for my
question and answer ses-
sion. They actually appreci-
ated me" (same location).
This learning preference for
direct participation appears to in-
fluence the residents' attitudes to-
ward various sites.
"Best part was the actual
play-based assessment. In
behavior/development
(rotation) we do it, too.
but we stand on one side
of the window and just
Takagishi et al
watched through the win-
dow. But this month they
actually let us in the room
and I followed around
one of the occupational
therapists, watched her do
her stuff with each one of
the kids in there" (re:
Early Intervention).
Residents viewed passive expe-
riences, such as watching assess-
ments, more negatively.
"The worst part was the in-
take . . . because we didn't
do anything. I just kind of
sat there and listened to
them do something over
the phone" (re: child pro-
tective team services).
General Rotation Challenges
One potential hurdle of this
type of block rotation is convey-
ing to the residents the impor-
tance of learning to advocate for
their patients and that knowl-
edge of available resources is
critical to this advocacy. A re-
lated issue is the recognition that
the same general types of re-
sources are available throughout
the country, making visitations
to local resources important
even for those moving out of the
area. Some learned this during
the rotation.
"I am most interested in
fmding out about national-
based programs and access
to these programs. Ver-
mont will have a national
program and access to
these programs for chil-
dren with disahilities . . . I
hope. I didn't have to pay
much attention before and
now I need to know my re-
sources! Maybe I need to
spend some time once we
get settled looking into
similar programs in Ver-
mont. I will probably be
surprised by what is out
there" (re: program for
children with mental retar-
dation or other develop-
mental disabilities).
Safety concerns also present a
potential resident barrier to full
rotation participation. However,
visiting such sites with their in-
herent danger seemed to give
them a greater appreciation for
the employees of the community
agencies.
' " • -
"... My hushand found out
that I was going and said.
'You're not going there.'
(He) actually came and
followed me there and sat
outside a while, then de-
cided it was safe so he
left . . ." (re: HIV-infected
men's residence).
"The worst part was going
to houses. . . . These work-
ers should have pepper
spray or something as a
protective device. I truly
appreciate that people do
thisjoh" (re: children's
preventive services).
There were also logistic chal-
lenges such as schedule mix-ups
and unavailable administrators.
"Another schedule mis-
take—I didn't have to get
here until 9:00 AM—I usu-
ally don't care but now I
have a baby and I am really
lacking in sleep" (re:
school for behaviorally
handicapped children).
". . . No one was prepared
for me to visit. Thus, there
was no agenda for me, and
the brand new director
242 CUNICAL PEJ)IATR]CS APRIL 2006
5. Lessons Learned from Pediatric Residents
had no idea why I was
there" (re: day care for
children with disabilities).
Discussion
Organization of a block rota-
tion is best accomplished with
hoth a physician and administra-
tive coordinator. The physician
coordinator makes the initial con-
tacts with potential sites and
should visit the sites periodically.
He or she should meet with the
residents at the beginning of the
rotation to review expectations,
and at the end to determine if the
expectations were met. Using res-
ident feedback, he or she should
determine if the sites are provid-
ing the types of information and
experience expected of them,
and if not, revise the locations as
needed. A rotation coordinator—
which can be an attending physi-
cian if needed although an obses-
sive administrator is
preferable—has several tasks to
accomplish. The coordinator
must maintain updated commu-
nity site administrator informa-
tion, location directions, and
each site's scheduling prefer-
ences. He or she must also bear in
mind individual residents' conti-
nuity clinic and call schedules
when arranging the schedule.
One drawback to such a block
rotation is the logistic challenges
inherent, such as schedule con-
flicts and safety concerns. Com-
munity site administrator contact
information should be given to
residents, and resident beeper
numbers to the administrators, to
enhance coinmunication in case
of schedule changes. An obses-
sive rotation coordinator is also
essential to arranging the compli-
cated schedule. However, as we
had discovered in the first part of
this study, these logistic chal-
lenges have been acknowledged
by both community site and rota-
tion coordinators and are being
worked on to optimize the resi-
dents' experiences.
This study was limited by the
small sample size, a total of 19 res-
idents in two programs. Addi-
tional studies with larger numbers
of residents may help define the
best ways to increase interest in
child advocacy. As this rotation is
required, no bias due to interest
in advocacy should have skewed
the data toward more positive
comments. Another limit is the
concern that residents answered
questions in front of evaluators or
only wrote comments in journals
in a socially desirable manner.
However, as residents admitted to
problems at different sites, and to
their own biases against certain
patient populations or commu-
nity sites themselves, the authors
believe the residents were truthful
in their comments. A final con-
cern is combining written and in-
terview data, as different media
may reveal different answers.
However, as residents were given
the opportunity to write and to
discuss their feelings, one of the
media should have allowed for ac-
curate data collection for each in-
dividual resident.
Civen that level of participa-
tion seemed to have influenced
the residents' educational experi-
ences, finding ways to engage the
residents more actively at each
site may make the rotation
stronger. Requiring lectures or
implementing a community
"good deed" each month, as sug-
gested by one resident, may make
the experience more tangible.
Programs such as that at the Uni-
versity of Washington have re-
quired independent projects."
Additionally, although entry and
exit interviews may allow resi-
dents to reflect about the need for
community advocacy, they are
time intensive for supervising
physicians. However, requiring
written pre- and post-site visit
journals may allow residents this
same opportunity for reflection
and are tools that other residency
programs could use to systemati-
cally document competency in
the ACCME Systems Based Prac-
tice requirement.
Finally, using the postvisit
journal format as a guide, the
University of South Florida group
recently designed Advocacy Activ-
ity Companions for each location
visited. They comprise written
questions the residents answer re-
garding knowledge, attitudes, and
skills acquired following each site
visit. This tool also assists in
ACCME documentation, but will
require further assessment before
any data publication.
Conclusions
Block rotations in community
pediatrics, located in both Florida
and Ohio, appeared to have been
favorably viewed by residents
learning about local resources.
Despite initial negative reactions
to certain locations, residents ad-
mitted that the exposures were
beneficial, some even seeming
enlightened by the experience.
The need for child advocacy was
also better appreciated when res-
idents saw what resources were
available, or not, for their fami-
lies and what was needed to ac-
cess these resources.
Acknowledgments
Drs. Christner and Dabrow
would like to thank the
APA/HRSA Faculty Development
Scholars Program, which fostered
this collaboration. The authors
APRIL 2006 CLINICAL PEDIATRICS 243
6. Takagishi et al
would also like to thank Dr. Sandy
Puczynski, Director of the Joint
Research Program for Pediatrics
and Family Medicine, Medical
University of Ohio, for her help in
reviewing this manuscript.
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