PEDIATRICS: A Competency-Based Companion Maureen C. McMahon MD Assistant Professor of Pediatrics Jefferson Medical College Thomas Jefferson University Philadelphia, Pennsylvania General Pediatrician Nemours/Alfred I. duPont Hospital for Children Wilmington, Delaware Lankenau Medical Center, Main Line Health System Wynnewood, Pennsylvania Glenn R. Stryjewski MD, MPH Associate Professor Department of Pediatrics Jefferson Medical College Thomas Jefferson University Philadelphia, Pennsylvania Pediatric Intensivist Nemours/Alfred I. duPont Hospital for Children Wilmington, Delaware Series Editor: Barry D. Mann MD, FACS 1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899 PEDIATRICS: A COMPETENCY-BASED COMPANION ISBN: 9781416053507 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 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Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods, they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. Withrespecttoanydrugorpharmaceutical productsidentified,readersareadvisedtocheck the most current information provided (i) onprocedures featured or(ii) bythe manufacturer of each product to be administered to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practition- ers, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appro- priate safety precautions. Tothefullestextentofthelaw,neitherthePublishernortheauthors,contributors,oreditors assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Library of Congress Cataloging-in-Publication Data Pediatrics : a competency-based companion/[edited by] Maureen McMahon, Glenn Stryjewski. p. ; cm.—(Competency-based companion) Includes bibliographical references and index. ISBN 978-1-4160-5350-7 (pbk. : alk. paper) 1. Pediatrics. 2. Clinical competence. 3. Patients—Care. 4. Physician and patient. I. McMahon, Maureen (Maureen C.) II. Stryjewski, Glenn. III. Series: Competency-based companion. [DNLM: 1. Pediatrics. 2. Clinical Competence. 3. Patient Care. 4. Physician—Patient Relations. WS 21] RJ45.P3976 2011 618.92—dc22 2011005356 Acquisitions Editor: James Merritt Developmental Editor: Christine Abshire Publishing Services Manager: Anne Altepeter Senior Project Manager: Beth Hayes Project Manager: Louise King Design Direction: Louis Forgione For Kathleen and Joseph McMahon –MCM For Alison, Sophia, and Isabella, the three most amazing women in the world and the best teachers a student like me could ever have –GRS Educator’s Foreword Medical education has changed dramatically in recent years. The ultimate goal, to develop a pediatrician who can practice “competently and independently,” remains the same. However,theroutetothisendhasbeenaltered.Itisnolongeradequatetoassumethattrain- ees will learn how to care for patients appropriately and gain the necessary medical know- ledge for pediatrics just by “showing up” and participating in the daily routine of medical school rotations and residency training. Medical educators must now prove that they have included all of the key components of medical training (the six core competencies) in their programs. They must have evaluation tools to show that their trainees have grasped these concepts. Likewise, one can no longer assume that medical students and pediatric residents willcommunicate wellwithpatients andfamilies orthattheywillactprofessionally intheir dailywork.Educatorsmustnowdemonstratethattheyhavetaughtandassessedtheinterper- sonal and communication skills and professionalism of their graduates. Furthermore, train- ees must now learn to function effectively as part of a larger health-care system and use re- sources effectively. They must evaluate their own patient care and practice evidence-based medicine. Changing the culture of medical education is not easy. Medical educators are obligated to change the way students and residents think. The six core competencies must be incorpor- atedintothedailylivesoftraineessotheyapproacheachpatientandeachchallengeinmedi- cine with them in mind. Pediatrics: A Competency-Based Companion will play a vital role in our changing educa- tional culture. This is not just another traditional textbook. It is instead a unique guide that effectively helps readers to tackle pediatric problems in a systematic manner, with the core competencies in the foreground. The distinctive format encourages trainees to think differ- ently and logically. Whereas many “old” textbooks supply an arsenal of medical informa- tion,thiscomprehensivetextcoversmuchmore.Practicalconceptslearnedfromexperience arecombinedwithevidencefromscientificstudies.Earlychaptersteachhowtosucceedasa medical student orapediatric resident inclinical settings andindependent study.Othercon- tributions advise trainees to function as part of a medical team, on inpatient wards and out- patientclinics.Latersectionsshowhowtoapproachanillchildwithaspecificcomplaintor medicalproblem.Eachchapteremphasizeswhattodofirstandhowtodevelopadifferential diagnosis when confronted with a simple or puzzling case. All chapters remind the reader to treat patients, families, and colleagues with respect and compassion. Authors stress the importance of including the family in medical decisions. The authors and editors are skill- ful clinicians and talented teachers. They have a wealth of knowledge and experience to share. This important new book will undoubtedly have a great impact on medical education. I congratulate the authors and editors for having the courage to change our approach to pe- diatrics. I applaud their effort to modify traditional readings and develop a new thought process,withaneyetowardcompetenceinallareas.Thisbookisexceptionalandexciting. Our medical students and pediatrics residents will be better for it. Steven M. Selbst MD Pediatric Residency Program Director Jefferson Medical College/Nemours/Alfred I. duPont Hospital for Children Pediatrician’s Foreword In September 1999 the board of the Accreditation Council for Graduate Medical Education (ACGME) approved the Outcome Project. In the decade that has followed there have been significant changes in graduate and undergraduate medical education stimulated by the pro- ject. The Outcome Project is a long-term initiative by which the ACGME intended to in- creaseemphasisoneducationaloutcomes.Initsroleastheaccreditationagencyforgraduate medical education programs, the ACGME wanted to shift from looking at the structure and process of education, which are assessments of potential, to the measurement of outcomes and actual accomplishments. The project defined the six areas of competence: patient care, medical knowledge, professionalism, systems-based practice, practice-based learning and improvement,andinterpersonalandcommunicationskills.Clearly,thesearenotuniqueand fully distinct areas of competence, but they do define the breadth and depth of what a train- ee must know to practice in the twenty-first century. Since the launch of the project there have been many years of moving from concept to program requirements and ultimately to an understanding of what these terms mean and how to use them for enhanced learning and improved clinical practice. From a pediatrician’s point of view, Pediatrics: A Competency-Based Companion takes the aforementioned training paradigm and moves it into the reality of clinical practice. Using the competency framework, the authors and editors provide the pediatrician with a concise setofinformationpointsthatwillhelpguidepractice.Thechapterseachstartwithaclinical scenario, and that is the vantage point of a practitioner. It is not a starting point of a theory or a topical matter but the setting of a commonly seen patient in a clinical context. Next the reader is provided medical knowledge—not an expansive amount of knowledge, but a quantum the practitioner needs to know for clinical thinking, history, physical examination, andlaboratorytestingconsiderations.Wherethistextbreaksnewgroundisintheconsidera- tionofinterpersonalcommunication,professionalism,practice-basedlearning,andsystems- based practice. These topics place the book uniquely in the twenty-first century and adjust the practitioner’s thinking and action in important new directions. Beyond the chapters on all the key well child and ill child conditions, the chapters on giving bad news, difficult en- counters,teamwork,andpatientsafetyareuniqueandveryimportant.Introductorychapters on each of the competencies and on how to be successful in the student and resident roles are also unique.