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Educational Intervention |

Teaching Residents About Development and Behavior:  Meeting the New Challenge FREE

Carolyn Frazer, MD; S. Jean Emans, MD; Elizabeth Goodman, MD; Maria Luoni; Terrill Bravender, MD; John Knight, MD
[+] Author Affiliations

From the Divisions of General Pediatrics (Drs Frazer and Knight) and Adolescent/Young Adult Medicine (Dr Emans, Goodman, and Bravender and Ms Luoni), Children's Hospital and the Department of Pediatrics, Harvard Medical School (Dr Frazer, Emans, Goodman, Bravender, and Knight and Ms Luoni), Boston, Mass.


Arch Pediatr Adolesc Med. 1999;153(11):1190-1194. doi:10.1001/archpedi.153.11.1190.
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Published online

Objective  To determine the teaching methods, materials currently used, and unmet needs for teaching developmental-behavioral pediatrics (DBP) at pediatric training programs in the United States.

Design  Cross-sectional survey of US pediatric residency training programs. The survey questionnaire consisted of 3 instruments: a program director survey, a developmental-behavioral pediatrics survey, and an adolescent medicine survey.

Participants  Survey packets were mailed in January 1997 to 211 programs identified by mailing labels from the Association of Pediatric Program Directors.

Results  Data from 148 programs (70%) completing both the DBP survey and program director survey were analyzed. Ninety-five percent of programs reported a block rotation, and 95% of those stated that the rotation was mandatory. Eighty-seven percent had a formal curriculum. Most programs reported using articles, lecture outlines, and precepting for teaching DBP. Few programs used standardized case-based or computerized materials. Most programs, however, indicated a desire for these materials. Few programs felt that 4 topics were covered adequately: adoption (12%), violence (24%), substance use (28%), and conduct problems (41%). Programs that perceived that they covered these topics adequately were more likely to use written cases as part of their curriculum (Mann-Whitney test, 1373.5; P = .04). Barriers to teaching included lack of adequate faculty, time, money, and curricular resources.

Conclusions  Pediatric residency programs have made significant gains in mandatory DBP training. However, many programs report a lack of adequate faculty, teaching materials, and methods. Responding programs indicated an interest in case-based materials. This approach may represent an alternative and underutilized resource for teaching DBP.

Figures in this Article

PRIMARY CARE pediatricians are challenged by the need to diagnose and treat many children with chronic illness and behavioral and developmental problems. Up to 15% to 20% of all children present to their pediatrician with behavioral or developmental problems at some time during childhood. In addition, up to 10% have a developmental delay and 12% have learning difficulties serious enough to require special education.1,2 Advances in medical technology over the past 20 years have resulted in increased survival of children with premature birth, congenital anomalies, and chronic disease. In addition, more children and families are living in poverty and face stresses related to overcrowding, poor nutrition, and exposure to violence.3 Pediatric primary care providers often feel ill prepared to ask the appropriate screening questions and manage these problems after residency training,4,5 and a number of experts have recognized the urgent need to enhance pediatric residency training in developmental and behavioral pediatrics (DBP).4,611

In 1978, the Task Force on Pediatric Education recommended increased training during pediatric residency in child development and behavior.12 In 1997, the Residency Review Committee (RRC) mandated training in DBP with specific new objectives. According to RRC guidelines, pediatric residency training programs are now required to have both a block rotation and a longitudinal curriculum in DBP.13 The Ambulatory Pediatric Association has also developed specific goals and objectives for teaching DBP to residents.14 However, little is known about how pediatric residency programs are currently responding to the RRC training guidelines and what resources are available for teaching DBP. Given the complexities of developmental and behavioral concerns in children and adolescents, case-based discussion may offer an ideal teaching method. While case-based teaching has been used extensively in medical schools, not much is known about the use of standardized cases in pediatric resident education.1519

The objective of the current study was to determine the teaching methods, materials currently used, and unmet needs for teaching developmental-behavioral pediatrics at pediatric training programs in the United States.

SURVEY INSTRUMENT

A 92-item pediatric residency program survey was developed and pilot-tested as previously described.20 The survey consisted of 3 sections: a residency program director survey, a DBP survey, and an adolescent medicine survey. Only the DBP survey results and selected results for the program director survey will be reported in this article. The DBP survey contained questions about the person completing the form, presence of a formal curriculum in DBP, teaching materials currently used and desired, DBP faculty and trainers, and a series of 5-point Likert scale21 questions about the frequency with which various teaching methods were used (from 1, never, to 5, very frequently). Given a checklist of 7 items, programs were asked to identify teaching materials they currently used and those they would find helpful. Programs were also asked to indicate on a checklist which of 17 specific content topics they believed were adequately covered in their present curriculum. Finally, there were open-ended questions asking whether programs had adequate faculty and what barriers existed for DBP teaching.

SUBJECTS

Survey packets were mailed in January 1997 to 211 programs identified by mailing labels from the Association of Pediatric Program Directors. The packet was sent to residency directors, asking them to either complete the survey or forward it to a DBP faculty member for completion. An instructional video in pelvic examination was offered as an incentive for completion of all 3 sections of the program survey. Reminder telephone calls were made at 3 months.

ANALYSIS

Programs completing both the program director and DBP surveys were included in the analysis. Data were entered and analyzed using SPSS 8.0 for Windows statistical software.22 Categorical variables were analyzed using Pearson χ2 or Fisher exact tests. Mann-Whitney tests were used for group comparison of continuous variables since they were not normally distributed.

One hundred forty-eight (70%) of 211 programs returned both the program director and DBP surveys. The person completing the DBP survey was a DBP faculty member (55%), the residency director (35%), or the chief resident or fellow (2%). In the remaining cases, the person was listed as other than residency director but not specified (3%) or not identified (5%). Ninety-five percent of programs reported having a block rotation in DBP. Of those programs with a block rotation, 95% stated that the rotation was mandatory. Most (78%) reported a 4-week block; however, 13% of programs reported a 5- to 8-week rotation. Other training in DBP occurred as follows:

Eighty-seven percent of programs reported having a "formal curriculum" (eg, rotations, lectures, readings), and 82% had a specific faculty coordinator. The faculty supervising residents included fellowship-trained developmental-behavioral pediatricians (79% of programs), psychologists (59%), and general pediatricians (47%). Less commonly cited were adult and child neurologists, adult and child psychiatrists, nurse practitioners, and social workers (each reported by fewer than 30% of programs) (Table 1).

Table Graphic Jump LocationTable 1. Faculty Supervising Residents in Their Clinical Developmental-Behavioral Pediatrics Training Programs

The materials most commonly used for teaching DBP included articles and chapters (93% of programs) and lecture outlines (80%). Few programs stated they would find additional articles, chapters, or lecture outlines helpful. Teaching materials least commonly used included standardized written cases (20%), computerized cases (3%), and CD-ROMs (1%); however, most programs indicated that they would find these materials helpful for teaching DBP (Figure 1). In response to open-ended questions, programs indicated that they would find specific materials, including standardized written cases, videos, computer programs, slide series, specific assessment tools, and pretests and posttests, helpful for teaching DBP.

Place holder to copy figure label and caption

Materials used to teach developmental-behavioral pediatrics and the need for additional resources.

Graphic Jump Location

The teaching methods used frequently or very frequently included precepting (94% of programs), independent reading (82%), and informal discussion (67%). Videotapes and grand rounds were used frequently or very frequently as a format for DBP teaching by only about a quarter of programs. Standardized written cases and computer materials, in contrast, were used infrequently (13% and 2% of programs, respectively) (Table 2).

Table Graphic Jump LocationTable 2. Methods Used "Frequently" or "Very Frequently" in Teaching Developmental-Behavioral Pediatrics

Fifty-one percent of programs reported that they did not have an adequate number of faculty to teach DBP. However, having adequate faculty was not associated with having either a faculty coordinator (95% adequate faculty vs 92% inadequate, P = .72) or a formal curriculum (91% adequate faculty vs 89% inadequate, P = .65). There was no association between having a formal curriculum and the teaching methods used except for case discussion. There was a significant association between programs having a formal curriculum and those using informal case discussion for teaching DBP (Mann-Whitney test, 613.0; P = .046).

Most programs reported that the following topics were covered adequately in their residency training programs: attentional and learning disorders (88%), normal development (87%), and normal behavior (80%). Discipline, mental retardation, toilet training, and child abuse were reported as adequately covered by at least 60% of programs. Sleep disturbance, sexual abuse, and behavior problems were covered adequately by at least 50% of programs (Table 3). Residency directors were more likely than DBP faculty to report that "normal behavior" was adequately covered (P = .02). Developmental-behavioral pediatrics faculty were more likely than residency directors to report that cognitive disabilities (P = .01) and discipline/behavior management were adequately covered (P = .02).

Table Graphic Jump LocationTable 3. Pediatric Residency Programs Reporting That Specific Developmental-Behavioral Pediatrics Topics Are Adequately Covered in Their Current Curriculum

The 4 topics least often reported as adequately covered were adoption (12% of programs), violence (24%), substance use (28%), and conduct problems (41%). A sum score of the total number of these "psychosocial topics" reported as covered adequately by each program was created for purposes of further analysis. Forty-four percent of programs covered none of the 4 topics adequately, 28% covered 1 topic adequately, and only 7% of programs covered all 4 topics adequately. There was no association between coverage of these 4 topics and having a formal curriculum. However, there was a significant association between coverage of the 4 topics and the specific teaching materials used. Programs that reported using written cases perceived that they covered a higher number of the 4 psychosocial topics adequately than those programs not using written cases (Mann-Whitney test, 1373.5; P = .04).

Responses to open-ended questions indicated that a number of barriers exist to teaching DBP, including lack of time, money, teaching and curricular resources; limited faculty; lack of coordination of resources; lack of department support; and lack of integration into the pediatric residency training program. Developmental and behavioral pediatrics was seen as a broad and time-consuming field, which further hampered reimbursement and teaching. As noted earlier, programs felt limited by inadequate resources and evaluation tools. In addition, some programs commented on lack of clinical material and/or sites as a barrier, including the following: "We do not have a method to guarantee that each resident covers a wide breadth of topics in the area. Teaching cases would round out experiences." "The most important thing is real case material and effective faculty. Computer-based and video material would augment this."

Our survey results indicate that nearly all of the pediatric residency programs that responded are in compliance with the RRC mandate for a formal curriculum and block rotation in DBP. The number of residency programs that require training in DBP has increased consistently since the 1978 Task Force Report. In 1984, a survey of US residency programs showed that 49% offered formal training in DBP, 46% had mandatory training in DBP, and 27% used a block rotation.6 More recently, a 1993 survey of pediatric training programs found 73% of programs offered a mandatory rotation, with 89% offering some training in DBP.9 Thirty-nine percent of programs used a specific curriculum. The current survey shows that the percentages of programs offering a mandatory rotation (95%) and using a specific curriculum (87%) have increased further. The number of faculty specializing in DBP has also increased, possibly reflecting the increased fellowship training available in this field and programs' response to the RRC requirements that "the resident must be directly supervised throughout the experience by faculty with training in behavioral-developmental pediatrics."13 However, consistent with previous surveys of residency training,6,7,9,23 many programs do not feel they are adequately covering all content areas. Many barriers still exist, including lack of faculty, time, and effective teaching materials. Part of the difficulty in teaching DBP centers around the contextual nature of the problems and the fact that there is rarely one standard management technique or "textbook" answer that will be effective in all cases. Learning the management of behavioral problems may require actual practice, precepting, and discussion of alternative approaches, all of which take extra faculty time and resources.

Most responding programs indicated an interest in obtaining additional case-based materials for their DBP curricula. Over the past decade, the importance of adult learning styles has been appreciated, and the use of case-based learning and group discussion has been extensively tested and evaluated in medical schools.1518 In contrast, most materials developed in residency training programs are lecture outlines, texts, slides, and collections of relevant articles. Curricula are not generally learner centered; that is, the learners do not participate in identifying learning goals for the teaching sessions. Case-based materials encourage a more active learning experience for the student and are generally well received by learners. However, there are limited data on the use of case-based learning in pediatric residency programs, although Rosenblum et al19 did outline the positive value of case-based teaching in the setting of senior rounds.

It is possible that case-based teaching has been used more commonly in the medical school setting than in residency training programs because of limitations on faculty and resident time. During undergraduate years, case discussions may take place over several sessions, with students doing independent reading and research in the interim. This approach is more difficult to use in postgraduate hospital-based training because of the demands of providing clinical care. However, the case-based approach may be ideal for teaching about complex psychosocial/behavioral problems during residency. Discussion allows for consideration of multiple approaches and management strategies and allows mutual learning within the group. Our survey demonstrated that programs using written cases to teach DBP perceived that they covered a higher number of complex psychosocial topics adequately than those programs not using cases. It is not possible from the survey format to demonstrate a cause-and-effect relationship between use of cases and coverage of these specific topics; however, the data do suggest an association. Further studies are needed on the use of interactive approaches to teaching DBP in residency programs. In addition, programs that had a formal curriculum were more likely to use case-based teaching. This may reflect an increased breadth of training methods used with a formal curriculum. Case-based materials take more time and money to develop than lectures and handouts and require dedicated, trained faculty for teaching sessions.

One important limitation of this study is the nonresponse rate of 30%. We do not have any information on how nonresponding programs are teaching DBP. These programs may be more likely to lack a formal block rotation and curriculum, and it would be helpful to assess their needs as well. Our response rate is fairly consistent with prior surveys of DBP training, however. For example, Zebal and Friedman6 had a 60% response rate in 1984 and Teplin et al9 had a 73% response rate in 1993. For programs that did respond, we do not have information about methods used for teaching specific topics. In addition, this survey assessed only faculty perception of training adequacy. There is no confirmatory evidence of the actual adequacy of their training. It is likely that there is some respondent bias as well; program directors and faculty might be likely to overreport adequacy of training. Despite the likelihood of respondent bias, these same respondents are probably the best to comment on barriers to training.

The reason for the difference in perception of program directors vs DBP faculty regarding the adequacy of training in certain topic areas might be explained by differences in training, clinical practice, and curricular responsibilities. Normal behavior may be covered by DBP rotations in some programs, but in others may be embedded throughout the residents' curriculum or concentrated in the continuity clinic or the newborn nursery, settings where residents get the greatest exposure to normal behavior and development in children. Developmental-behavioral pediatric faculty and program directors might also have different expectations for what defines adequate coverage of certain topics. It is likely that DBP faculty would have greater knowledge of how well topics such as cognitive disabilities and behavior management are covered, as these topics are more likely to be specifically addressed during a DBP rotation.

Dworkin et al4 and Breunlin et al5 did look at learners' perceptions of the adequacy of their training. However, no survey has looked at learners' or graduates' perceptions since the new RRC guidelines have been in effect. In addition, direct assessment of the adequacy of training through competency measurement is the criterion standard, but it is difficult to accomplish. It would be important for future studies to look at learner perceptions as well as the actual competency of learners to better assess the adequacy of their training.

Residency programs have made significant gains in mandatory DBP training. However, many programs report a lack of adequate teaching methods, which may contribute to inadequate training. In response to our query, many programs indicated an interest in case-based materials for their DBP curricula. This learner-centered approach may represent an alternative and underutilized approach for teaching DBP. Standardized written cases would allow for teaching in settings with variable patient demographics and broaden faculty resources available to diverse training sites.

Accepted for publication March 19, 1999.

This study was supported in part by project grants MCJ 259368 (Drs Frazer, Emans, Goodman, Bravender, and Knight, and Ms Luoni), MCJ259195, MCJ259360 (Dr Knight), and MCJ009163, from the Maternal and Child Health Bureau (Title V, Social Security Act), Health Resources and Services Administration, Department of Health and Human Services, Washington, DC.

Presented in part at the Ambulatory Pediatrics Association Annual Meeting, New Orleans, La, May 4, 1998.

We thank James Simon, MD, Russell Chesney, MD, Robert DuRant, PhD, Frederick Lovejoy, Jr, MD, Jonathan Finkelstein, MD, Estherann Grace, MD, Henry Bernstein, DO, Arthur Elster, MD, Richard Kreipe, MD, and Gwendolyn Gladstone, MD, for development of the questionnaire; all the program directors and developmental/behavioral pediatrics faculty who responded to the survey; and the Maternal and Child Health Bureau.

Editor's Note: As the demands for practicing in managed cost environments increase, I'm afraid that developmental-behavioral teaching is not the only education victim. Time, money, and other resources seem to disappear from the teaching mission first.—Catherine D. DeAngelis, MD

Corresponding author: Carolyn H. Frazer, MD, Department of Medicine–General Pediatrics, Children's Hospital, 300 Longwood Ave, Boston, MA 02115 (e-mail: frazer@a1.tch.harvard.edu).

First  LRPalfrey  JS The infant or young child with developmental delay. N Engl J Med. 1994;330478- 483
Link to Article
Terman  DLLarne  MBStevenson  CSBehrman  RE Special education for students with disabilities: analysis and recommendations. Future Child. Spring 1996;64- 24
Link to Article
Palfrey  JS Community Child Health: An Action Plan for Today.  New York, NY Praeger Publishers1994;31- 42
Dworkin  PHShonkoff  JPLeviton  ALevine  MD Training in developmental pediatrics: how practitioners perceive the gap. Am J Dis Child. 1979;133709- 712
Link to Article
Breunlin  DCMann  BJRichtsmeier  ALillian  ZRichman  JSBernotas  T Pediatricians' perceptions of their behavioral and developmental training. J Dev Behav Pediatr. 1990;11165- 169
Link to Article
Zebal  BHFriedman  SB A nationwide survey of behavioral pediatric residency training. J Dev Behav Pediatr. 1984;5331- 335
Link to Article
Bennett  FCGuralnick  MJRichardson  HB  JrHeiser  KE Teaching developmental pediatrics to pediatric residents: effectiveness of a structured curriculum. Pediatrics. 1984;74514- 522
Yancy  WSCoury  DLDrotar  DGottlieb  MIKohen  DPSarles  RM A curriculum guide for developmental-behavioral pediatrics. J Dev Behav Pediatr. 1988;9(suppl 6)S1- S8
Link to Article
Teplin  SWKuhn  THPalsha  SA Preparing residents for Public Law 99-457: a survey of pediatric training programs. Am J Dis Child. 1993;147175- 179
Link to Article
Guralnick  MJBennett  FCHeiser  KERichardson  HBShibley  RE Training residents in developmental pediatrics: results from a national replication. J Dev Behav Pediatr. 1987;8260- 265
Link to Article
Phillips  SFriedman  SBZebal  BH The impact of training in behavioral pediatrics: a study of 24 residency programs. J Dev Behav Pediatr. 1984;615- 21
Task Force on Pediatric Education, The Future of Pediatric Education.  Evanston, Ill American Academy of Pediatrics1978;
Accreditation Council for Graduate Medical Education, Program requirement for education in pediatrics. Graduate Medical Education Directory Chicago, Ill American Medical Association1997;
Trimm  F Developmental and behavioral pediatrics. Kittredge  Dand APA Education Committee. Ambulatory Pediatric Association (APA) Educational Guidelines for Residency Training in General Pediatrics McLean, Va Ambulatory Pediatrics Association1996;133- 144
Armstrong  EG A hybrid model of problem-based learning. Boud  DFeletti  Geds.The Challenge of Problem-Based Learning 2nd ed. London, England Kogan Page Publishers1997;137- 150
Glick  THArmstrong  EG Crafting cases for problem-based learning: experience in a neuroscience course. Med Educ. 1996;3024- 30
Link to Article
Wetzel  MS Problem-based learning: an update on problem-based learning at Harvard Medical School. Ann Community Oriented Educ. 1994;7237- 247
Not Available, A new pathway for medical education Harvard Med Alumni Bull. Winter 1984;5814- 24
Rosenblum  NDNagler  JLovejoy  FH  JrHafler  JP The pedagogic characteristics of a clinical conference for senior residents and faculty. Arch Pediatr Adolesc Med. 1995;1491023- 1028
Link to Article
Emans  SJBravender  TKnight  J  et al.  Adolescent medicine training in pediatric programs: are we doing a good job? Pediatrics. 1998;102588- 595
Link to Article
Edwards  ALKilpatrick  FP Scale analysis and the measurement of social attitudes. Psychometrika. 1948;1399- 114
Link to Article
Not Available, SPSS for Windows Base System User's Guide, Release 8.0.  Chicago, Ill SPSS Inc1998;
Weinberger  HLOski  FA A survey of pediatric resident training programs 5 years after the Task Force report. Pediatrics. 1984;74523- 526

Figures

Place holder to copy figure label and caption

Materials used to teach developmental-behavioral pediatrics and the need for additional resources.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Faculty Supervising Residents in Their Clinical Developmental-Behavioral Pediatrics Training Programs
Table Graphic Jump LocationTable 2. Methods Used "Frequently" or "Very Frequently" in Teaching Developmental-Behavioral Pediatrics
Table Graphic Jump LocationTable 3. Pediatric Residency Programs Reporting That Specific Developmental-Behavioral Pediatrics Topics Are Adequately Covered in Their Current Curriculum

References

First  LRPalfrey  JS The infant or young child with developmental delay. N Engl J Med. 1994;330478- 483
Link to Article
Terman  DLLarne  MBStevenson  CSBehrman  RE Special education for students with disabilities: analysis and recommendations. Future Child. Spring 1996;64- 24
Link to Article
Palfrey  JS Community Child Health: An Action Plan for Today.  New York, NY Praeger Publishers1994;31- 42
Dworkin  PHShonkoff  JPLeviton  ALevine  MD Training in developmental pediatrics: how practitioners perceive the gap. Am J Dis Child. 1979;133709- 712
Link to Article
Breunlin  DCMann  BJRichtsmeier  ALillian  ZRichman  JSBernotas  T Pediatricians' perceptions of their behavioral and developmental training. J Dev Behav Pediatr. 1990;11165- 169
Link to Article
Zebal  BHFriedman  SB A nationwide survey of behavioral pediatric residency training. J Dev Behav Pediatr. 1984;5331- 335
Link to Article
Bennett  FCGuralnick  MJRichardson  HB  JrHeiser  KE Teaching developmental pediatrics to pediatric residents: effectiveness of a structured curriculum. Pediatrics. 1984;74514- 522
Yancy  WSCoury  DLDrotar  DGottlieb  MIKohen  DPSarles  RM A curriculum guide for developmental-behavioral pediatrics. J Dev Behav Pediatr. 1988;9(suppl 6)S1- S8
Link to Article
Teplin  SWKuhn  THPalsha  SA Preparing residents for Public Law 99-457: a survey of pediatric training programs. Am J Dis Child. 1993;147175- 179
Link to Article
Guralnick  MJBennett  FCHeiser  KERichardson  HBShibley  RE Training residents in developmental pediatrics: results from a national replication. J Dev Behav Pediatr. 1987;8260- 265
Link to Article
Phillips  SFriedman  SBZebal  BH The impact of training in behavioral pediatrics: a study of 24 residency programs. J Dev Behav Pediatr. 1984;615- 21
Task Force on Pediatric Education, The Future of Pediatric Education.  Evanston, Ill American Academy of Pediatrics1978;
Accreditation Council for Graduate Medical Education, Program requirement for education in pediatrics. Graduate Medical Education Directory Chicago, Ill American Medical Association1997;
Trimm  F Developmental and behavioral pediatrics. Kittredge  Dand APA Education Committee. Ambulatory Pediatric Association (APA) Educational Guidelines for Residency Training in General Pediatrics McLean, Va Ambulatory Pediatrics Association1996;133- 144
Armstrong  EG A hybrid model of problem-based learning. Boud  DFeletti  Geds.The Challenge of Problem-Based Learning 2nd ed. London, England Kogan Page Publishers1997;137- 150
Glick  THArmstrong  EG Crafting cases for problem-based learning: experience in a neuroscience course. Med Educ. 1996;3024- 30
Link to Article
Wetzel  MS Problem-based learning: an update on problem-based learning at Harvard Medical School. Ann Community Oriented Educ. 1994;7237- 247
Not Available, A new pathway for medical education Harvard Med Alumni Bull. Winter 1984;5814- 24
Rosenblum  NDNagler  JLovejoy  FH  JrHafler  JP The pedagogic characteristics of a clinical conference for senior residents and faculty. Arch Pediatr Adolesc Med. 1995;1491023- 1028
Link to Article
Emans  SJBravender  TKnight  J  et al.  Adolescent medicine training in pediatric programs: are we doing a good job? Pediatrics. 1998;102588- 595
Link to Article
Edwards  ALKilpatrick  FP Scale analysis and the measurement of social attitudes. Psychometrika. 1948;1399- 114
Link to Article
Not Available, SPSS for Windows Base System User's Guide, Release 8.0.  Chicago, Ill SPSS Inc1998;
Weinberger  HLOski  FA A survey of pediatric resident training programs 5 years after the Task Force report. Pediatrics. 1984;74523- 526

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