Journal of Adolescent Health 55 (2014) 301e303
www.jahonline.org Adolescent health brief
Measuring Pediatric Resident Competencies in Adolescent Medicine Paritosh Kaul, M.D. a, *, Jennifer Gong, Ph.D. b, Gretchen Guiton, Ph.D. c, Adam Rosenberg, M.D. d, and Gwyn Barley, Ph.D. b a
Section of Adolescent Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado d Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado b c
Article history: Received February 21, 2014; Accepted May 7, 2014 Keywords: Adolescent medicine education; Resident education; Medical education
A B S T R A C T
Purpose: To compare third-year pediatric resident competence on an adolescent medicine with competence in treating younger children. Methods: The participants were third-year residents (2010 [n ¼ 24] and 2011 [n ¼ 23]) at University of Colorado School of Medicine. Resident competence was measured in the domains of professionalism, communication, and history-taking skills in a multicase Objective Structured Clinical Examination. Results: Percent correct scores in professionalism, history-taking, and communication skills on the adolescent case ranked in the bottom half of cases in both years. T-tests comparing mean score difference between the adolescent case and pediatric cases combined were statistically significant for professionalism (79.57 4.15 vs. 89.51 14.14, p ¼ .01) and history taking (66.27 11.02 vs. 75.10 18.40, p ¼ .05). Conclusions: Resident’s history taking addressed immediate issues but not public health issues with adolescents. The professionalism findings suggest that residents engage in less patientcentered care when caring for adolescents, even while their communication skills remain on par. Ó 2014 Society for Adolescent Health and Medicine. All rights reserved.
Adolescents and young adults constitute 21% of the U.S. population [1] and 11.5% of annual visits to pediatric physicians’ offices [2]. There is a shortage of board-certified adolescent medicine specialists with a proportion of 1 in 105,001 adolescents [3]. Almost 20 years ago, pediatric residencies were mandated to provide a month-long training in adolescent medicine. Despite this mandate, pediatricians still feel poorly trained in taking care of adolescents [4]. Fox et al. [5] surveyed pediatric Conflicts of Interest: The authors have no conflicts of interest or financial disclosures. * Address correspondence to: Paritosh Kaul, M.D., Section of Adolescent Medicine, University of Colorado e School of Medicine, Children’s Hospital Colorado, 13123 East 16th Avenue, Box B025, Aurora, CO 80045. E-mail address: [email protected] (P. Kaul).
IMPLICATIONS AND CONTRIBUTION
Third-year pediatric resident competence on an adolescent medicine case showed that while residents were able to effectively communicate with the patient, they were less able to gather information or engage in patientcentered care. Educational efforts need to advance competency in both content and process when caring for adolescents.
residency program directors and faculty responsible for adolescent medicine training in pediatric programs. Their findings confirmed that previously identified problems from a decade ago persist [6]. In brief, there is great variability in training across programs, mental health and behavioral issues are poorly covered if at all, and the actual time spent with adolescents is minimal [7]. To assess competency in adolescent medicine and evaluate the clinical curriculum, all third-year pediatric residents completed a multistation Objective Structured Clinical Examination (OSCE). The OSCE involves standardized patients (SPs) who play roles depicting real patients. This OSCE tested competence in the six Accreditation Council for Graduate Medical Education (ACGME) competencies of patient care,
1054-139X/$ e see front matter Ó 2014 Society for Adolescent Health and Medicine. All rights reserved. http://dx.doi.org/10.1016/j.jadohealth.2014.05.003
302
P. Kaul et al. / Journal of Adolescent Health 55 (2014) 301e303
medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. Given the difficulties, pediatric residents demonstrate when working with adolescents and the issues identified by pediatric residency program directors, we hypothesized that residents would perform better on the nonadolescent cases as compared with adolescent cases across the ACGME competencies. Methods The participants were all third-year pediatric residents at the University of Colorado School of Medicine, in 2010 (n ¼ 24) and 2011 (n ¼ 23). The residents were mainly female (73%) and white (89%). The adolescent medicine rotation was for 4 weeks in the first year of the pediatric residency. The rotation included lectures on adolescent interviewing, contraception, menstrual disorders, violence, and mental health issues. In addition, teaching occurred on a case-by-case basis during the rotation. The setting for the rotation was in the ambulatory setting. It consisted of working with adolescents in adolescent clinics (tertiary center and federally qualified health center), school-based health centers, eating disorder intake, and a field trip to a substance abuse program. The residents did not receive any specific adolescent medicine training in the second and third years of the residency. Their exposure to adolescent patients was in the hospitalized adolescent and in their ambulatory continuity clinic settings. To assess resident competency and evaluate the clinical curriculum, all residents completed a six-station OSCE at the end of the third year of the residency. Although OSCEs are widely recognized as reliable measures of performance, there is a paucity of published literature regarding adolescent SPs. This literature is mainly among medical students [7,8] and not for pediatric residents. In addition, we were not aware of any published data from another training site which indicates that pediatric residents perform better on the general pediatrics OSCE cases as compared with adolescent medicine cases. The data were recorded from a multistation OSCE. The SPs completed a 15- to 20-item checklist rating the resident’s skill and competency in each case. The program director in consultation with content experts developed the OSCE to assess the competencies taught across residency training. The cases and checklists were designed and reviewed to assure content validity. The reliability for each case and each standardized patient was calibrated using trained observers viewing live cases. The adolescent case, performed by a young looking 23-yearold white actress, depicted a 16-year old coming in for a sports physical with no high-risk behaviors. The SPs received 3 hours of training. The reliability of SPs was checked using an independent trained observer. Once an SP was deemed to perform reliably, observers no longer rated the OSCE station. The other cases were
pediatric patients with asthma, attention deficit disorder, a wellchild visit, a telephone triage, and a child abuse situation. The study focused on history taking and the six ACGME core competencies. History-taking items, medical knowledge, and systems-based practice were rated on a two-point scale as performed or not performed. The four ACGME competencies of patient care, practice-based learning and improvement, interpersonal and communication skills, and professionalism were rated on a fivepoint scale, of always, most of the time, some of the time, rarely, and never. The competencies of patient care, medical knowledge, and practice-based learning were assessed with three, two, and two items, respectively. Communications skills, professionalism, and systems-based practice had four, five, and three items, respectively. The areas assessed in history taking included home, school, work, diet, activities, tobacco, alcohol, illicit drugs, depression, suicide, sexuality, and safety [9]. On review of the 2010 data, checklist items were modified to elicit more specific responses from the interview in the areas of home, school, sexuality, and safety (e.g., in 2010, the standardized patient was asked about home and in 2011, the same question was specified to include parents and siblings). There were 12 history-taking items in 2010 and 18 in 2011. The residents in both years received the required 4-week training in adolescent medicine. Descriptive statistics were computed using SPSS version 18 (SPSS, Inc., Chicago, IL). The study was approved by the Colorado Multi-institutional institutional review board. Results Percent correct scores in professionalism, history-taking, and communication skills on the adolescent case ranked in the bottom half of six cases seen by residents in both 2010 and 2011. Overall residents performed less well on the adolescent case than the average of nonadolescent cases (Table 1). T-tests comparing mean score difference between the adolescent and nonadolescent cases combined were statistically significant for professionalism (79.57 4.15 vs. 89.51 14.14, p ¼ .01) and history taking (66.27 11.02 vs. 75.10 18.40, p ¼ .05). With regard to the category of professionalism in the adolescent case, residents more often failed to elicit feelings and/ or thoughts about concerns, respond to patient needs, and convey compassion. Changes in the rating checklist for history taking in 2011 enabled a more detailed view of what residents were and were not asking their adolescent patient. The topics residents failed to ask during history taking are described in Table 2. Discussion These results deserve attention for a number of reasons. First, they suggest that pediatric residents are not receiving the
Table 1 History-taking, communication, and professionalism scores by type of case, 2010 and 2011 2010, Mean (Standard deviation)
History taking Communication Professionalism * **
p ¼ .05 level. p ¼ .01 level.
2011, Mean (Standard deviation)
Adolescent case
Nonadolescent case
Adolescent case
Nonadolescent case
71.87 (14.4) 85 (11.59) 92.17 (10.92)
77.91 (17.11) 89.45 (16.09) 93.13 (18.54)
66.27 (11.02)* 80.43 (6.32) 79.57 (4.15)**
75.10 (18.40) 84.15 (12.69) 89.51 (14.14)
P. Kaul et al. / Journal of Adolescent Health 55 (2014) 301e303 Table 2 Percent of resident asking content-specific questions 2011 Content
2011 (n ¼ 23)
Working (employment) Seat belt usage Sexual orientation Siblings Diet Safe driving Suicide Violence at home
0% 8.7% 13.0% 26.1% 39.1% 52.2% 60.9% 69.6%
appropriate education and experience in the care of adolescents. Second, as the Accountable Care Act was enacted in 2013, we will see many of the over 4,000,000 uninsured adolescents becoming insured [10]. Adolescents are presently the least likely to have access to health care, and use less primary care, than any age group. The proportion of children who receive well-care visits declines with age. Only 70% of 10- to 14-year-olds and 67% of 15- to 17-year-olds received preventive health care in 2008. Even if these usage rates remain the same, the increase in the number of insured adolescents means that not only pediatricians but all primary care providers will see greater numbers of adolescents in their offices. All the primary care specialties, advanced practice nurses and physician’s assistants will need more education in adolescent medicine to achieve our goals in caring for this important population. Limitations Our study is limited in that it was conducted at one pediatric residency program, and results were measured using a single adolescent case. Our results may not be generalizable to cases of other adolescent health problems or other residency sites or specialties. The study compares case performance and does not include a control group. Although multiyear, our numbers are small. In addition, we are unable to measure the impact of the addition of questions in the second year of the study. We do not have data to assess the adolescent medicine exposure residents received in the inpatient and ambulatory settings during the second and third years of the residency. In addition, the OSCE was given at a minimum of 2 years after the residents’ exposure to their adolescent medicine rotation. Conclusions Third-year residents performed less competently on the adolescent case than other required pediatric cases. The data
303
show that residents remain unaware of many common elements of adolescent life such as employment status, seat belt use, sexual orientation, siblings, and diet that have consequences for providing quality health care and opportunities for healthy living in this population. The professionalism findings suggest that residents engage in less patient-centered care when caring for adolescents, even while their communication skills remain on par for other case types. Findings that showed generally lower scores on sexual orientation and siblings suggest that residents were not building strong relationships with their adolescent patients. These study findings suggest that residents are not receiving a consistent quality and quantity of adolescent competency development and clinical experience to develop the skills required to effectively care for adolescents as individuals and as a population. Further studies are needed to explore resident attitudes toward caring for adolescents and the relationship to curricular experiences. In addition, programs promoting patient-centered care within the framework of adolescent health will need to carefully document their effectiveness and provide best practice information for widespread adoption.
References [1] U.S. Census Bureau. 2008 population estimates: National characteristics, national sex, age, race and Hispanic origin. Washington. Available at:, http://www.census.gov/popest/data/historical/2000s/vintage_2008/index. html; 2008. Accessed February 18, 2014. [2] American Academy of Pediatrics. Profile of pediatric visits April 2010. Available at: http://www.aap.org/en-us/professional-resources/practicesupport/financing-and-payment/Billing-and-Payment/Documents/Profile_ Pediatric_Visits.pdf. Accessed May 6, 2014. [3] Althouse LA, Stockman JA 3rd. Pediatric workforce: A look at adolescent medicine data from the American Board of Pediatrics. J Pediatr 2007;150. 100e2.e2. [4] Fox HB, McManus MA, Klein JD, et al. Adolescent medicine training in pediatric residency programs. Pediatrics 2010;125:165e72. [5] Fox HB, McManus MA, Diaz A, et al. Advancing medical education training in adolescent health. Pediatrics 2008;121:1043e5. [6] Emans SJ, Bravender T, Knight J, et al. Adolescent medicine training in pediatric residency programs: Are we doing a good job? Pediatrics 1998; 102(3 Pt 1):588e95. [7] Kaul P, Barley G, Guiton G. Medical student performance on an adolescent medicine examination. J Adolesc Health 2012;51:299e301. [8] Blake K. Sex, drugs, and rock and roll-teaching with adolescent standardized patients. Med Teach 2009;31:571e3. [9] Klein DA, Goldenring JM, Adelman WP. HEEADSSS 3.0: The psychosocial interview for adolescent updated for a new century fueled by media. Contemp Pediatr:1e16. Available at: http://contemporarypediatrics. modernmedicine.com/contemporary-pediatrics/news/probing-scars-howask-essential-questions?page¼full; Jan 2014. Accessed May 6, 2014. [10] Summary health statistics for U.S. children: National Health Interview Survey, 2011. Virtual and Health Statistics 10 (254), December 2012.
www.jahonline.org Adolescent health brief
Measuring Pediatric Resident Competencies in Adolescent Medicine Paritosh Kaul, M.D. a, *, Jennifer Gong, Ph.D. b, Gretchen Guiton, Ph.D. c, Adam Rosenberg, M.D. d, and Gwyn Barley, Ph.D. b a
Section of Adolescent Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado d Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado b c
Article history: Received February 21, 2014; Accepted May 7, 2014 Keywords: Adolescent medicine education; Resident education; Medical education
A B S T R A C T
Purpose: To compare third-year pediatric resident competence on an adolescent medicine with competence in treating younger children. Methods: The participants were third-year residents (2010 [n ¼ 24] and 2011 [n ¼ 23]) at University of Colorado School of Medicine. Resident competence was measured in the domains of professionalism, communication, and history-taking skills in a multicase Objective Structured Clinical Examination. Results: Percent correct scores in professionalism, history-taking, and communication skills on the adolescent case ranked in the bottom half of cases in both years. T-tests comparing mean score difference between the adolescent case and pediatric cases combined were statistically significant for professionalism (79.57 4.15 vs. 89.51 14.14, p ¼ .01) and history taking (66.27 11.02 vs. 75.10 18.40, p ¼ .05). Conclusions: Resident’s history taking addressed immediate issues but not public health issues with adolescents. The professionalism findings suggest that residents engage in less patientcentered care when caring for adolescents, even while their communication skills remain on par. Ó 2014 Society for Adolescent Health and Medicine. All rights reserved.
Adolescents and young adults constitute 21% of the U.S. population [1] and 11.5% of annual visits to pediatric physicians’ offices [2]. There is a shortage of board-certified adolescent medicine specialists with a proportion of 1 in 105,001 adolescents [3]. Almost 20 years ago, pediatric residencies were mandated to provide a month-long training in adolescent medicine. Despite this mandate, pediatricians still feel poorly trained in taking care of adolescents [4]. Fox et al. [5] surveyed pediatric Conflicts of Interest: The authors have no conflicts of interest or financial disclosures. * Address correspondence to: Paritosh Kaul, M.D., Section of Adolescent Medicine, University of Colorado e School of Medicine, Children’s Hospital Colorado, 13123 East 16th Avenue, Box B025, Aurora, CO 80045. E-mail address: [email protected] (P. Kaul).
IMPLICATIONS AND CONTRIBUTION
Third-year pediatric resident competence on an adolescent medicine case showed that while residents were able to effectively communicate with the patient, they were less able to gather information or engage in patientcentered care. Educational efforts need to advance competency in both content and process when caring for adolescents.
residency program directors and faculty responsible for adolescent medicine training in pediatric programs. Their findings confirmed that previously identified problems from a decade ago persist [6]. In brief, there is great variability in training across programs, mental health and behavioral issues are poorly covered if at all, and the actual time spent with adolescents is minimal [7]. To assess competency in adolescent medicine and evaluate the clinical curriculum, all third-year pediatric residents completed a multistation Objective Structured Clinical Examination (OSCE). The OSCE involves standardized patients (SPs) who play roles depicting real patients. This OSCE tested competence in the six Accreditation Council for Graduate Medical Education (ACGME) competencies of patient care,
1054-139X/$ e see front matter Ó 2014 Society for Adolescent Health and Medicine. All rights reserved. http://dx.doi.org/10.1016/j.jadohealth.2014.05.003
302
P. Kaul et al. / Journal of Adolescent Health 55 (2014) 301e303
medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. Given the difficulties, pediatric residents demonstrate when working with adolescents and the issues identified by pediatric residency program directors, we hypothesized that residents would perform better on the nonadolescent cases as compared with adolescent cases across the ACGME competencies. Methods The participants were all third-year pediatric residents at the University of Colorado School of Medicine, in 2010 (n ¼ 24) and 2011 (n ¼ 23). The residents were mainly female (73%) and white (89%). The adolescent medicine rotation was for 4 weeks in the first year of the pediatric residency. The rotation included lectures on adolescent interviewing, contraception, menstrual disorders, violence, and mental health issues. In addition, teaching occurred on a case-by-case basis during the rotation. The setting for the rotation was in the ambulatory setting. It consisted of working with adolescents in adolescent clinics (tertiary center and federally qualified health center), school-based health centers, eating disorder intake, and a field trip to a substance abuse program. The residents did not receive any specific adolescent medicine training in the second and third years of the residency. Their exposure to adolescent patients was in the hospitalized adolescent and in their ambulatory continuity clinic settings. To assess resident competency and evaluate the clinical curriculum, all residents completed a six-station OSCE at the end of the third year of the residency. Although OSCEs are widely recognized as reliable measures of performance, there is a paucity of published literature regarding adolescent SPs. This literature is mainly among medical students [7,8] and not for pediatric residents. In addition, we were not aware of any published data from another training site which indicates that pediatric residents perform better on the general pediatrics OSCE cases as compared with adolescent medicine cases. The data were recorded from a multistation OSCE. The SPs completed a 15- to 20-item checklist rating the resident’s skill and competency in each case. The program director in consultation with content experts developed the OSCE to assess the competencies taught across residency training. The cases and checklists were designed and reviewed to assure content validity. The reliability for each case and each standardized patient was calibrated using trained observers viewing live cases. The adolescent case, performed by a young looking 23-yearold white actress, depicted a 16-year old coming in for a sports physical with no high-risk behaviors. The SPs received 3 hours of training. The reliability of SPs was checked using an independent trained observer. Once an SP was deemed to perform reliably, observers no longer rated the OSCE station. The other cases were
pediatric patients with asthma, attention deficit disorder, a wellchild visit, a telephone triage, and a child abuse situation. The study focused on history taking and the six ACGME core competencies. History-taking items, medical knowledge, and systems-based practice were rated on a two-point scale as performed or not performed. The four ACGME competencies of patient care, practice-based learning and improvement, interpersonal and communication skills, and professionalism were rated on a fivepoint scale, of always, most of the time, some of the time, rarely, and never. The competencies of patient care, medical knowledge, and practice-based learning were assessed with three, two, and two items, respectively. Communications skills, professionalism, and systems-based practice had four, five, and three items, respectively. The areas assessed in history taking included home, school, work, diet, activities, tobacco, alcohol, illicit drugs, depression, suicide, sexuality, and safety [9]. On review of the 2010 data, checklist items were modified to elicit more specific responses from the interview in the areas of home, school, sexuality, and safety (e.g., in 2010, the standardized patient was asked about home and in 2011, the same question was specified to include parents and siblings). There were 12 history-taking items in 2010 and 18 in 2011. The residents in both years received the required 4-week training in adolescent medicine. Descriptive statistics were computed using SPSS version 18 (SPSS, Inc., Chicago, IL). The study was approved by the Colorado Multi-institutional institutional review board. Results Percent correct scores in professionalism, history-taking, and communication skills on the adolescent case ranked in the bottom half of six cases seen by residents in both 2010 and 2011. Overall residents performed less well on the adolescent case than the average of nonadolescent cases (Table 1). T-tests comparing mean score difference between the adolescent and nonadolescent cases combined were statistically significant for professionalism (79.57 4.15 vs. 89.51 14.14, p ¼ .01) and history taking (66.27 11.02 vs. 75.10 18.40, p ¼ .05). With regard to the category of professionalism in the adolescent case, residents more often failed to elicit feelings and/ or thoughts about concerns, respond to patient needs, and convey compassion. Changes in the rating checklist for history taking in 2011 enabled a more detailed view of what residents were and were not asking their adolescent patient. The topics residents failed to ask during history taking are described in Table 2. Discussion These results deserve attention for a number of reasons. First, they suggest that pediatric residents are not receiving the
Table 1 History-taking, communication, and professionalism scores by type of case, 2010 and 2011 2010, Mean (Standard deviation)
History taking Communication Professionalism * **
p ¼ .05 level. p ¼ .01 level.
2011, Mean (Standard deviation)
Adolescent case
Nonadolescent case
Adolescent case
Nonadolescent case
71.87 (14.4) 85 (11.59) 92.17 (10.92)
77.91 (17.11) 89.45 (16.09) 93.13 (18.54)
66.27 (11.02)* 80.43 (6.32) 79.57 (4.15)**
75.10 (18.40) 84.15 (12.69) 89.51 (14.14)
P. Kaul et al. / Journal of Adolescent Health 55 (2014) 301e303 Table 2 Percent of resident asking content-specific questions 2011 Content
2011 (n ¼ 23)
Working (employment) Seat belt usage Sexual orientation Siblings Diet Safe driving Suicide Violence at home
0% 8.7% 13.0% 26.1% 39.1% 52.2% 60.9% 69.6%
appropriate education and experience in the care of adolescents. Second, as the Accountable Care Act was enacted in 2013, we will see many of the over 4,000,000 uninsured adolescents becoming insured [10]. Adolescents are presently the least likely to have access to health care, and use less primary care, than any age group. The proportion of children who receive well-care visits declines with age. Only 70% of 10- to 14-year-olds and 67% of 15- to 17-year-olds received preventive health care in 2008. Even if these usage rates remain the same, the increase in the number of insured adolescents means that not only pediatricians but all primary care providers will see greater numbers of adolescents in their offices. All the primary care specialties, advanced practice nurses and physician’s assistants will need more education in adolescent medicine to achieve our goals in caring for this important population. Limitations Our study is limited in that it was conducted at one pediatric residency program, and results were measured using a single adolescent case. Our results may not be generalizable to cases of other adolescent health problems or other residency sites or specialties. The study compares case performance and does not include a control group. Although multiyear, our numbers are small. In addition, we are unable to measure the impact of the addition of questions in the second year of the study. We do not have data to assess the adolescent medicine exposure residents received in the inpatient and ambulatory settings during the second and third years of the residency. In addition, the OSCE was given at a minimum of 2 years after the residents’ exposure to their adolescent medicine rotation. Conclusions Third-year residents performed less competently on the adolescent case than other required pediatric cases. The data
303
show that residents remain unaware of many common elements of adolescent life such as employment status, seat belt use, sexual orientation, siblings, and diet that have consequences for providing quality health care and opportunities for healthy living in this population. The professionalism findings suggest that residents engage in less patient-centered care when caring for adolescents, even while their communication skills remain on par for other case types. Findings that showed generally lower scores on sexual orientation and siblings suggest that residents were not building strong relationships with their adolescent patients. These study findings suggest that residents are not receiving a consistent quality and quantity of adolescent competency development and clinical experience to develop the skills required to effectively care for adolescents as individuals and as a population. Further studies are needed to explore resident attitudes toward caring for adolescents and the relationship to curricular experiences. In addition, programs promoting patient-centered care within the framework of adolescent health will need to carefully document their effectiveness and provide best practice information for widespread adoption.
References [1] U.S. Census Bureau. 2008 population estimates: National characteristics, national sex, age, race and Hispanic origin. Washington. Available at:, http://www.census.gov/popest/data/historical/2000s/vintage_2008/index. html; 2008. Accessed February 18, 2014. [2] American Academy of Pediatrics. Profile of pediatric visits April 2010. Available at: http://www.aap.org/en-us/professional-resources/practicesupport/financing-and-payment/Billing-and-Payment/Documents/Profile_ Pediatric_Visits.pdf. Accessed May 6, 2014. [3] Althouse LA, Stockman JA 3rd. Pediatric workforce: A look at adolescent medicine data from the American Board of Pediatrics. J Pediatr 2007;150. 100e2.e2. [4] Fox HB, McManus MA, Klein JD, et al. Adolescent medicine training in pediatric residency programs. Pediatrics 2010;125:165e72. [5] Fox HB, McManus MA, Diaz A, et al. Advancing medical education training in adolescent health. Pediatrics 2008;121:1043e5. [6] Emans SJ, Bravender T, Knight J, et al. Adolescent medicine training in pediatric residency programs: Are we doing a good job? Pediatrics 1998; 102(3 Pt 1):588e95. [7] Kaul P, Barley G, Guiton G. Medical student performance on an adolescent medicine examination. J Adolesc Health 2012;51:299e301. [8] Blake K. Sex, drugs, and rock and roll-teaching with adolescent standardized patients. Med Teach 2009;31:571e3. [9] Klein DA, Goldenring JM, Adelman WP. HEEADSSS 3.0: The psychosocial interview for adolescent updated for a new century fueled by media. Contemp Pediatr:1e16. Available at: http://contemporarypediatrics. modernmedicine.com/contemporary-pediatrics/news/probing-scars-howask-essential-questions?page¼full; Jan 2014. Accessed May 6, 2014. [10] Summary health statistics for U.S. children: National Health Interview Survey, 2011. Virtual and Health Statistics 10 (254), December 2012.
