What Are Risk Factors for Grade Retention?

Patient Presentation
A 6-year-old male came to clinic for a health supervision visit. He was healthy, had friends, and enjoyed swimming and playing soccer. He had struggled in kindergarten with pre-reading concepts and the school was going to have him repeat kindergarten. He had been tested for hearing and vision problems during the previous school year. The family history showed that the father saying that reading was a struggle for him and he still did not like to read. No family members had been retained or needed additional help in school. None had attentional issues.

The pertinent physical exam showed a healthy male with growth parameters in the 10-25% and normal development. His physical examination was unremarkable. The diagnosis of a healthy male who was going to be retained in kindergarten was made. During the interview the father said that the school had recommended him being retained because of his reading problem, that he was more immature than the other students and that he was physically small. He didn’t know if the school was going to give his son any special help with his reading and social skills. “I think they are just going to have him do it again,” he said. The pediatrician voiced her concern that there is little data to support holding a child back to begin kindergarten, nor for retaining in kindergarten, and noted that there was data which showed children who were retained had poorer school and psychosocial development as the children got older. The pediatrician encouraged the father to make an appointment at the school to clarify the reasons for the retention and what interventions the child would receive so he could be successful in kindergarten and/or first grade. The father said that he would think about it “but the school usually knows best.” The pediatrician again encouraged the father to work with the school to monitor his son’s progress over the year.

Discussion
Grade retention is often an emotionally charged discussion and decision. Unfortunately there is not a comprehensive body of research literature to draw upon to make these important decisions. Grade retention is common and costly. An estimated 9.6% of student were retained at least once before 9th grade. One estimate, in Texas in 2006-2007, had a yearly per student cost of $10,162 per retained student or over 2 billion dollars to the Texas school systems.
Research has shown that:

  • Children who are retained have poorer academic achievement than promoted peers
  • After retention, the academic gains from the retained year fade after 2-3 years.
  • Retention often is associated with increased behavior problems – particularly as they get older (i.e. junior high, high school and young adulthood)
  • “Retained students are more likely to have poorer educational and employment outcomes during late adolescence and early adulthood.”
  • “Retention negatively impacts “…all areas of a child’s achievement (reading, math, and language) and socio-emotional adjustment (peer relationships, self-esteem, problem behaviors and attendance).””
  • “Retention is more likely to have benign or positive impact when students are not simply held back, but receive specific remediation to address skill and/or behavioral problems and promote achievement and social skills.

The National Association of School Psychologists recommends alternatives to retention and social promotion (moving a child ahead to the next grade because of age discrepancy with peers without corresponding academic achievement) where the child is promoted with specific individual activities and interventions developed with the educational personnel and family together. These interventions should be put into place and actively monitored to assist the student to be successful in school. Examples include early reading programs, behavior management strategies, mental health programs, tutoring programs, extended school year, etc. The interventions should be multitiered with equal opportunities for students of all backgrounds to learn and “universal screening for academic, behavioral, and social-emotional difficulties.”

Questions for parents to consider when faced with this difficult decision can be found in the To Learn More section below.

Learning Point
Risk factors for grade retention include:

  • Male
  • African-American
  • Hispanic
  • Late birthday (i.e. close to cut off date for beginning school)
  • Developmental delay or attentional issues
  • Behavior problems including aggression and immaturity
  • Living in poverty or single parent household
  • Parents with low educational attainment
  • Language problems including those learning English
  • Inner city location
  • Student mobility

Questions for Further Discussion
1. What are your local school district’s policy (official and unofficial) on grade retention?
2. What resources are available in the schools and community to help students with grade retention/school failure?
3. What is the differential diagnosis of grade retention/school failure?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: School Health and Learning Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Byrd RS, Weitzman ML. Predictors of early grade retention among child in the United States. Pediatrics. 1994;93:481-487.

Byrd RS, Weitzman ML, Auinger P. Increased behavior problems associated with delayed school entry and delayed school progress. Pediatrics. 1997;100:654-611.

Shea Stump, C. Repeating a grade: the pros and cons. GreatSchools.com.
Available from the Internet at http://www.greatschools.org/special-education/health/659-repeating-a-grade.gs?page=1 (cited 9/1/11).

National Association of School Psychologists. Grade retention and social promotion (White
Paper). Bethesda, MD.Available from the Internet at http://www.nasponline.org/about_nasp/positionpapers/WhitePaper_GradeRetentionandSocialPromotion.pdf (rev. 2/26/2011, cited 9/1/2011).

Cortiella, C. The State of Learning Disabilities. National Center for Learning Disabilities, NY, NY. 2011.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Professionalism
    22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.

  • Systems Based Practice
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What Are Indications for IUD Use in Teens?

    Patient Presentation
    An 18-year-old male came to clinic for a health supervision visit. During the interview he acknowledged being sexually active with the same female partner for more than 1 year. They always used male condoms for sexually transmitted infection (STI) protection and he said that his 19 year old partner had an intrauterine device (IUD) for additional contraception. Both partners had been tested for STIs before beginning their sexual relationship and had recently been retested at a health clinic as part of her health care. The pertinent physical exam showed a well male with normal psychosocial development.

    The diagnosis of a healthy male was made. The resident physician congratulated him on consistent condom use and appropriate testing. He reiterated the need for consistent condom use, and also recommended that a spermicide could also be used for additional protection. When discussing the patient with his attending physician, the resident stated that he didn’t know that adolescents and young adults used IUDs. The staff physician agreed that it was a little unusual, but she had seen them used for patients with multiple adolescent pregnancies. Later on the staff physician looked up the American Academy of Pediatrics policy statement on contraception methods and shared it with the resident.

    Discussion
    Intrauterine devices (IUDs) are inserted into the uterus to remain in place for usually 1-10 years. They prevent implantation or fertilization by releasing hormones (progestin) or ions (copper). They are very effective when used appropriately amd are up to 99% successful in preventing pregnancy and they are generally safe. Infection is one of the biggest risks which is why IUDs often are not recommended for adolescents who often are serially monogamous or have multiple partners thus increasing their risk of a STI. Liability is also a concern for an adolescent who may have future infertility problems and attribute them to the IUD use. IUDs do not affect fertility in the absence of an infection.

    Learning Point
    IUDs can be useful in patients who are consistently using STI prevention methods (such as spermicide and condoms) and already have had children and want to prevent pregnancy. IUDs can also be useful for severe menorrhagia and dysmenorrhea.

    Two of the major IUD brands in the US are Mirena®, which releases levonorgestrel for up to 5 years, and ParaGard® which releases copper for up to 10 years. Although there is a low pregnancy rate with IUD use, expulsion of the IUD can occur, usually in the first year of use. Problems with increased bleeding or pain may also cause women to have the IUD removed.

    Questions for Further Discussion
    1. What is the pregnancy failure rate for fertility awareness and periodic abstinence?
    2. What is the pregnancy failure rate for other contraception and family planning?
    3. What are some of the potential side effects of contraceptive methods?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Teen Sexual Health

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Klein JD, American Academy of Pediatrics Committee on Adolescence.Adolescent pregnancy: current trends and issues. Pediatrics. 2005 Jul;116(1):281-6.

    American Academy of Pediatrics Committee on Adolescence, Blythe MJ, Diaz A. Contraception and adolescents. Pediatrics. 2007 Nov;120(5):1135-48.

    Mirena. Bayer Healthcare.
    Available from the Internet at http://www.mirena-us.com/index.jsp?WT.mc_id=MIS119497&WT.srch=1. (cited 8/30/11).

    ParaGard. Duramed Pharmaceuticals Inc.
    Available from the Internet at http://www.paragard.com/ (rev. 2009, cited 8/30/11).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    6. Information technology to support patient care decisions and patient education is used.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.
    16. Learning of students and other health care professionals is facilitated.

  • Professionalism
    22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • When Can Our Patient with Anorexia Go to the Psychiatry Unit?

    Patient Presentation
    An 18-year-old female was admitted to the general pediatric inpatient unit for continued weight loss despite intensive outpatient treatment for her anorexia nervosa. She began having problems 6 months previously when she began to restrict calories to around 500-600 calories/day and increase her running from 2 miles/day to 6 miles/day in addition to the regular sports workouts she had for soccer and basketball. In the outpatient clinic she complained of generalized fatigue and dizziness when standing and walking. She was admitted for medical stabilization prior to her going to the eating disorders unit. The past medical history shows a healthy female with mild intermittent asthma when she was school aged. The family history is negative for eating disorders but positive for anxiety and depression on both sides of the family. The social history found that she was proud to be an “all A” student who liked athletics. The review of systems had her denying purging behaviors and no temperature instability, but did have constipation and amenorrhea.

    The pertinent physical exam showed her weight was <75% for ideal body weight (=body mass index of 16), heart rate of ~30 that was reactive to mid-30s, blood pressure of 86/55, and temperature of 36.8° C. She was gaunt appearing, and wore sweat clothes despite warm temperatures. HEENT – no parotid swelling or dental enamel problems noted. Her thyroid had no masses or enlargement. Lungs were clear. Heart rate was regular but bradycardic. There was a S1, S2 cardiac sounds without a murmur. Abdomen was soft without organomegaly, but generalized stool was noted. Genitourinary exam showed a Tanner Stage V female. Musculoskeletal exam found generalized weakness. She had fine lanugo hair. Neurologically she was intact including no Trousseau sign. Psychiatric examination showed her to be alert and oriented x 4, but with an increased time lag to answering questions. Emotionally she seemed restricted overall yet would be tearful or smiling depending on how distressing the discussion was to her. She stated that she wanted to be hospitalized because she wanted to be healthy. The work-up showed normal electrolytes, amylase, lipase, liver function tests, urinalysis, thyroid function tests, phosphorus, calcium, and complete blood count. Urine pregnancy test and drug screen were negative. An electrocardiogram was consistent with sinus bradycardia without heart block.

    The diagnosis of severe anorexia nervosa was confirmed. The patient was placed on cardiac telemetry with exercise restriction. She was begun on a low fat, low lactose diet with 3 meals/day initially, with the goal of gaining 200-400 g/day. The plan was to increase the meals and snacks to allow for an increase in calories by 400 g every 4 days. During the initial 3 days, she was compliant with the activity restriction and was taking all calories with normal food and no purging. Her heart rate was slowly increasing to the mid-30s consistently. There was a discussion about when she would be ready to go to the eating disorders unit. The inpatient team and the cardiologists were not sure if there was a specific heart rate the patient needed to achieve before transferring. They thought the mid-40s would be appropriate assuming she was otherwise stable because this was the heart rate where patients who are otherwise hemodynamically stable do not need to have a pacemaker placed. With a further literature search and discussions with the psychiatrists, a clinical pathway was found which used a heart rate > 46 beats/minutes as its criterion for being medically compromised but not medically instable, and a clinical report used > 50 beats/minutes as defining a moderate eating disorder (not severe). The team planned to utilize these and other criteria for transfer timing.

    Discussion
    Patients with anorexia nervosa refuse to maintain their body weight at or above a minimally normal weight for age and height (basically less than 85% of expected). They have an intense fear of gaining weight or becoming fat, even though they are underweight. They also have a distorted view of their own body weight or shape and often deny the seriousness of being underweight. For women who are postmenarchal, amenorrhea often occurs.

    Anorexia nervosa can have numerous complications which can be reviewed in the To Learn More section below. Cardiovascular problems include vascular instability with orthostasis, bradycardia and poor perfusion. Conduction abnormalities and repolarization abnormalities are potentially life-threatening requiring aggressive management. Myocardial dysfunction, pericardial effusion and functional mitral valve prolapse also occur. Congestive heart failure can also occur particularly during refeeding, and especially if there are concomitant electrolyte abnormalities also.

    A discussion of common medical tests for evaluation and medical clearance of patients presenting with psychiatric problems can be found here.

    Learning Point
    Hospital admission criteria for anorexia nervosa cited by the American Academy of Pediatrics from the Society for Adolescent Medicine includes:

    • <75% ideal body weight or ongoing weight loss despite intensive treatment
    • Refusal to eat
    • Body fat < 10%
    • Heart rate < 50 beat per minute during the day and < 45 at night
    • Systolic blood pressure of < 90 mm Hg
    • Orthostatic changes in pulse (> 20 beats/minute) or blood pressure ( > 10 mg Hg)
    • Temperature < 96° F
    • Arrhythmia

    The clinical pathway from the Lucille Packard Children’s Hospital in 1999 describes 3 stages of treatment.

    • Admission/stage 1 is medical instability defined as:
      • < 75% ideal body weight
      • Dehydration
      • Abnormal electrolytes
      • Temperature < 36.3° day or evening or < 36° C at night
      • Irregular pulse or electrocardiogram QT interval of = .43
      • Pulse < 46 beats/minute
      • Orthostatic changes of systolic BP > 10 mg/Hg or pulse > 35 beats/minute
      • Urine specific gravity < 1.030 or between 1.010 and 1.020 and weight criteria not met
      • Pulse between 46 and 50 beats/minute and pulse change between 30-35 beats/minute
    • Stage 2 is medical compromise with criteria of stable vital signs for 24-48 hours, no acute findings on physical exam, solid food intake initiation but may still be on liquid nutrition, and is progressing toward unobserved eating
    • Stage 3 is practicing with criteria of stable vital signs for 48-72 hours, independent planning of caloric intake and eating, and 100% solid food intake.

    Hospitalization discharge criteria was completion of Stage 2 program “includ[ing] weight rehabilitation to at least exercise weight and partaking of adequate nutrition with minimal support.” Patients (100%) had weight gain of 1 kg/week during the 20 months of followup.

    Questions for Further Discussion
    1. What are some physical examination findings in a patient with anorexia nervosa?
    2. What other entities should be considered in the differential diagnosis of an eating disorder?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Eating Disorders

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Fisher M, Golden NH, Katzman DK, Kreipe RE, Rees J, Schebendach J, Sigman G, Ammerman S, Hoberman HM. Eating disorders in adolescents: a background paper. J Adolesc Health. 1995 Jun;16(6):420-37.

    Lock J. How clinical pathways can be useful: an example of a clinical pathway for the treatment of anorexia nervosa in adolesents. Clin Child Psychol Psychiary. 1999;4:331-340.

    Rome ES, Ammerman S, Rosen DS, Keller RJ, Lock J, Mammel KA, O’Toole J, Rees JM, Sanders MJ, Sawyer SM, Schneider M, Sigel E, Silber TJ. Children and adolescents with eating disorders: the state of the art. Pediatrics. 2003 Jan;111(1):e98-108.

    Rosen DS, American Academy of Pediatrics Committee on Adolescence. Identification and management of eating disorders in children and adolescents. Pediatrics. 2010 Dec;126(6):1240-53.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.

  • Interpersonal and Communication Skills
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • When Should Children Begin Fasting?

    Patient Presentation
    An 11-year-old male came to clinic for bug bites. The mother stated that he seemed to get more and they were bigger than those her other children had. During the conversation, the mother said that she was going to start having him fast during an upcoming religious holiday and wanted to know how long he should do it for. The past medical history showed a healthy male. The pertinent physical exam showed a healthy male with normal growth parameters and multiple insect bites that had been scratched on his arms, legs, neck and face. He was Tanner stage 1.

    The diagnosis of insect bites was made and the mother and child were counseled about how to avoid the insects and use of insect spray. The physician knew that children should not fast for long periods of time, yet also knew that he would be required by his religion to do so in a few years. The physician discussed the usual sleep and dietary habits with the mother and recommended the child not fast because of his age. However he recognized the religious importance to the family, and recommended that if they were still going to have him fast then only for a couple hours to stretch his normal fasting at night but that appropriate food and water be available for the rest of the day for the child. The physician recommended that this be done under direct parent supervision so someone could recognize any possible problems, stop the fast and food and water could be provided immediately. He also recommended the family talk with their spiritual advisor before beginning any fast and if the advisor recommended a much longer fast then he offered to discuss the issue with the family and advisor together. The mother said she would discuss it with her husband, the child and their advisor.

    Discussion
    Fasting means different things to different people. Usually it is refraining from eating and/or drinking for a period of time, or abstaining from certain foods or drinks. Fasting can be caused by physiology (i.e. sleeping), volitional (i.e. due to personal preferences, religious reasons, political protests, etc.) or non-volitional (i.e. pre-surgical fasting, lack of water or food availability, etc.).

    An energy source, especially for the brain, and fluid are necessary to maintain a healthy body. If someone is denying calories, after a few hours, glucose that is readily available from the digestive system is depleted. Gluconeongenesis then begins utilizing stores mainly within the liver (gluconeogenesis occurs for hours to days). If the fast continues, then protein is utilized for gluconeogenesis from the muscles (protein utilization occurs for hours to weeks). If the fast continues again, then fat is used as a ketone energy source (fat utilization occurs for days to weeks). With prolonged fasts muscle and fat wasting thus happen. If someone is denying free fluid, then over time dehydration occurs with increased thirst, oliguria/anuria, muscle spasms, cardiac abnormalities, mental status changes, respiratory changes and possible death if not treated.

    Fasting combined with other practices may decrease the onset time before the effects occur. For example, fasting and purposeful sweating can increase the severity of dehydration. Fasting along with taking purgatory medications may increase fluid loss and electrolyte abnormalities.

    Fasting as a religious/cultural practice can have many benefits including discipline, self-sacrifice, social belonging, and an increased awareness of one’s own spiritual beliefs.

    Learning Point
    Children can be at particular risk for fasting problems because of their smaller size, surface area, increased metabolic needs, and inability to communicate or help themselves to obtain food and/or fluid. Other individuals are also more vulnerable including the elderly, pregnant and nursing women, and those with temporary or chronic medical conditions. Children have been shown to have decreased cognitive function with short fasts (i.e. skipping breakfast).

    Most religious and cultural groups recognize these vulnerable populations and make appropriate exceptions to fasting requirements. For example, Islam recognizes fasting should not occur during Ramadan, for example, for those who are pre-pubertal, mentally ill, elderly, those that are sick, those that are traveling, pregnant or breastfeeding women or women who are menstruating. Judaism recognizes fasting should not occur during Yom Kippur, for example, for those who are pre-pubertal, the elderly, those that are sick, and women who are early post-partum.

    Some religious/cultural groups recommend that children nearing puberty begin to do some fasting for them to learn about the physical changes and to participate in the social/spiritual aspects of the practice. They usually do not fast for as long a time as adults though, i.e. a few hours instead of daylight hours or 24 hours for example. Most groups also recommend individuals discuss their personal situation with their medical professionals and spiritual advisors regarding their ability to safely fast.

    Questions for Further Discussion
    1. What fasting practices are followed by families in your practice?
    2. What local resources are available to advise families about religious/cultural fasting practices locally?
    3. What are some other benefits of fasting?
    4. How common is food insecurity in your practice?

    Related Cases

      Symptom/Presentation: Rash

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Child Nutrition and Family Issues.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Pollitt E, Lewis NL, Garza C, Shulman RJ. Fasting and cognitive function. J Psychiatr Res. 1982-1983;17(2):169-74.

    Pollitt E, Cueto S, Jacoby ER. Fasting and cognition in well- and undernourished schoolchildren: a review of three experimental studies. Am J Clin Nutr. 1998 Apr;67(4):779S-784S.

    Lazarou C, Matalas AL. A critical review of current evidence, perspectives and research implications of diet-related traditions of the Eastern Christian Orthodox Church on dietary intakes and health consequences.
    Int J Food Sci Nutr. 2010 Nov;61(7):739-58.

    El-Ashi, A. Fasting in Islam. Islamic Society of Rutgers University.
    Available from the Internet at http://www.eden.rutgers.edu/~muslims/fasting.htm (cited 8/22/2011).

    Author. Overview of Yom Kippur Laws. Chabad-Lubavitch Media Center.
    Available from the Internet at http://www.chabad.org/holidays/JewishNewYear/template_cdo/aid/995074/jewish/An-Overview-of-Yom-Kippur-Laws.htm (rev. 2011, cited 8/22/2011).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Professionalism
    20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.
    22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital