Addressing Gender Inequality in Our Disciplines: Report from the Association of Pulmonary, Critical Care, and Sleep Division Chiefs.

Despite the increasing proportion of women in U.S. medical schools, there are relatively few women in leadership positions, and a number of recent publications have highlighted many factors that could contribute to gender inequity and inequality in medicine. The Association of Pulmonary, Critical Care, and Sleep Division Directors, an organization of Division Directors from across the United States, convened a workshop to review data and obtain input from leaders on the state of gender equity in our field. The workshop identified a number of factors that could contribute to gender inequality and inequity: gender climate (including implicit and perceived biases); disproportionate family responsibilities; lack of women in leadership positions; poor retention of women; and lack of gender equality in compensation. The panel members developed a roadmap of concrete recommendations for societies, leaders, and individuals that should promote gender equity to achieve gender equality and improve retention of women in the field of pulmonary, critical care, and sleep medicine.

Validation of the Family Meeting Behavioral Skills Checklist. An Instrument to Assess Fellows' Communication Skills.

RATIONALE: Fellows in pulmonary and critical care medicine are required to show competency in facilitating family meetings for critically ill patients. There are many assessment measures available for evaluating physician-patient communication (e.g., the SEGUE Framework [Set the stage, Elicit information, Give information, Understand the patient's perspective, End the encounter]) and some designed for family meetings. However, no validated measure exists that is specifically designed to assess communication skills during family meetings with surrogate decision makers in intensive care settings. OBJECTIVES: We developed the Family Meeting Behavioral Skills Checklist (FMBSC) to measure advanced communication skills of fellows in family meetings of critically ill patients based on a literature review and consensus of an interdisciplinary group of communications experts. We evaluated the psychometric properties of the FMBSC. METHODS: We digitally recorded 16 pulmonary/critical care fellows performing a simulated family meeting for a critically ill patient at the end of 1 year of fellowship training. Two clinical health psychologists evaluated each recording independently using the FMBSC Rating Scale and the SEGUE Framework. Judges recorded the number of skills performed using the checklist and employed a summary rating scale to judge the level of performance for each of nine subsets of skills. Each instrument was scored and converted to percentage scores. The FMBSC and SEGUE Framework items were summed and converted to percentage scores for each category and as a total for each instrument. The rating scale items on the FMBSC were also summed and converted to a percentage score. Four primary analyses were conducted to evaluate interjudge reliability, internal consistency, and concurrent validity. MEASUREMENTS AND MAIN RESULTS: Interrater reliability was higher for the FMBSC (intraclass correlation [ICC2,2] = 0.57) than for the SEGUE instrument (ICC2,2 = 0.32) or the FMBSC Rating Scale (ICC2,2 = 0.23). The FMBSC demonstrated evidence of concurrent validity through high positive correlations with both the FMBSC Rating Scale and the SEGUE instrument (r = +0.83, P ≤ 0.01; r = +0.65, P ≤ 0.01 respectively). All but one of the nine subscales on the FMBSC showed adequate internal consistency (reliabilities ranged from 0.18 to 0.68). Interjudge reliability was higher for the FMBSC (ICC2,2 = 0.57) than for the SEGUE instrument (ICC2,2 = 0.32) or the FMBSC Rating Scale (ICC2,2 = 0.23). CONCLUSIONS: The FMBSC demonstrated internal consistency and structural validity in assessing advanced communication skills of fellows in facilitating family meetings of critically ill patients in the ICU. Interjudge reliability was better for the FMBS Checklist than it was for the other measures.

Pulmonary and Critical Care Medicine Program Directors' Attitudes toward Training in Medical Education. A Nationwide Survey Study.

RATIONALE: Many pulmonary and critical care medicine (PCCM) fellows are interested in improving their teaching skills as well as learning about careers as clinician educators. Educational opportunities in PCCM fellowship programs designed to address these interests have not been well characterized in U.S. training programs. OBJECTIVES: We aimed to characterize educational content and structure for training fellows to teach in PCCM fellowship programs. We evaluated three major domains: (1) existing educational opportunities, (2) PCCM program directors' attitudes toward the importance of teaching fellows how to teach, and (3) potential components of an optimal teaching skills curriculum for PCCM fellows. METHODS: We surveyed program and associate program directors who were members of the Association of Pulmonary and Critical Care Medicine Program Directors in 2014. Survey domains included existing teaching skills content and structure, presence of a formal medical education curriculum or clinician educator track, perceived barriers to teaching fellows teaching skills, and open-ended qualitative inquiries about the ideal curricula. Data were analyzed both quantitatively and qualitatively. MEASUREMENTS AND MAIN RESULTS: Of 158 invited Association of Pulmonary and Critical Care Medicine Program Directors members, 85 program directors and associate directors responded (53.8% response rate). Annual curricular time dedicated to teaching skills varied widely (median, 3 h; mean, 5.4 h; interquartile range, 2.0-6.3 h), with 17 respondents (20%) allotting no time to teaching fellows to teach and 14 respondents (17%) dedicating more than 10 hours. Survey participants stated that the optimal duration for training fellows in teaching skills was significantly less than what they reported was actually occurring (median optimal duration, 1.5 h/yr; mean, 2.1 h/yr; interquartile range, 1.5-3.5 h/yr; P < 0.001). Only 28 (33.7%) had a formal curriculum for teaching medical education skills. Qualitative analyses identified several barriers to implementing formal teaching skills curricula, including "time," "financial resources," "competing priorities," and "lack of expert faculty." CONCLUSIONS: While prior work has demonstrated that fellows are interested in obtaining medical education skills, PCCM program directors and associate directors noted significant challenges to implementing formal educational opportunities to teach fellows these skills. Effective strategies are needed to design, implement, sustain, and assess teaching skills curricula for PCCM fellowships.

Communication skills training curriculum for pulmonary and critical care fellows.

RATIONALE: The Accreditation Council for Graduate Medical Education requires physicians training in pulmonary and critical care medicine to demonstrate competency in interpersonal communication. Studies have shown that residency training is often insufficient to prepare physicians to provide end-of-life care and facilitate patient and family decision-making. Poor communication in the intensive care unit (ICU) can adversely affect outcomes for critically ill patients and their family members. Despite this, communication training curricula in pulmonary and critical care medicine are largely absent in the published literature. OBJECTIVES: We evaluated the effectiveness of a communication skills curriculum during the first year of a pulmonary and critical care medicine fellowship using a family meeting checklist to provide formative feedback to fellows during ICU rotations. We hypothesized that fellows would demonstrate increased competence and confidence in the behavioral skills necessary for facilitating family meetings. METHODS: We evaluated a 12-month communication skills curriculum using a pre-post, quasiexperimental design. Subjects for this study included 11 first-year fellows who participated in the new curriculum (intervention group) and a historical control group of five fellows who had completed no formal communication curriculum. Performance of communication skills and self-confidence in family meetings were assessed for the intervention group before and after the curriculum. The control group was assessed once at the beginning of their second year of fellowship. RESULTS: Fellows in the intervention group demonstrated significantly improved communication skills as evaluated by two psychologists using the Family Meeting Behavioral Skills Checklist, with an increase in total observed skills from 51 to 65% (P ≤ 0.01; Cohen's D effect size [es], 1.13). Their performance was also rated significantly higher when compared with the historical control group, who demonstrated only 49% of observed skills (P ≤ 0.01; es, 1.55). Fellows in the intervention group also showed significantly improved self-confidence scores upon completion of the curriculum, with an increase from 77 to 89% (P ≤ 0.01; es, 0.87) upon completion of the curriculum CONCLUSIONS: A structured curriculum that includes abundant opportunities for fellows to practice and receive feedback using a behavioral checklist during their ICU rotations helps to develop physicians with advanced communication skills.

Preparing for Fellowship in Internal Medicine. Steps for Success with a Focus on Pulmonary and/or Critical Care Programs.

This paper outlines specific tips for those applying to pulmonary and/or critical care medicine fellowship training in the United States using the PAIR-Match steps: preparation, application, interview, ranking, and match. Preparation for fellowship begins long before the application process with an assessment of one's long-term goals (to the extent that these are known). The cornerstone of the application is the curriculum vitae, which should highlight applicants' pulmonary and critical care-related experiences and scholarly work. Applicants should obtain letters of recommendation from faculty members who know them well and can write a letter that speaks to their strengths in clinical, scholarly, or leadership areas. The personal statement is an opportunity to share experiences not otherwise shared in the application and is an opportunity to explain any breaks in training or performance lapses. When selecting programs to which they will apply, applicants should pay close attention to the areas of education and curriculum, clinical experience, scholarly opportunity, and personal factors. Preparing for interviews should include a review of the program at which one is interviewing and development of relevant questions regarding details of the program. The interview day is the applicant's opportunity to see the "personality" of the program by meeting with the program director, faculty, and current fellows and to assess whether the program is a good fit for their goals. Applicants should only rank those programs they are willing to attend, in order of preference; they should be aware that the match process is binding.