Race and Ethnicity in Pulmonary Function Test Interpretation: An Official American Thoracic Society Statement.

Current American Thoracic Society (ATS) standards promote the use of race and ethnicity-specific reference equations for pulmonary function test (PFT) interpretation. There is rising concern that the use of race and ethnicity in PFT interpretation contributes to a false view of fixed differences between races and may mask the effects of differential exposures. This use of race and ethnicity may contribute to health disparities by norming differences in pulmonary function. In the United States and globally, race serves as a social construct that is based on appearance and reflects social values, structures, and practices. Classification of people into racial and ethnic groups differs geographically and temporally. These considerations challenge the notion that racial and ethnic categories have biological meaning and question the use of race in PFT interpretation. The ATS convened a diverse group of clinicians and investigators for a workshop in 2021 to evaluate the use of race and ethnicity in PFT interpretation. Review of evidence published since then that challenges current practice and continued discussion concluded with a recommendation to replace race and ethnicity-specific equations with race-neutral average reference equations, which must be accompanied with a broader re-evaluation of how PFTs are used to make clinical, employment, and insurance decisions. There was also a call to engage key stakeholders not represented in this workshop and a statement of caution regarding the uncertain effects and potential harms of this change. Other recommendations include continued research and education to understand the impact of the change, to improve the evidence for the use of PFTs in general, and to identify modifiable risk factors for reduced pulmonary function.

Enhancing Clinical Teaching in Critical Thinking, High-Value Care, and Health Care Equity.

INTRODUCTION: Faculty development in the clinical setting is challenging to implement and assess. This study evaluated an intervention (IG) to enhance bedside teaching in three content areas: critical thinking (CT), high-value care (HVC), and health care equity (HCE). METHODS: The Communities of Practice model and Theoretical Domains Framework informed IG development. Three multidepartmental working groups (WGs) (CT, HVC, HCE) developed three 2-hour sessions delivered over three months. Evaluation addressed faculty satisfaction, knowledge acquisition, and behavior change. Data collection included surveys and observations of teaching during patient care. Primary analyses compared counts of post-IG teaching behaviors per hour across intervention group (IG), comparison group (CG), and WG groups. Statistical analyses of counts were modeled with generalized linear models using the Poisson distribution. RESULTS: Eighty-seven faculty members participated (IG n = 30, CG n = 28, WG n = 29). Sixty-eight (IG n = 28, CG n = 23, WG n = 17) were observed, with a median of 3 observation sessions and 5.2 hours each. Postintervention comparison of teaching (average counts/hour) showed statistically significant differences across groups: CT CG = 4.1, IG = 4.8, WG = 8.2; HVC CG = 0.6, IG = 0.9, WG = 1.6; and HCE CG = 0.2, IG = 0.4, WG = 1.4 ( P < .001). DISCUSSION: A faculty development intervention focused on teaching in the context of providing clinical care resulted in more frequent teaching of CT, HVC, and HCE in the intervention group compared with controls. WG faculty demonstrated highest teaching counts and provide benchmarks to assess future interventions. With the creation of durable teaching materials and a cadre of trained faculty, this project sets a foundation for infusing substantive content into clinical teaching.

Optimizing allocation of curricular content across the Undergraduate & Graduate Medical Education Continuum.

BACKGROUND: Medical educators struggle to incorporate socio-cultural topics into crowded curricula. The "continuum of learning" includes undergraduate and graduate medical education. Utilizing an exemplar socio-cultural topic, we studied the feasibility of achieving expert consensus among two groups of faculty (experts in medical education and experts in social determinants of health) on which aspects of the topic could be taught during undergraduate versus graduate medical education. METHODS: A modified Delphi method was used to generate expert consensus on which learning objectives of social determinants of health are best taught at each stage of medical education. Delphi respondents included experts in medical education or social determinants of health. A survey was created using nationally published criteria for social determinants of health learning objectives. Respondents were asked 1) which learning objectives were necessary for every physician (irrespective of specialty) to develop competence upon completion of medical training and 2) when the learning objective should be taught. Respondents were also asked an open-ended question on how they made the determination of when in the medical education continuum the learning objective should be taught. RESULTS: 26 out of 55 experts (13 social determinants of health and 13 education experts) responded to all 3 Delphi rounds. Experts evaluated a total of 49 learning objectives and were able to achieve consensus for at least one of the two research questions for 45 of 49 (92%) learning objectives. 50% more learning objectives reached consensus for inclusion in undergraduate (n = 21) versus graduate medical education (n = 14). CONCLUSIONS: A modified Delphi technique demonstrated that experts could identify key learning objectives of social determinants of health needed by all physicians and allocate content along the undergraduate and graduate medical education continuum. This approach could serve as a model for similar socio-cultural content. Future work should employ a qualitative approach to capture principles utilized by experts when making these decisions.

Health Care in the United States: Individual Right or Government Duty?

The authors discuss the notion of health care as a governmental duty rather than a right of individuals. The notion of individual rights was proposed by political philosophers of the 17th and 18th centuries, who posited that people existed in a state of nature before coming together to form communities. Members of communities relinquish certain freedoms in exchange for services provided by government, including protection of the natural rights of "life, liberty, and the pursuit of happiness." In this tradition, there are natural rights that exist before government and must be protected from government infringement. The U.S. Constitution almost exclusively enshrines negative rights, which protect natural rights from government interference. Rights belong to individuals, whereas the government has duties to provide services, such as basic education, that society deems to be important. The discussion of health care as a positive right, one requiring government to provide citizens with services, runs counter to this tradition of natural rights.The authors propose that reframing the discussion to see universal access to health care as an obligation of government, rather than a right of individuals, will center the discussion more accurately within U.S. political tradition. This may drain the emotional charge associated with claims to "rights" from public debate and allow for productive negotiations over the extent of health care appropriate for government to provide, within the context of the other obligations that form the social contract between the citizenry and its government.

Frame-of-Reference Training: Establishing Reliable Assessment of Teaching Effectiveness.

INTRODUCTION: Frame-of-reference (FOR) training has been used successfully to teach faculty how to produce accurate and reliable workplace-based ratings when assessing a performance. We engaged 21 Harvard Medical School faculty members in our pilot and implementation studies to determine the effectiveness of using FOR training to assess health professionals' teaching performances. METHODS: All faculty were novices at rating their peers' teaching effectiveness. Before FOR training, we asked participants to evaluate a recorded lecture using a criterion-based peer assessment of medical lecturing instrument. At the start of training, we discussed the instrument and emphasized its precise behavioral standards. During training, participants practiced rating lectures and received immediate feedback on how well they categorized and scored performances as compared with expert-derived scores of the same lectures. At the conclusion of the training, we asked participants to rate a post-training recorded lecture to determine agreement with the experts' scores. RESULTS: Participants and experts had greater rating agreement for the post-training lecture compared with the pretraining lecture. Through this investigation, we determined that FOR training is a feasible method to teach faculty how to accurately and reliably assess medical lectures. DISCUSSION: Medical school instructors and continuing education presenters should have the opportunity to be observed and receive feedback from trained peer observers. Our results show that it is possible to use FOR rater training to teach peer observers how to accurately rate medical lectures. The process is time efficient and offers the prospect for assessment and feedback beyond traditional learner evaluation of instruction.

Consensus of the Millennium Conference on Teaching High Value Care.

ISSUE: Healthcare costs have spiraled out of control, yet students and residents may lack the knowledge and skills to provide high value care, which emphasizes the best possible care while reducing unnecessary costs. EVIDENCE: Mainly national campaigns are aimed at physicians to reconsider their test ordering behaviors, identify overused diagnostics, and disseminate innovative practices. These efforts will fall short if principles of high value care are not incorporated across the spectrum of training for the next generation of physicians. IMPLICATIONS: Consensus findings of an invitational conference of 7 medical school teams consisting of academic leaders included strategies for institutions to meaningfully incorporate high value care into their medical school, residency, and faculty development curricula.

Considering cognition. Current challenges and future directions in pulmonary and critical care fellowship training.

Fellowship training in pulmonary and critical care has evolved substantially over the past decade. Training programs are increasingly focused on a rigorous, multifaceted assessment of an individual trainee's progress toward achieving specific curricular milestones, and their ability to independently manage a series of entrustable professional activities. This new system has provided programs with an enormous amount of detailed information related to the specific goals and outcomes of training. However, it has not addressed the unmet need for fellowship programs to systematically assess and teach advanced clinical reasoning and judgment. Training programs must address these cognitive processes in a proactive and supportive way, and are challenged to develop novel approaches that encourage continuous self-evaluation. Only by addressing these critical deficiencies will programs enable trainees to progress beyond a level of clinical competence to one of true expertise. These efforts will also encourage physicians at all levels of training to embrace their commitment to lifelong learning.

The PrOSTE: identifying key components of effective procedural teaching.

RATIONALE: Novel approaches for faculty development and assessment of procedural teaching skills are needed to improve the procedural education of trainees. The Objective Structured Teaching Exercise (OSTE) entails a simulated encounter in which faculty are observed teaching a standardized student and has been used to evaluate teaching skills. Use of an OSTE to assess the teaching of central venous catheterization has not been reported. OBJECTIVES: The purpose of this study was to develop a procedural OSTE for subclavian central venous catheter (CVC) insertion and to determine specific aspects of procedural teaching associated with improved skills in novices. METHODS: Critical care faculty/fellows taught a standardized student to insert a CVC in a simulator. We assessed the instructor's teaching skills using rating scales to generate a procedural teaching score. After this encounter, the instructor taught novice medical students to place CVCs in simulators. Novices then independently placed catheters in simulators and were evaluated by trained observers using a checklist. Generalized estimating equations were used to examine the correlation between specific teaching behaviors and the novices' skills in CVC placement. MEASUREMENTS AND MAIN RESULTS: We recruited 10 participants to serve as teachers and 30 preclinical medical students to serve as novice learners. The overall mean procedural teaching score was 85.5 (±15.4). Improved student performance was directly related to the degree to which the teacher "provided positive feedback" (ß = 1.53, SE = 0.44, P = 0.001), "offered learner suggestions for improvement" (ß = 1.40, SE = 0.35, P < 0.001), and "demonstrated the procedure in a step-by-step manner" (ß = 2.50, SE = 0.45, P < 0.001). There was no significant correlation between total scores and student skills (ß = 0.06, SE = 0.46, P = 0.18). CONCLUSIONS: The OSTE is a standardized method to assess procedural teaching skills. Our findings suggest that specific aspects of procedural teaching should be emphasized to ensure effective transfer of psychomotor skills to trainees.

An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea.

BACKGROUND: Dyspnea is a common, distressing symptom of cardiopulmonary and neuromuscular diseases. Since the ATS published a consensus statement on dyspnea in 1999, there has been enormous growth in knowledge about the neurophysiology of dyspnea and increasing interest in dyspnea as a patient-reported outcome. PURPOSE: The purpose of this document is to update the 1999 ATS Consensus Statement on dyspnea. METHODS: An interdisciplinary committee of experts representing ATS assemblies on Nursing, Clinical Problems, Sleep and Respiratory Neurobiology, Pulmonary Rehabilitation, and Behavioral Science determined the overall scope of this update through group consensus. Focused literature reviews in key topic areas were conducted by committee members with relevant expertise. The final content of this statement was agreed upon by all members. RESULTS: Progress has been made in clarifying mechanisms underlying several qualitatively and mechanistically distinct breathing sensations. Brain imaging studies have consistently shown dyspnea stimuli to be correlated with activation of cortico-limbic areas involved with interoception and nociception. Endogenous and exogenous opioids may modulate perception of dyspnea. Instruments for measuring dyspnea are often poorly characterized; a framework is proposed for more consistent identification of measurement domains. CONCLUSIONS: Progress in treatment of dyspnea has not matched progress in elucidating underlying mechanisms. There is a critical need for interdisciplinary translational research to connect dyspnea mechanisms with clinical treatment and to validate dyspnea measures as patient-reported outcomes for clinical trials.

Developing expert-derived rating standards for the peer assessment of lectures.

PURPOSE: For peer review of teaching to be credible and reliable, peer raters must be trained to identify and measure teaching behaviors accurately. Peer rater training, therefore, must be based on expert-derived rating standards of teaching performance. The authors sought to establish precise lecture rating standards for use in peer rater training at their school. METHOD: From 2008 to 2010, a panel of experts, who had previously helped to develop an instrument for the peer assessment of lecturing, met to observe, discuss, and rate 40 lectures, using a consensus-building model to determine key behaviors and levels of proficiency for each of the instrument's 11 criteria. During this process, the panelists supplemented the original instrument with precise behavioral descriptors of lecturing. The reliability of the derived rating standards was assessed by having the panelists score six sample lectures independently. RESULTS: Intraclass correlation coefficients of the panelists' ratings of the lectures ranged from 0.75 to 0.96. There was moderate to high positive association between 10 of the 11 instrument's criteria and the overall performance score (r = 0.752-0.886). There were no statistically significant differences among raters in terms of leniency or stringency of scores. CONCLUSIONS: Two relational themes, content and style, were identified within the instrument's variables. Recommendations for developing expert-derived ratings standards include using an interdisciplinary group for observation, discussion, and verbal identification of behaviors; asking members to consider views that contrast with their own; and noting key teaching behaviors for use in future peer rater training.

Developing a peer assessment of lecturing instrument: lessons learned.

Peer assessment of teaching can improve the quality of instruction and contribute to summative evaluation of teaching effectiveness integral to high-stakes decision making. There is, however, a paucity of validated, criterion-based peer assessment instruments. The authors describe development and pilot testing of one such instrument and share lessons learned. The report provides a description of how a task force of the Shapiro Institute for Education and Research at Harvard Medical School and Beth Israel Deaconess Medical Center used the Delphi method to engage academic faculty leaders to develop a new instrument for peer assessment of medical lecturing. The authors describe how they used consensus building to determine the criteria, scoring rubric, and behavioral anchors for the rating scale. To pilot test the instrument, participants assessed a series of medical school lectures. Statistical analysis revealed high internal consistency of the instrument's scores (alpha = 0.87, 95% bootstrap confidence interval [BCI] = 0.80 to 0.91), yet low interrater agreement across all criteria and the global measure (intraclass correlation coefficient = 0.27, 95% BCI = -0.08 to 0.44).The authors describe the importance of faculty involvement in determining a cohesive set of criteria to assess lectures. They discuss how providing evidence that a peer assessment instrument is credible and reliable increases the faculty's trust in feedback. The authors point to the need for proper peer rater training to obtain high interrater agreement measures, and posit that once such measures are obtained, reliable and accurate peer assessment of teaching could be used to inform the academic promotion process.

Procedural competence in internal medicine residents: validity of a central venous catheter insertion assessment instrument.

PURPOSE: Despite mandates from accreditation bodies for programs to ensure procedural competence, standardized measures do not exist to assess residents' skills in performing central venous catheter (CVC) insertion. The objective of the present study was to develop an instrument to assess residents in subclavian (SC) CVC insertion, to set performance standards, and to validate the tool using performance data. METHOD: In 2007, the authors convened experts to create an assessment tool for CVC insertion using a modified Delphi method. They applied the Angoff method to a second set of experts to determine minimum passing scores (MPSs) for both the borderline trainee and the competent trainee. Two faculty evaluators then used the checklist to assess residents performing CVCs on simulators. RESULTS: The authors created and experts confirmed a 24-item checklist. Using the Angoff method, the MPS required completion of 10 major and 2 minor criteria for a trainee to show borderline proficiency with CVC insertion under supervision. This MPS was correlated with a global rating of 2 on a 5-point scale. The MPS for competence was 17 major and 5 minor criteria. None of the residents deemed competent on a global rating scale achieved the MPS for competence. CONCLUSIONS: The authors were able to create and validate a consensus-driven procedural assessment tool with data-driven standards for basic proficiency and competence that faculty can use to assess residents as they perform CVC insertion.

Development and implementation of a comprehensive strategic plan for medical education at an academic medical center.

Despite their vital contributions to the training of future physicians, many academic teaching hospitals have grown operationally and financially distinct from affiliated medical schools because of divergent missions, contributing to the erosion of clinical training. Some institutions have responded by building hybrid organizations; others by creating large health care networks with variable relationships with the affiliated medical school. In this case, the authors wished to establish the future educational mission of their medical center as a core element of the institution by creating data-driven recommendations for reorganization, programs, and financing. They conducted a self-study of all constituents, the results of which confirmed the importance of education at their institution but also revealed the insufficiency of incentives for teaching. They underwent an external review by a committee of prominent educators, and they involved administrators at the hospital and the medical school. Together, these inputs composed an informed assessment of medical education at their teaching hospital, from which they developed and actualized an institution-wide strategic plan for education. Over the course of three years, they centralized the administrative structure for education, implemented programs that cross departments and reinforce the UME-GME continuum, and created transparency in the financing of medical education. The plan was purposefully aligned with the clinical and research strategic plans by supporting patient safety in programs and the professional development of faculty. The application of a rigorous strategic planning process to medical education at an academic teaching hospital can focus the mission, invigorate faculty, and lead to innovative programs.