Entrustment Decision Making in the Intensive Care Unit: It's About More Than the Learner.

Background: The provision of graded supervision affording progressive autonomy is fundamental to the progression of a medical learner toward competency for independent practice; the decision of how much supervision versus autonomy to provide a trainee in the execution of clinical care constitutes an entrustment decision. Despite entrustment decision making occurring both daily in practice and summatively at points of matriculation through stages of medical training, the factors influencing entrustment decisions remain poorly understood across clinical contexts. Objective: This study was designed to explore the central research question: How are entrustment decisions made in the medical intensive care unit (ICU)? Methods: This qualitative case study used semistructured interviews with attending pulmonary and critical care physicians in the medical ICU at a major midwestern medical center to explore the entrustment decision-making process as it was enacted in the clinical environment. Results: Five major themes emerged from the data: 1) task, circumstance, and trainee factors contribute to entrustment decision making; 2) ad hoc entrustment decisions are enacted by supervisors with a consideration of the care team as a unit, not only an individual; 3) autonomy does not only arise out of entrustment, but outcomes of prior autonomous actions by the trainee inform the intention to entrust; 4) entrustment decision making includes a social process of back-and-forth akin to negotiation; and 5) entrustment is a learned skill. Conclusion: The process of entrustment decision making in the ICU is more complex than prior frameworks have captured; a model with more complete incorporation of the factors that influence entrustment in the ICU is presented. It is not clear how often ad hoc entrustment decisions in clinical practice are primarily driven by factors pertaining directly to trainee competence, which carries implications in the use of entrustment for assessment.

Preparing for Fellowship in Internal Medicine With a Focus on Pulmonary or Critical Care Medicine: Major Principles and New Realities.

In this article, the authors provide guidance for applicants to any subspecialty in the medical specialties matching program, with a particular focus on those seeking a match into a pulmonary or critical care medicine training program, or both. The preparation, application, interview, ranking, and match steps are used to discuss available literature that informs this process. Preparing a fellowship application is discussed in terms of personal career goals, and specific strategies are suggested that can help a candidate to assess a program's fit with those goals. In addition to review of recent data on virtual interviewing and interview questioning, the authors provide practical recommendations for candidates seeking to maximize their success in the current interview environment. Finally, key points about generating a rank order list are summarized. This resource will prove useful to any candidate pursuing medical subspecialty training in the current era.

National opioid shortage is associated with increased use of ketamine infusion for analgosedation in the medical intensive care unit.

OBJECTIVE: To assess the impact of the national shortage of injectable opioids during the winter of 2017-2018 on the use of ketamine infusion for analgosedation in the medical intensive care unit (MICU). DESIGN: A retrospective cohort study. SETTING: Single-center tertiary care MICU at The Ohio State University Wexner Medical Center. PATIENTS: All patients who received continuous infusion of ketamine to facilitate mechanical ventilation between May 1, 2015 and September 1, 2018. MEASUREMENTS AND MAIN RESULTS: Seventy-seven patients were identified during the study time frame: 43 before and 19 during the opioid shortage. During the peak of the shortage, there was a sevenfold increase in orders for ketamine infusion (2.2 patients/week vs 0.32 patients/week; p < 0.001). Median time from the start of mechanical ventilation to initiation of ketamine infusion was significantly shorter during the shortage (14.1 hours) versus before (51.2 hours; p = 0.03). There was a trend toward adding ketamine into the sedation regimen earlier during the shortage (mean number of drips added prior to ketamine was 2.74 during the shortage vs 3.3 before; p = 0.06). There was also a trend toward increased use of ketamine infusion as monotherapy during (21.1 percent of patients) versus before the shortage (7 percent), though this did not reach statistical significance (p = 0.19). CONCLUSION: The national opioid shortage may have led to earlier and more frequent use of ketamine infusion for anaglosedation in mechanically ventilated MICU patients.

Balancing Demands: Determinants of Burnout Reported by Fellows in Pulmonary and Critical Care Medicine.

Background: Burnout is common among physicians who care for critically ill patients and is known to contribute to worse patient outcomes. Fellows training in pulmonary and critical care medicine (PCCM) have risk factors that make them susceptible to burnout; for example, clinical environments that require increased intellectual and emotional demands with long hours. The Accreditation Council for Graduate Medical Education has recognized the increasing importance of trainee burnout and encourages training programs to address burnout. Objective: To assess factors related to training and practice that posed a threat to the well-being among fellows training in PCCM and to obtain suggestions regarding how programs can improve fellow well-being. Methods: We conducted a qualitative content analysis of data collected from a prior cross-sectional electronic survey with free-response questions of fellows enrolled in pulmonary, PCCM, and critical care medicine training programs in the United States. Fellows were asked what factors posed a threat to their well-being and what changes their training program could implement. Responses were qualitatively coded and categorized into themes using thematic analysis. Results: A total of 427 fellows (44% of survey respondents) completed at least one free-response question. The majority of respondents (60%) identified as male and white/non-Hispanic (59%). The threats to well-being and burnout were grouped into five themes: clinical burden, individual factors, team culture, limited autonomy, and program resources. Clinical burden was the most common threat discussed by fellows. Fellows highlighted factors contributing to burnout that specifically pertained to trainees including challenging interpersonal relationships with attending physicians and limited protected educational time. Fellows proposed solutions addressing clinical care, changes at the program or institution level, and organizational culture changes to improve well-being. Conclusion: This study provides insight into factors fellows report as contributors to burnout and decreased well-being in addition to investigating fellow-driven solutions toward improving well-being. These solutions may help pulmonary, PCCM, and critical care medicine program directors better address fellow well-being in the future.

Post-Clerkship Curricular Reform: Specialty-Specific Tracks and Entrustable Professional Activities to Guide the Transition to Residency.

The development of core entrustable professional activities (EPA) for entering residency and Accreditation Council for Graduate Medical Education's milestones have spurred thinking about the fourth year of medical school as a transition to residency. In this monograph, we lay out our specialty focused post-clerkship curriculum and report learner and residency director perceptions over the first three years of implementation. Ongoing curricular monitoring has reinforced core principles but has also informed actionable quality improvement efforts. EPA-focused learning experiences, integration of specialty-specific milestones, addition of the feedforward process, and accessible mentorships have been key curricular elements to guide the transition to residency.

A National Survey of Burnout and Depression Among Fellows Training in Pulmonary and Critical Care Medicine: A Special Report by the Association of Pulmonary and Critical Care Medicine Program Directors.

BACKGROUND: The prevalence of burnout and depressive symptoms is high among physician trainees. RESEARCH QUESTION: What is the burden of burnout and depressive symptoms among fellows training in pulmonary and critical care medicine (PCCM) and what are associated individual fellow, program, and institutional characteristics? STUDY DESIGN AND METHODS: We conducted a cross-sectional electronic survey of fellows enrolled in pulmonary, PCCM, and critical care medicine training programs in the United States to assess burnout and depressive symptoms. Burnout symptoms were measured using the Maslach Burnout Index two-item measure. The two-item Primary Care Evaluation of Mental Disorders Procedure was used to screen for depressive symptoms. For each of the two outcomes (burnout and depressive symptoms), we constructed three multivariate logistic regression models to assess individual fellow characteristics, program structure, and institutional polices associated with either burnout or depressive symptoms. RESULTS: Five hundred two of the 976 fellows who received the survey completed it-including both outcome measures-giving a response rate of 51%. Fifty percent of fellows showed positive results for either burnout or depressive symptoms, with 41% showing positive results for depressive symptoms, 32% showing positive results for burnout, and 23% showing positive results for both. Reporting a coverage system in the case of personal illness or emergency (adjusted OR [aOR], 0.44; 95% CI, 0.26-0.73) and access to mental health services (aOR, 0.14; 95% CI, 0.04-0.47) were associated with lower odds of burnout. Financial concern was associated with higher odds of depressive symptoms (aOR, 1.13; 95% CI, 1.05-1.22). Working more than 70 hours in an average clinical week and the burdens of electronic health record (EHR) documentation were associated with a higher odds of both burnout and depressive symptoms. INTERPRETATION: Given the high prevalence of burnout and depressive symptoms among fellows training in PCCM, an urgent need exists to identify solutions that address this public health crisis. Strategies such as providing an easily accessible coverage system, access to mental health resources, reducing EHR burden, addressing work hours, and addressing financial concerns among trainees may help to reduce burnout or depressive symptoms and should be studied further by the graduate medical education community.

What Do Program Directors Value in Personal Statements? A Qualitative Analysis.

Background: All applicants to accredited training programs must write a personal statement as part of the application process. This may provoke anxiety on the part of the applicant and can result in an impersonal product that does not enhance his or her application. Little has been written about what program directors are seeking in personal statements. Objective: To gain a better understanding of how pulmonary and critical care fellowship program directors view and interpret these essays and to help applicants create more effective personal statements and make the writing process less stressful. Methods: We surveyed the membership of the Association of Pulmonary and Critical Care Medicine Program Directors in 2018. Quantitative data were collected regarding the importance of the personal statement in the candidate selection process. Qualitative data exploring the characteristics of personal statements, what the personal statement reveals about applicants, and advice for writing them were also collected. Comparative analysis was used for coding and analysis of qualitative data. Results: Surveys were completed by 114 out of 344 possible respondents (33%). More than half of the respondents believed that the personal statement is at least moderately important when deciding to offer an interview, and 40% believed it is at least moderately important when deciding rank order. A qualitative analysis revealed consistent themes: communication skills, provision of information not found elsewhere, applicant characteristics, and things to avoid. Conclusion: The respondents view the personal statement as moderately important in the application process. They value succinct, quality writing that reveals personal details not noted elsewhere. The information presented may help reduce anxiety associated with writing the personal statement and result in making the personal statement a more meaningful part of the application.

Virtually Hosting a National Medical Society Conference. Lessons Learned from the 2020 Association of Pulmonary and Critical Care Medicine Program Directors Conference.

The coronavirus pandemic forced the Association of Pulmonary and Critical Care Medicine Program Directors to change the 2020 annual conference to a virtual format with relatively short notice. Using the experience of the planning committee and survey feedback from attendees, we describe the steps taken to implement a virtual conference and lessons learned in the process. The lessons described include frequent and concise communication, establishment of roles within a discrete production team, preparing speakers with a protocolized training session, active moderation of the chat box, using interactive polling and online documents to improve interactivity, a shorter agenda with more frequent breaks, encouraging "virtual happy hours" to connect with colleagues, and establishing facilitators for breakout rooms.

Communication Training in Adult and Pediatric Critical Care Medicine. A Systematic Review.

Background: Interpersonal and communication skills are essential for physicians practicing in critical care settings. Accordingly, demonstration of these skills has been a core competency of the Accreditation Council for Graduate Medical Education since 2014. However, current practices regarding communication skills training in adult and pediatric critical care fellowships are not well described. Objective: To describe the current state of communication curricula and training methods in adult and pediatric critical care training programs as demonstrated by the published literature. Methods: We performed a systematic review of the published literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Three authors reviewed a comprehensive set of databases and independently selected articles on the basis of a predefined set of inclusion and exclusion criteria. Data were independently extracted from the selected articles. Results: The 23 publications meeting inclusion criteria fell into the following study classifications: intervention (n = 15), cross-sectional survey (n = 5), and instrument validation (n = 3). Most interventional studies assessed short-term and self-reported outcomes (e.g., learner attitudes and perspectives) only. Fifteen of 22 publications represented pediatric subspecialty programs. Conclusion: Opportunities exist to evaluate the influence of communication training programs on important outcomes, including measured learner behavior and patient and family outcomes, and the durability of skill retention.

Development of a National Academic Boot Camp to Improve Fellowship Readiness.

Background: Pulmonary and critical care medicine (PCCM) fellowship requires a high degree of medical knowledge and procedural competency. Gaps in fellowship readiness can result in significant trainee anxiety related to starting fellowship training.Objective: To improve fellowship readiness and alleviate anxiety for PCCM-bound trainees by improving confidence in procedural skills and cognitive domains.Methods: Medical educators within the American Thoracic Society developed a national resident boot camp (RBC) to provide an immersive, experiential training program for physicians entering PCCM fellowships. The RBC curriculum is a 2-day course designed to build procedural skills, medical knowledge, and clinical confidence through high-fidelity simulation and active learning methodology. Separate programs for adult and pediatric providers run concurrently to provide unique training objectives targeted to their learners' needs. Trainee assessments include multiple-choice pre- and post-RBC knowledge tests and confidence assessments, which are scored on a four-point Likert scale, for specific PCCM-related procedural and cognitive skills. Learners also evaluate course material and educator effectiveness, which guide modifications of future RBC programs and provide feedback for individual educators, respectively.Results: The American Thoracic Society RBC was implemented in 2014 and has grown annually to include 132 trainees and more than 100 faculty members. Mean knowledge test scores for participants in the 2019 RBC adult program increased from 55% (±14% SD) on the pretest to 72% (±11% SD; P < 0.001) after RBC completion. Similarly, mean pretest scores for pediatric course attendees increased from 54% (±13% SD) to 62% (±19% SD; P = 0.17). Specific content domains that improved by 10% or more between pre- and posttests included airway management, bronchoscopy, pulmonary function testing, and code management for adult course participants, and airway management, pulmonary function testing, and extracorporeal membrane oxygenation for pediatric course participants. Trainee confidence also significantly improved across all procedural and cognitive domains for adult trainees and in 10 of 11 domains for pediatric course attendees. Course content for the 2019 RBC was overwhelmingly rated as "on target" for the level of learner, with <4% of respondents indicating any specific session was "much too basic" or "much too advanced."Conclusion: RBC participation improved PCCM-bound trainee knowledge, procedural familiarity, and confidence. Refinement of the RBC curriculum over the past 7 years has been guided by educator and course evaluations, with the ongoing goal of meeting the evolving educational needs of rising PCCM trainees.

Incorporating Retrieval Practice Into Intensive Care Unit Teaching Rounds: A Feasibility Study.

BACKGROUND: Teaching rounds are an important component of the learning environment for residents in the intensive care unit (ICU). Retrieval practice is a cognitive learning tool that helps learners consolidate information and might improve the quality and culture of teaching rounds. OBJECTIVE: We performed a feasibility study from October 2018 to June 2019 to investigate the incorporation of retrieval practice into ICU rounds. METHODS: Participants included internal medicine and family medicine residents and pulmonary and critical care medicine fellows and faculty on medical ICU (MICU) teams at a tertiary care academic medical center. For 1-week periods, residents were asked to use retrieval practice after rounds, sharing one learning point. Participants were anonymously surveyed about the feasibility and acceptability of this strategy and perceptions of the educational value of ICU rounds before and after incorporating retrieval practice. RESULTS: We enrolled 9 MICU teams, including 31 residents, 8 fellows, and 8 attendings. Pre- and postsurvey response rates were 89% and 91% (42 and 43 of 47, respectively). Sixty-nine percent of respondents (30 of 43) reported sharing learning points on at least 3 days of the intervention week. Eighty-six percent of respondents (37 of 43) said retrieval practice did not adversely affect the workflow at the end of rounds. The perception that teaching on rounds was a priority increased after the intervention (3.93 versus 4.28 on 1-5 Likert scale, P = .047). CONCLUSIONS: Using retrieval practice on MICU rounds was feasible and acceptable and was associated with an increase in the perceived priority given to teaching on rounds.

Design and Implementation of a Peer-Reviewed Medical Education Video Competition: The Best of American Thoracic Society Video Lecture Series.

BACKGROUND: Video is an increasingly popular medium for consuming online content, and video-based education is effective for knowledge acquisition and development of technical skills. Despite the increased interest in and use of video in medical education, there remains a need to develop accurate and trusted collections of peer-reviewed videos for medical learners. OBJECTIVE: We developed the first professional society-based, open-access library of crowd-sourced and peer-reviewed educational videos for medical learners and health care providers. METHODS: A comprehensive peer-review process of medical education videos was designed, implemented, reviewed, and modified using a plan-do-study-act approach to ensure optimal accuracy and effective pedagogy, while emphasizing modern teaching methods and brevity. The number of submissions and views were tracked as metrics of interest and engagement of medical learners and educators. RESULTS: The Best of American Thoracic Society Video Lecture Series (BAVLS) was launched in 2016. Total video submissions for 2016, 2017, and 2018 were 26, 55, and 52, respectively. Revisions to the video peer-review process were made after each submission cycle. By 2017, the total views of BAVLS videos on www.thoracic.org and YouTube were 9100 and 17 499, respectively. By 2018, total views were 77 720 and 152 941, respectively. BAVLS has achieved global reach, with views from 89 countries. CONCLUSIONS: The growth in submissions, content diversity, and viewership of BAVLS is a result of an intentional and evolving review process that emphasizes creativity and innovation in video-based pedagogy. BAVLS can serve as an example for developing institutional or society-based video platforms.

A Sleep Medicine Curriculum for Pulmonary and Pulmonary/Critical Care Fellowship Programs: A Multisociety Expert Panel Report.

BACKGROUND: Pulmonary medicine specialists find themselves responsible for the diagnosis and management of patients with sleep disorders. Despite the increasing prevalence of many of these conditions, many sleep medicine fellowship training slots go unfilled, leading to a growing gap between the volume of patients seeking care for sleep abnormalities and the number of physicians formally trained to manage them. To address this need, we convened a multisociety panel to develop a list of curricular recommendations related to sleep medicine for pulmonary fellowship training programs. METHODS: Surveys of pulmonary and pulmonary/critical care fellowship program directors and recent graduates of these programs were performed to assess the current state of sleep medicine education in pulmonary training, as well as the current scope of practice of pulmonary specialists. These data were used to inform a modified Delphi process focused on developing curricular recommendations relevant to sleep medicine. RESULTS: Surveys confirmed that pulmonary medicine specialists are often responsible for the diagnosis and treatment of a number of sleep conditions, including several that are not traditionally considered related to respiratory medicine. Through five rounds of voting, the panel crafted a list of 52 curricular competencies relevant to sleep medicine for recommended inclusion in pulmonary training programs. CONCLUSIONS: Practicing pulmonary specialists require a broad knowledge of sleep medicine to provide appropriate care to patients they will be expected to manage. Training program directors may use the list of competencies as a framework to ensure adequate mastery of important content by graduating fellows.