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.

Leveraging multisource feedback to address diversity, equity, and inclusivity.

Multisource feedback has long been a recommended tool to assess clinical competencies within graduate medical education. Additionally, incorporating feedback supplied by patients and other members of the healthcare team can provide the framework to bridge perspectives and viewpoints that may be different from their own. This, in effect, can aid in fortifying values in diversity, equity, and inclusivity by developing more knowledgeable, empathetic, and respectful future healthcare providers.

Build It and They Shall Come: Medical Education Communities of Practice.

Background: Producing scholarship in education is essential to the career development of a clinician-educator. Challenges to scholarly production include a lack of resources, time, expertise, and collaborators. Objective: To develop communities of practice for education scholarship through an international society to increase community and academic productivity. Methods: We developed multi-institutional scholarship pods within the American Thoracic Society through the creation of a working group (2017-2019). Pods met virtually, and meetings were goal focused to advance education scholarship within their area of interest. To understand the impact of these scholarship pods, we surveyed pod leaders and members in 2021 and analyzed the academic productivity of each pod via a survey of pod leaders and a review of the PubMed index. Results: Nine pods were created, each with an assigned educational topic. The survey had a response rate of 76.6%. The perceived benefits were the opportunity to meet colleagues with similar interests at other institutions, production of scholarly work, and engagement in new experiences. The main challenges were difficulty finding times to meet because of competing clinical demands and aligning times among pod members. Regarding academic productivity, eight publications, four conference presentations, and one webinar/podcast were produced by six of the nine pods. Conclusion: The development of communities of practice resulted in increased multi-site collaboration, with boosted academic productivity as well as an enhanced sense of belonging. Multiple challenges remain but can likely be overcome with accountability, early discussion of roles and expectations, and clear delegation of tasks and authorship.

Comparing the Accuracy of Mini-BAL to Bronchoscopic BAL in the Diagnosis of Pneumonia Among Ventilated Patients: A Systematic Literature Review.

Background: Despite its widespread use, there are no direct studies comparing mini-bronchoalveolar lavage (mini-BAL) to bronchoscopic bronchoalveolar lavage (BAL) for diagnosing pneumonia in ventilated patients. The aim of this study was to perform a systematic review of studies comparing ventilated patients undergoing both bronchoscopic BAL and mini-BAL, to determine the mini-BAL's diagnostic accuracy. Methods: We conducted a systematic review searching the databases PubMed (MEDLINE), EMBASE, Cochrane Library, Scopus, and clinicaltrials.gov from inception until January 2022, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Search terms included variations on "pneumonia," "critical illness," and "mini-bronchoalveolar lavage." Article screening and data extraction were performed independently by 2 reviewers. Results: Our search yielded 4296 abstracts. This was narrowed to 6 studies in which each patient underwent both mini-BAL and bronchoscopic BAL in succession. Included patients had a mean APACHE II score of 20.02 ± 3.81 and 15.95 ± 11.46 ventilator days. The sensitivity of the mini-BAL for diagnosis of pneumonia was 0.90 (95% confidence interval [CI]: 0.778-1.000) and the specificity was 0.827 (95% CI: 0.716-0.938). Limitations included inconsistency in volume of saline instilled and heterogeneity in included patients Conclusion: This study is the first to compile data from multiple publications directly comparing the mini-BAL to bronchoscopic BAL for diagnosing pneumonia in ventilated patients. Our data demonstrate a high degree of both sensitivity and specificity of mini-BAL for the diagnosis of pneumonia in ventilated patients and indicate that mini-BAL could be considered as an acceptable alternative diagnostic study.

The Virtual Interview Experience: Perspectives of Pulmonary and Critical Care Fellowship Applicants.

Background: Because of the coronavirus disease (COVID-19) pandemic, graduate medical education programs adopted virtual interviews (VIs) as the default modality for the 2020 recruitment season. It is unknown whether VIs allowed applicants to effectively evaluate programs, and the best interview format for the future is unclear. Objective: To 1) assess pulmonary and critical care applicants' perceived ability to evaluate programs using VIs, 2) determine the attitudes of applicants toward the components of VIs, and 3) identify applicants' preferences for the future fellowship interview format. Methods: After the National Residency Matching Program medical subspecialty match, an electronic survey was sent to 1,067 applicants to pulmonary and critical care medicine programs asking them to compare their fellowship VI experience with their residency in-person interview (IPI) experience. Results: Three hundred six (29%) applicants responded to the survey, and 289 completed it (27%). There were 117 (40%) women and 146 (51%) White individuals. Most respondents believed that VIs hindered their ability to evaluate programs' culture, faculty-fellow relationships, location, facilities, and their own fit within the program. They believed they were able to evaluate the clinical experience, curriculum, and potential for academic development equally well compared with IPIs. The most helpful elements of VIs were the interview with the program director, meetings with the fellows, and interviews with faculty members. Less helpful elements included conference access, prerecorded program director presentations, virtual hospital and city tours, and video testimonials. One hundred twenty-three respondents (43%) chose VIs with an optional visit as their preferred future interview format, 85 (29%) chose IPIs, 54 (19%) wanted a choice between VIs and IPIs, and 27 (9%) chose VIs only. Conclusion: Most pulmonary and critical care medicine applicants preferred future interviews to include both VIs and the option of an in-person visit or interview. This study can assist programs in designing their future interview formats in a trainee-centric fashion.

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.

How and Why Trainees Choose a Career in Pediatric Pulmonology. A Qualitative Study.

Background: There is concern that inadequate recruitment of new subspecialty trainees to replace the aging physician population will lead to significant workforce issues in pediatric pulmonology. The factors leading trainees to pursue a fellowship in pediatric pulmonology are unclear. Objective: To gain a better understanding of the decision-making process surrounding the choice to pursue a pediatric pulmonary fellowship and to provide informed recommendations to increase recruitment of new trainees. Methods: Informed by the Social Cognitive Career Theory, eight focus groups were held with pediatric residents and fellows attending the 2019 American Thoracic Society International Conference. Questions focused on personal background, learning experiences, self-efficacy and outcome expectations, interests, and goals. Transcripts were analyzed by conventional content analysis. Results: Fifty-six residents and fellows representing 42 different institutions participated. Responses resulted in seven major themes: 1) attractive aspects of pediatric pulmonology draw trainees to the field, 2) exposure to the breadth and scope of the field is limited, 3) mentorship is key, 4) decisions surrounding fellowship selection occur early in the second year, 5) trainees want flexibility in length and structure of fellowship, 6) financial considerations are not the driving factor in decision-making, and 7) there are inherent aspects of pulmonology that trainees may not enjoy. Conclusion: A lack of broad exposure to pediatric pulmonology during residency results in false perceptions of the field and is a deterrent to recruitment. Improving faculty engagement, guaranteeing broad and early exposure to the field, and creating learning experiences aimed at raising self-efficacy may improve recruitment and ultimately improve the pediatric pulmonary workforce.

Twelve tips for conducting successful interprofessional teaching rounds.

Inpatient bedside teaching rounds provide an opportunity to foster effective interprofessional collaboration between members of the healthcare team. Although effective interprofessional practice has been shown to improve patient satisfaction, patient outcomes, and job satisfaction, there is limited literature for successful implementation of interprofessional teaching rounds. To address this gap, we have compiled 12 tips for conducting effective interprofessional bedside teaching rounds. These tips offer strategies for creating a structured rounding system, with clear delineation of expectations, defined opportunities for learning across disciplines, and active engagement of and respect for all team members. By adopting and promoting this model of interprofessional collaborative practice, the quality and effectiveness of bedside teaching rounds can be improved for the benefit of patients, trainees, and the team as a whole.

Twelve tips for just in time teaching of communication skills for difficult conversations in the clinical setting.

The ability to communicate well with patients and other members of the healthcare team is a vital skill for physicians to have, but one that is often not emphasized in medical education. Learners of all levels can obtain and develop good communication skills regardless of their natural ability in this area, and the clinical setting represents an underutilized resource to accomplish this task. With this in mind, we have reviewed the growing body of literature on the subject and organized our findings into twelve tips to help educators capitalize on these missed opportunities. While our emphasis is helping learners with difficult discussions, these tips can be easily adapted to any other clinical encounter requiring clear communication. Teaching effective communication skills in the clinical setting requires some extra time, but the steps outlined should not take more than a few minutes to complete. Taking the time to develop these skills in our learners will make a significant difference not only their lives but also their patients and their families.

Factors associated with family satisfaction with end-of-life care in the ICU: a systematic review.

BACKGROUND: Family satisfaction with end-of-life care in the ICU has not previously been systematically reviewed. Our objective was to perform a review, synthesizing published data identifying factors associated with family satisfaction with end-of-life care in critically ill adult populations. METHODS: The following electronic databases were searched: MEDLINE (Medical Literature Analysis and Retrieval System Online), MEDLINE Updated, EMBASE (Excerpta Medical Database), CINAHL (Cumulative Index to Nursing and Allied Health Literature), PsycInfo, and PubMed. Two authors reviewed retrieved titles and abstracts. Studies describing nonadult and non-ICU populations or not addressing end-of-life care, family satisfaction, or factors affecting satisfaction were excluded. The remaining articles underwent full review and data extraction by two authors. Quality was assessed using a checklist based on the recommendations of the Consolidated Standards for Reporting Trials group. RESULTS: The search yielded 1,072 articles, with 23 articles describing 14 studies meeting inclusion criteria. All studies obtained satisfaction data from family members via surveys and structured interviews. Specific communication strategies increasing satisfaction included: expressions of empathy, nonabandonment, and assurances of comfort and provision of written information. Additionally, support for shared decision-making, family presence at time of death, and specific patient-care measures such as extubation before death were associated with increased satisfaction. CONCLUSIONS: Good-quality communication, support for shared decision-making, and specific patient-care measures were associated with increased satisfaction with end-of-life care. Assessing the family's desire to participate in shared decision-making may also be an important factor. Few interventions increased satisfaction. Future research is needed to further define optimal communication strategies, understand effective integration of palliative care into the ICU, and define significant score changes in survey instruments.