Innovative Blended Learning Curriculum in Noninvasive Ventilation for Pulmonary and Critical Care Fellows

Attitudes and Perceptions of Internal Medicine Residents Regarding Pulmonary and Critical Care Subspecialty Training

Background: Invasive procedures are a core aspect of pulmonaryand critical care practice. Procedures performed in the intensive care unitcan be divided into high-risk, low-volume (HRLV) procedures and low-risk,high-volume (LRHV) procedures. HRLV procedures include cricothyroidotomy,pericardiocentesis, Blakemore tube placement, and bronchial blockerplacement. LRHV procedures include arterial line placement, central venouscatheter placement, thoracentesis, and flexible bronchoscopy. Despite thefrequency and importance of procedures in critical care medicine, little isknown about the similarities and differences in procedural training betweendifferent Pulmonary and Critical Care Medicine (PCCM) and Critical CareMedicine (CCM) training programs. Furthermore, differences in proceduraltraining practices for HRLV and LRHV procedures have not previously beendescribed.Objective: To assess procedural training practices in PCCM andCCM fellowship programs in the United States, and compare differences intraining between HRLV and LRHV procedures.Methods: A novel survey instrument was developed anddisseminated to PCCM and CCM program directors and associate programdirectors at PCCM and CCM fellowship programs in the United States to assessprocedural teaching practices for HRLV and LRHV procedures.Results: The survey was sent to 221 fellowship programs, 168PCCM and 34 CCM, with 70 unique respondents (31.7% response rate). Of theprocedural educational strategies assessed, each strategy was usedsignificantly more frequently for LRHV versus HRLV procedures. The majorityof respondents (51.1%) report having no dedicated training for HRLVprocedures versus 6.9% reporting no dedicated training for any LRHVprocedure (P < 0.001). For HRLVprocedures, 76.9% of respondents indicated that there was no set number ofprocedures required to determine competency, versus 25.3% for LRHVprocedures (P < 0.001). For LRHVprocedures, fellows were allowed to perform procedures independently withoutsupervision 21.7% of the time versus 3.9% for HRLV procedures(P = 0.004). Programdirectors’ confidence in their ability to determine fellows’competence in performing procedures was significantly lower for HRLV versusLRHV versus HRLV procedures(P < 0.001).Conclusion: Significant differences exist in procedural trainingeducation for PCCM and CCM fellows for LRHV versus HRLV procedures, andawareness of this discrepancy presents an opportunity to address thiseducational gap in PCCM and CCM fellowship training.

In the United States, Pulmonary and Critical Care Medicine (PCCM) fellowship training traditionally requires performing a minimum number of bronchoscopy and pleural procedures to be deemed competent. However, expert panel recommendations favor assessments based on skill and knowledge. PCCM trainees have a variable exposure to the advanced procedures in the presence of interventional pulmonary (IP) fellowships, so we surveyed the PCCM program directors (PD) across the United States to assess the procedural volume and competency of their fellows. Survey invitations were emailed between April 2022 and May 2022, and responses were collected from PCCM fellowship programs. The PD assessed the competency and volume of procedures performed by PCCM fellows at the end of training. The primary objective was to determine the effect of IP fellowship or IP faculty on fellows' procedural competency. The secondary objective was to assess the same impact on procedural volume. The survey response rate was 41.9% (n=109/260) with an average of 4.23 fellows/program (95% CI: 3.9-4.6). 74.5% (73/98) programs reported having access to IP faculty, while 26.5% (26/98) had an AABIP-accredited IP fellowship. No significant difference was noted for procedural competency or volume in programs with or without an IP fellowship or IP faculty during training. Most programs reported that PCCM fellows do not perform advanced bronchoscopy procedures. An IP fellowship or IP faculty at a PCCM training institution did not appear to influence the PD-assessed volume or competency of common bronchoscopy and pleural procedures performed by fellows.

BackgroundPhysicians require extensive training to achieve proficiency in mechanical ventilator (MV) management of the critically ill patients. Guided self-directed learning (GSDL) is usually the method used to learn. However, it is unclear if this is the most proficient approach to teaching mechanical ventilation to critical care fellows. We, therefore, investigated whether critical care fellows achieve higher scores on standardized testing and report higher satisfaction after participating in a hands-on tutorial combined with GSDL compared to self-directed learning alone.MethodsFirst-year Pulmonary and Critical Care Medicine (PCCM) fellows (n=6) and Critical Care Internal Medicine (CCIM) (n=8) fellows participated. Satisfaction was assessed using the Likert scale. MV knowledge assessment was performed by administering a standardized 25-question multiple choice pre- and posttest. For 2 weeks the CCIM fellows were exposed to GSDL, while the PCCM fellows received hands-on tutoring combined with GSDL.ResultsNinety-three percentage (6 PCCM and 7 CCIM fellows, total of 13 fellows) completed all evaluations and were included in the final analysis. CCIM and PCCM fellows scored similarly in the pretest (64% vs. 52%, p=0.13). Following interventions, the posttest scores increased in both groups. However, no significant difference was observed based on the interventions (74% vs. 77%, p=0.39). The absolute improvement with the hands-on-tutoring and GSDL group was higher than GSDL alone (25% vs. 10%, p=0.07). Improved satisfaction scores were noted with hands-on tutoring.ConclusionsHands-on tutoring combined with GSDL and GSDL alone were both associated with an improvement in posttest scores. Absolute improvement in test and satisfaction scores both trended higher in the hands-on tutorial group combined with GSDL group.

BackgroundAlthough it is well known that the coronavirus disease (COVID-19) pandemic has had a profound effect on health care, its impact on fellowship training in Pulmonary and Critical Care Medicine (PCCM) has not been well described.ObjectiveWe conducted an anonymous survey of PCCM program directors (PDs) to assess the impact of the COVID-19 pandemic on PCCM fellowship training across the United States.MethodsWe developed a 30-question web-based survey that was distributed to U.S. PCCM PDs through the Association of Pulmonary and Critical Care Medicine Program Directors.ResultsThe survey was sent to 242 PDs, of whom 28.5% responded. Most of the responses (76.8%) came from university-based programs. Almost universally, PDs reported a decrease in the number of pulmonary function tests (100%), outpatient visits (94.1%), and elective bronchoscopies (96%). Three-quarters (77.6%) of the PDs reported that their PCCM fellows spent more time in the intensive care unit than originally scheduled.ConclusionThe COVID-19 pandemic has had a variable impact on different aspects of fellowship training. PDs reported a significant decrease in the core components of pulmonary training, whereas certain aspects of critical care training increased. It is likely that targeted mitigation strategies will be needed to ensure no gaps in PCCM training while optimizing well-being.

BackgroundThere exists no standardized longitudinal curriculum for teaching bedside ultrasonography (US) in Pulmonary and Critical Care Medicine (PCCM) fellowship programs. Given the importance of mastering bedside US in clinical practice, we developed an integrated year-long US curriculum for first-year PCCM fellows.Methods11 first-year PCCM fellows completed the entire seven-step Blended Learning Curriculum. We provide results from an evaluation of Step I, the initial training course. Evaluation included a 17-question multiple-choice knowledge test and a hands-on skill exam delivered pre-, immediately post-, and 6 months post-course. Performance on these same evaluation measures was compared between learners who completed a traditionally designed curriculum, which contained a formal in-person didactic course, and learners who completed a blended learning curriculum covering the same learning objectives.ResultsAll learners showed a significant improvement immediately after the course in both knowledge (p = 0.007) and skills (p = 0.004) with adequate retention of both knowledge and skills after 6 months. Scores on a multiple-choice knowledge test increased from a median (interquartile range [IQR]) of 24% (15–41%) pre-course to a median of 71% (59–82%) post-course, while scores on a hands-on skill exam increased from a median of 16% (7–45%) pre-course to a median of 87% (74–94%) post-course. There was no difference in learning or retention between those who learned via the blended learning model as compared with a more traditional model. Learners agreed the course was well-designed, with relevant learning topics, sufficient time to learn, and fair evaluation modalities. The blended learning model required 15 fewer faculty-hours than the traditional learning model.DiscussionA blended learning model for bedside US education implemented at a single PCCM fellowship performs comparably to a traditional model for both acquisition and retention of knowledge and skills. The incorporation of asynchronous learning mitigates the barrier of insufficient time and quantity of US skilled teaching faculty that many PCCM fellowships face and provides flexibility to both instructors and learners.

Noninvasive Ventilation as a Weaning Tool: Response

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

Limitations to Study on Noninvasive Ventilation

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.

BackgroundInternal medicine (IM) residents face significant challenges when pursing subspecialty fellowships. This study determined the factors that differentiate IM residents entering pulmonary and critical care medicine (PCCM) fellowships from those pursuing other careers.MethodsWe completed a retrospective study of 12 classes of IM residents at a single institution completing residency between 2010 and 2021. Data included pre-residency characteristics, global residency performance, and PCCM-specific experiences. Logistic regression models examined associations between these variables and the primary outcome of matching into a PCCM fellowship within one year of completing IM residency.ResultsAmong 522 residents, 10.3% matched into PCCM. Completing a pulmonary elective significantly increased the odds of matching into PCCM (OR 7.78, 99% CI 3.10–19.53, p < 0.0001). Residents who match into PCCM were more likely to have < 3 publications than 3 + (OR 3.51 (1.20–10.25), p = 0.003).” A stated intent to enter PCCM was positively associated with matching into PCCM in the univariable, but not the multivariable, model.ConclusionsMatriculating into PCCM fellowship was significantly associated with completing a pulmonary elective during residency. PCCM-bound residents were less likely to achieve high numbers of publications, suggesting these residents’ preferences for clinical learning and practice over scholarship. This study provides insights into characteristics of residents who match into PCCM and guides mentors as they counsel residents considering PCCM.

PurposeWe conducted a quality improvement study to gain insight into how the COVID-19 pandemic affected the education of trainees in pulmonary and critical care medicine (PCCM). We also sought to understand the experiences of fellows to better prepare for future pandemics.MethodsWe sent an electronic survey to fellows of an academic PCCM program and used data from the electronic survey to design semi-structured interviews for a qualitative study.ResultsThree themes were generated, centred on the emotional burden and physical demand, friendship, and education. Favourable aspects included the organizational response to the pandemic, particularly in terms of communication, personal protective equipment, and an emphasis on teamwork. Fellows became proficient in critical care procedures. The need for a trainees’ respite area was emphasized. Other areas of concern included the lack of leadership to facilitate assistance from various services in the ICU and ensuring adequate education in pulmonary medicine, despite the extended demands of critical care.ConclusionParticipants were dismayed at the lack of support from other services. The shift to virtual lectures resulted in a loss of personal contact and connections, as fellows much preferred in-person sessions. Our results highlight opportunities for learning, fulfillment, and challenges encountered while navigating a pandemic.

Hypercapnic encephalopathy syndrome: A new frontier for non-invasive ventilation?

Entry into the interventional pulmonary (IP) fellowship requires prerequisite training in pulmonary and critical care medicine (PCCM) fellowship in the United States. IP fellowship has become standardized, but the prerequisite training may be quite variable depending on the learner's exposure to IP during their PCCM fellowship. A survey study was conducted to identify potential foundational knowledge and/or skills gaps of new fellows entering IP fellowships. This may help both PCCM and IP fellowship directors to identify common knowledge gaps within PCCM training specific to IP. Based on components of the ACGME's common program requirements for PCCM fellowships, a survey was developed and categorized into 5 domains: nonprocedural skills, didactic knowledge, diagnostic bronchoscopy, pleural procedures, and airway/percutaneous procedures. The survey was then sent to 42 IP fellowship directors after the content validity review and approval by the Association of Interventional Pulmonary Program Directors. The survey response rate was 88.1% (37/42). The overall mean scores in all 5 domains were perceived as below competent (<3). The highest mean domain was nonprocedural skills, and the lowest was airway/percutaneous procedures. Within the domains, there were 4/ 30 topics that were considered competent with a score of ≥3 as competent or higher; bronchoscopy lavage (mean: 3.5/5, SD: 0.87), interpersonal skills (mean: 3.03/5, SD: 0.76), thoracentesis (mean: 3.14/5, SD: 0.89), and ultrasound for pleural effusion (mean: 3.19/5, SD: 0.84). There are perceived gaps in PCCM training pertaining to IP fellowship readiness.

To construct and validate the risk assessment tool of medical device-related pressure injury (MDRPI) for Pulmonary and Critical Care Medicine (PCCM), help clinical medical staff to quickly and effectively screen high-risk groups and provide a reference for the development of targeted early intervention measures. The department of PCCM mainly treats elderly patients and patients with chronic diseases of the respiratory system, and frequently uses oxygen therapy devices, monitors and treatment pipelines. It is a high-risk department for MDRPI. Once MDRPI occurs, it is not easy to heal and may lead to various complications and affect the disease prognosis. At present, there is no specialised assessment tool for PCCM patients. A multi-centre prospective study. We collected data from 932 PCCM patients who used medical devices in three Grade III Class A Comprehensive Hospitals from November 2022 to October 2023. Of those, 652 cases were assigned to the modelling and 280 to the verification groups. Logistic regression was used to construct the model. The AUC was used to test the predictive effect of the model. The risk assessment tool was constructed with the OR (odds ratio) value obtained by binary Logistic multi-variate regression analysis. Verification groups were used for validated the risk assessment tool. The factors entered into the prediction model were use of nasal catheter, high flow oxygen therapy, non-invasive ventilation, invasive ventilation, having chronic respiratory disease, using hormonal drugs, sedative drugs and abnormal skin condition. The prediction model was transformed into a risk assessment tool, and the OR values were rounded to form the MDRPI risk assessment tool with the values ranging from 0 to 66 points. The area under the ROC curve (AUC) is 0.861, and the maximum value of Youden index (YI) is 0.606, corresponding to a sensitivity of 80.6%, specificity of 80.0% and a cut-off value of 17, divided patients into low risk ≤ 17 and high risk > 17. The risk assessment tool applied to the clinic, and the accuracy was 92.75%. The risk assessment tool can provide clinical guidance and predict the risk of MDRPI for PCCM patients. Clinical nurses in PCCM can use the risk assessment tool to assess the risk of MDRPI occurrence and provide a reference for preventive measures.