Our Pipeline at Risk?: Burnout in Pulmonary and Critical Care Fellowship Training

Physician decision making is partially responsible for the roughly 30% of U.S. healthcare expenditures that are wasted annually on low-value care. In response to both the widespread public demand for higher-quality care and the cost crisis, payers are transitioning toward value-based payment models whereby physicians are rewarded for high-value, cost-conscious care. Furthermore, to target physicians in training to practice with cost awareness, the Accreditation Council for Graduate Medical Education has created both individual objective milestones and institutional requirements to incorporate quality improvement and cost awareness into fellowship training. Subsequently, some professional medical societies have initiated high-value care educational campaigns, but the overwhelming majority target either medical students or residents in training. Currently, there are few resources available to help guide subspecialty fellowship programs to successfully design durable high-value care curricula. The resource-intensive nature of pulmonary and critical care medicine offers unique opportunities for the specialty to lead in modeling and teaching high-value care. To ensure that fellows graduate with the capability to practice high-value care, we recommend that fellowship programs focus on four major educational domains. These include fostering a value-based culture, providing a robust didactic experience, engaging trainees in process improvement projects, and encouraging scholarship. In doing so, pulmonary and critical care educators can strive to train future physicians who are prepared to provide care that is both high quality and informed by cost awareness.

Emergency Medicine and Critical Care Medicine: Have the Stars (Finally) Aligned?

Critical care fellowship training in the United States differs based on specific specialty and includes medicine, surgery, anesthesiology, pediatrics, emergency medicine, and neurocritical care training pathways. We provide an update regarding the number and growth of US critical care fellowship training programs, on-duty residents and certified diplomates, and review the different critical care physician training pathways available to residents interested in pursuing a fellowship in critical care. Data were obtained from the Accreditation Council for Graduate Medical Education and specialty boards (American Board of Internal Medicine, American Board of Surgery, American Board of Anesthesiology, American Board of Pediatrics American Board of Emergency Medicine) and the United Council for Neurologic Subspecialties for the last 16 years (2001-2017). The number of critical care fellowship training programs has increased 22.6%, with a 49.4% increase in the number of on-duty residents annually, over the last 16 years. This is in contrast to the period of 1995 to 2000 when the number of physicians enrolled in critical care fellowship programs had decreased or remained unchanged. Although more than 80% of intensivists in the US train in internal medicine critical care Accreditation Council for Graduate Medical Education-approved fellowships, there has been a significant increase in the number of residents from surgery, anesthesiology, pediatrics, emergency medicine, and other specialties who complete specialty fellowship training and certification in critical care. Matriculation in neurocritical care fellowships is rapidly rising with 60 programs and over 1,200 neurocritical care diplomates. Critical care is now an increasingly popular fellowship in all specialties. This rapid growth of all critical care specialties highlights the magnitude of the heterogeneity that will exist between intensivists in the future.

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.

Editorial introductions

Editorial introductions

PREFACE

ASSESSMENT OF THE EFFICACY OF A VIRTUAL MENTORSHIP PROGRAM IN CRITICAL CARE

Critical care workforce in crisis: A path forward

Critical care is an expensive and limited resource in the United States. Estimates from more than a decade ago suggest that over $100 billion a year is spent on critical care services.1 Over the past two decades, the number of patients presenting to the Emergency Department (ED) requiring critical care services has increased at a much higher rate than the growth in overall ED volume.2,3 The proportion of ED patients requiring Intensive Care Unit (ICU) admission has increased 75% over the first decade of the twenty-first century. In addition to the increase in the absolute number of patients requiring critical care admission, the ED length of stay for critically ill patients increased by 60 minutes. This resulted in a total nationwide increase in critical care provided in the ED by more than threefold. This disproportionate increase in critical care time reflects both the increase in critical care volume and the increase in ED boarding of critically ill patients. Data from 2008 reported the median boarding time for a patient waiting in the ED for an ICU bed was more than 5 hours, and 30% of patients waited more than 6 hours for an ICU bed.2,3 This article is protected by copyright. All rights reserved.

Background: Pulmonary and critical care societies, including the American Thoracic Society, the American College of Chest Physicians, and the Society of Critical Care Medicine have large memberships that gather at academic conference events, attracting thousands of attendees.Objective: With the growth of social media use among pulmonary and critical care clinicians, our goal was to examine the Twitter presence and digital footprint of these three major medical society conferences.Methods: We used Symplur Signals (Symplur, LLC) to track the tweets and most active participants of the 2017–2019 annual conferences of American Thoracic Society, American College of Chest Physicians, and the Society of Critical Care Medicine. Attendance records of participants were obtained from each society.Results: During the study period, there was growth in the number of tweets, participants, and impressions for all three society conferences. Across all conferences, the amount of original content generated was less than the retweets, which comprised 50–72% of all tweets. Individuals physically attending each conference were more likely to post original content than those not in attendance (53–68% vs. 32–47%). For each society and at each meeting, clinicians made up the largest group of participants (44–60%), and most (59–82%) were physicians. A small cohort of participants was responsible for a large share of the tweets, with more than half of the participants at each conference for each society tweeting only once and only between 5–8% of participants tweeting more than 10 times. Seventy-eight individuals tweeted more than 100 times at one or more of the conferences. There was significant overlap in this group, with 32 of these individual participants tweeting more than 100 times at two or more of these conferences.Conclusion: Growth in conference digital footprints is largely due to increased activity by a small group of prolific participants that attend conferences by multiple academic societies. Original content makes up the smallest proportion of posts, suggesting that amplification of content is more prevalent than posting of original content. In a postpandemic environment, engagement of users producing original content may be even more important for medical societies.

Burnout Syndrome in ICU Caregivers: Time to Extinguish!

Evidence-Based Review and Discussion Points

Poverty is directly linked to public health care delivery in many ways and dimensions. Every aspect of the human sphere is preplanned, but a health crisis is the only emergency which pushes humanity into severe economic stress. Therefore, every nation aims to safeguard its citizens from a health crisis. In this aspect, India needs to improve its public health infrastructure in order to protect its citizens and save them from poverty. (1) To assess the current pitfalls in public critical health care delivery, (2) to analyze whether the health care delivery matches the requirements of its population in every state, (3) to produce solutions and guidelines to overcome the stress in this priority area. Data regarding the critical care workforce, which includes critical care doctors and nurses, were taken from official websites and other sources. Critical care infrastructure data were retrieved from the Internet sources. Data were validated by consulting state government sources and cross-checked for bias elimination. The data were analyzed using the "Statistical Package for Social Sciences" software version 20, and were presented using descriptive statistics. There is a 1:10 percentage of deficit in the case of critical care workforce and infrastructure when compared with its need analysis. Critical care medicine specialists are in 1:75 when compared to other specialties. Overall, the public sector critical care needs a total boost through out of box solutions. According to the Stockholm International Peace Research Institute (SIPRI), India spent the third most on defense in the world in 2021. India spent 76.6 billion dollars on its military in 2021, up 33% from 2012 and 0.9% from 2020. However, since India is considered a fast-growing economy, there is still a huge disparity in critical care. Without resetting critical health care, India cannot grow in welfare indices even if it is among the top gross domestic product (GDP) countries. Prabu D, Gousalya V, Rajmohan M, Dinesh MD, Bharathwaj VV, Sindhu R, et al. Need Analysis of Indian Critical Health Care Delivery in Government Sectors and its Impact on the General Public: A Time to Revamp Public Health Care Infrastructure. Indian J Crit Care Med 2023;27(4):237-245.

Resilience Lessons from COVID-19: Strengthening Critical Care Infrastructure and Workforce Capacity