Care Fellowship Training Research Articles

This paper outlines the need for developing a new training model for Integrated Care Medical Consultants in rural Northern Ireland, how the model was developed in collaboration with key stakeholders in the community using ECHO methodology, the implementation of the Integrated Care Fellowship scheme and the potential that this model offers for other rural areas where there are medical workforce challenges. Across the world sustaining a medical workforce in rural areas is a challenge. Existing training schemes tend to be based around major population areas and it is often hard to attract consultants to rural areas. In addition, existing training schemes may not be geared to the particular needs of a rural population, and recent changes in the training programmes of both Care of the Elderly and Palliative Care Doctors in the UK has been implicated for a fall off in numbers seeking such training. Through the Pathfinder project key stakeholders across the Western Trust used the ECHO methodology to identify the key priorities that the community living in rural Tyrone and Fermanagh wanted from a health service in relation to the elderly, frail and those needing palliative care services. The findings can be summarised as wanting more integrated and locally connected services. To respond to this and the demographic need of rapidly increasing numbers of elderly and frail people in the population we created an Integrated Care Fellowship training scheme combining the Care of the Elderly Curriculum with that of the Palliative Care Curriculum. The four year fellowship seeks to create a robust consultant workforce equipped with the skills and knowledge to lead the development of a more integrated way of working across the geography and in collaboration with existing assets and supports from both the statutory and voluntary sector to better deliver the care of the future that people in rural areas want. Support for the programme has been demonstrated by the Western Trust, the numbers of applicants for the programme, the quality of those candidates and by existing traditional training scheme leaders.

Increasing Primary Care Research Workforce and Output through T32 Primary Care Fellowship Training

Bu makale Amerika Birleşik Devletleri’nde (ABD) yoğun bakım uzmanı olmanın yolu hakkında bilgi vermektedir. ABD’deki yoğun bakım eğitiminin mevcut yapısının ve eğitim programlarına başvuru sürecinin ayrıntılı bir açıklamasıyla başlamaktadır. Daha sonra ABD’deki yoğun bakım ünitelerinin genel yapısına ve yoğun bakım ünitesi doktorlarının bu yapıya nasıl uyum sağladığına dair bir sunum içermektedir. Makale, Amerikan yoğun bakımının uluslararası yoğun bakım toplulukları içerisinde küresel olarak nasıl yer aldığının tartışılmasıyla son bulmaktadır.

202: Current State of Extracorporeal Membrane Oxygenation Education in Neonatal and Pediatric Critical Care Fellowship Training

Background: Postgraduate fellowship training for nurse practitioners (NP) in palliative care can ameliorate workforce shortages; however, currently there are few NP fellowships and little evidence about outcomes, such as retention in hospice and palliative nursing, job satisfaction, or professional contributions. Objective: To describe the impact of palliative care fellowship training on the careers of NP alumni. Methods: A survey was electronically distributed to all NP alumni of an interprofessional palliative care fellowship since adult and pediatric nursing cohorts were added (2009-2022). Results: Most respondents still worked in hospice and/or palliative care; a majority of them engaged in professional activities beyond clinical work and reported high career satisfaction. Alumni endorsed multiple benefits of postgraduate fellowship except for post-fellowship compensation. Conclusions: NP palliative care fellowship alumni reported multiple career benefits including job satisfaction, professional accomplishment, and ongoing employment at their training institutions.

We aimed to define and map subcompetencies required for pediatric cardiac critical care (PCCC) fellowship education and training under the auspices of the Pediatric Cardiac Intensive Care Society (PCICS). We used the 2022 frameworks for PCCC fellowship learning objectives by Tabbutt et al and for entrustable professional activities (EPAs) by Werho et al and integrated new subcompetencies to the EPAs. This complementary update serves to provide a foundation for standardized trainee assessment tools for PCCC. A volunteer panel of ten PCICS members who are fellowship education program directors in cardiac critical care used a modified Delphi method to develop the update and additions to the EPA-based curriculum. In this process, the experts rated information independently, and repetitively after feedback, before reaching consensus. The agreed new EPAs were later reviewed and unanimously accepted by all PCICS program directors in PCCC in the United States and Canada and were endorsed by the PCICS in 2023. The procedure for defining new subcompetencies to the established EPAs comprised six consecutive steps: 1) literature search; 2) selection of key subcompetencies and curricular components; 3) written questionnaire; 4) consensus meeting and critical evaluation; 5) approval by curriculum developers; and 6) PCICS presentation and endorsement. Overall, 110 subcompetencies from six core-competency domains were mapped to nine EPAs with defined levels of entrustment and examples of simple and complex cases. To facilitate clarity and develop a future assessment tool, three EPAs were subcategorized with subcompetencies mapped to the appropriate subcategory. The latter covering common procedures in the cardiac ICU. This represents the 2023 update to the PCCC fellowship education and training EPAs with the defining and mapping of 110 subcompetencies to the nine established 2022 EPAs. This goal of this update is to serve as the next step in the integration of EPAs into a standardized competency-based assessment framework for trainees in PCCC.

Graduate Medical Education (GME) emphasizes the role of the annual program evaluation to identify opportunities, create action plans, and track improvements longitudinally. There is a lack of a systematic approach to the evaluation of educational curricula. Comprehensive curriculum evaluation can inform the educators about specific modifications to achieve high standards, desired outcomes, and the anticipated objectives. To evaluate a leadership in quality improvement program in a pulmonary/critical care fellowship training program using the context, input, process, product (CIPP) model. The CIPP model, given its focus on evaluating different aspects of a program, provides concrete and targeted feedback to guide improvement decisions. Evaluation questions addressing the four focused areas were created, pilot tested, and revised. The questions were framed toward optimization of alignment (e.g., program activities with stated objectives, program goals with theoretical perspective, program curriculum with trainee needs) and gaining information about the efficacy of the program in achieving the desired outcomes. To enhance the validity of the results, we triangulated the data-gathering approach by administering surveys and conducting interviews and focus groups by random selection from the eligible participants. Qualitative data were transcribed, coded, and categorized into themes aligning with the four aspects of the CIPP model. We interviewed 9 participants and conducted three focus groups with 20 participants. The surveys provided vital quantitative information that was cross-verified with the qualitative data; 23 of the 25 (92%) participants completed the survey. The results of qualitative thematic analysis were organized in the CIPP format. The context evaluation of the program revealed that the fellows and faculty were unfamiliar with the guiding principles of the course. The input evaluation highlighted the competing interests that hampered the engagement of the fellows during the evening weekly report-outs. The process evaluation revealed clustering of didactic sessions at the start of the course. The product evaluation stressed the difficulty in completing the quality improvement projects in the allotted timeframe. Conducting a robust evaluation of an educational curriculum provides insights into gaps in the various stages of the program. Time and resources needed for conducting evaluation by using the CIPP model should be considered.

A Survey of Pediatric Neurocritical Care Fellowship Training in North America

Frequency and Prediction of Burnout Among Physicians Who Completed Palliative Care Fellowship Training - A 10 Year Survey.

Underrepresented minorities in medicine (URiMs) are disproportionally represented in surgery training programs. Rates of URiMs applying to and completing General Surgery residency remain low. We hypothesized that the patterns of URiMs disparities would persist into surgical critical care (SCC) fellowship applicants, matriculants, and graduates. We performed a retrospective analysis of SCC applicants, matriculants, and graduates from 2005 to 2020 using the graduate medical education resident survey and analyzed applicant characteristics using the Surgical Critical Care and Acute Care Surgery Fellowship Application Service from 2018 to 2020. The data were stratified by race/ethnicity and sex. Indicator variables were created for Asian, Hispanic, White, and Black trainees. Yearly proportions for each race/ethnicity and sex categories completing or enrolling in a program were calculated and plotted over time with Loess smoothing lines and overlying 95% confidence bands. The yearly rate and statistical significance of change over time were tested with linear regression models with race/ethnicity and sex proportion as the dependent variables and year as the explanatory variable. From 2005 to 2020, there were a total of 2,481 graduates. Black men accounted for 4.7% of male graduates with a significant decline of 0.3% per year for the study period of those completing the fellowship (p = 0.02). Black women comprised 6.4% of female graduates and had a 0.6% decline each year (p < 0.01). A similar trend was seen with Hispanic men, who comprised 3.2% of male graduates and had a 0.3% annual decline (p = 0.02). White men had a significant increase in both matriculation to and graduation from SCC fellowships during the same interval. Similarly, Black and Hispanic applicants declined from 2019 to 2020, while the percentage of White applicants increased. Disparities in URiMs representation remain omnipresent in surgery and extend from residency training to SCC fellowship. Efforts to enhance the recruitment and retention of URiMs in SCC training are warranted. Prognostic and Epidemiologic; level IV.

Patient-level factors related to cardiac arrest in the pediatric cardiac population are well understood but may be unmodifiable. The impact of cardiac ICU organizational and personnel factors on cardiac arrest rates and outcomes remains unknown. We sought to better understand the association between these potentially modifiable organizational and personnel factors on cardiac arrest prevention and rescue. Retrospective analysis of the Pediatric Cardiac Critical Care Consortium registry. Pediatric cardiac ICUs. All cardiac ICU admissions were evaluated for cardiac arrest and survival outcomes. None. Successful prevention was defined as the proportion of admissions with no cardiac arrest (inverse of cardiac arrest incidence). Rescue was the proportion of patients surviving to cardiac ICU discharge after cardiac arrest. Cardiac ICU organizational and personnel factors were captured via site questionnaires. The associations between organizational and personnel factors and prevention/rescue were analyzed using Fine-Gray and multinomial regression, respectively, accounting for clustering within hospitals. We analyzed 54,521 cardiac ICU admissions (29 hospitals) with 1,398 cardiac arrest events (2.5%) between August 1, 2014, and March 5, 2019. For both surgical and medical admissions, lower average daily cardiac ICU occupancy was associated with better cardiac arrest prevention. Better rescue for medical admissions was observed for higher registered nursing hours per patient day and lower proportions of "part time" cardiac ICU physician staff (< 6 service weeks/yr). Increased registered nurse experience was associated with better rescue for surgical admissions. Increased proportion of critical care certified nurses, full-time intensivists with critical care fellowship training, dedicated respiratory therapists, quality/safety resources, and annual cardiac ICU admission volume were not associated with improved prevention or rescue. Our multi-institutional analysis identified cardiac ICU bed occupancy, registered nurse experience, and physician staffing as potentially important factors associated with cardiac arrest prevention and rescue. Recognizing the limitations of measuring these variables cross-sectionally, additional studies are needed to further investigate these organizational and personnel factors, their interrelationships, and how hospitals can modify structure to improve cardiac arrest outcomes.

BackgroundCommunication skills is a core competency for critical care fellowship training. The coronavirus disease (COVID-19) pandemic has made it increasingly difficult to teach these skills in graduate medical education. We developed and implemented a novel, hybrid version of the Critical Care Communication (C3) skills with virtual and in-person components for pulmonary and critical care fellows.ObjectiveTo develop and implement a new hybrid virtual/in-person version of the traditional C3 serious illness communication skills course and to compare learner outcomes to prior courses.MethodsWe modified the C3 course in 2020 in response to the COVID-19 pandemic by adapting large-group didactic content to an online format that included both virtual asynchronous and virtual live content. Small-group skills training remained in person with trained actors and facilitators. We administered self-assessments to the participants and compared with historical data from the traditional in-person courses beginning in 2012. After the 2020 course, we collected informal feedback from a portion of the learners.ResultsLike the traditional in-person version, participants rated the hybrid version highly. Learners reported feeling well prepared or very well prepared over 90% of the time in most communication skills after both versions of the course. Over 90% of participants in both versions of the course rated the specific course components as effective or very effective. Feedback from the learners indicates that they prefer the virtual didactics over traditional in-person didactics.ConclusionsPulmonary and critical care fellows rated a hybrid version of a communication skills training similarly to the traditional in-person version of the course. We have provided a scaffolding on how to implement such a course. We anticipate some of the virtual components of this training will outlive the current pandemic based on learner feedback.

Objective: To assess the impact of the coronavirus-2019 (COVID-19) pandemic on pediatric critical care medicine (PCCM) fellowship training through a cross-sectional survey of both program directors (PDs) and fellows. Design: Cross-sectional internet-based survey. Setting: Accreditation Council for Graduate Medical Education (ACGME)-accredited PCCM fellowship programs in the United States. Subjects: PCCM PDs and fellows. Results: A total of 34 PDs and 92 fellows responded to the national survey (rate of 47% and 17%, respectively). The majority (69%) of respondents agreed that medical education has been negatively impacted by the COVID-19 pandemic. When PDs were surveyed, 91% noted a significant decrease in the patient census since March 2020, with 59% citing a >15% decrease. Further, 65% reported trainees had less procedural experience. All respondents reported that education was at least in part provided through virtual learning platforms, with nearly half having exclusive remote learning without in-person sessions. Fifty percent of PDs and 62% of fellows reported decreased learner engagement during virtual didactics when compared to in-person education. The majority of PDs reported specific decreases in simulation, procedural skills training, and ultrasound training. Few PDs (15%) and fellows (13-16%) reported redeployment to adult patient care, with northeastern programs having the highest rates. In univariate analyses, decreased PDs confidence in trainee procedural skills was associated with reported decreases in number of procedures performed (P = .0006) and number of procedural skills didactic sessions (P = .0245). Change in the unit census was associated with less PDs confidence in fellows' medical knowledge (P = .0004), fellows' management skills (P = .0232), and fellows' procedural skills (P = .0003), with larger decreases in patient census correlating with larger decreases in confidence. Conclusions: The COVID-19 pandemic has significantly impacted the education and clinical training of PCCM fellows. More knowledge on this topic can assist PDs in curriculum changes for the future to address any gaps in learning that have occurred.

Background: Dedicated ambulatory training during pulmonary andcritical care medicine (PCCM) fellowships is often limited. A novel 2-yearlongitudinal outpatient pulmonary fellowship curriculum was previouslydeveloped, piloted, and studied. The exportability and potential impact of thisambulatory curriculum on PCCM fellowship training nationally is not known.Objective: We aim to understand the current state of ambulatorytraining in PCCM fellowships and the impact of a standardized outpatientcurriculum on fellows’ ambulatory knowledge and competency.Methods: Nineteen programs participated in the study from 2017 to2019. Six programs received the first year of content, seven programs receivedthe entire 2-year curriculum, and seven programs served as a control. Fellows,faculty, and program directors (PDs) completed a series of surveys assessingsatisfaction with ambulatory education and the curriculum. Fellows completed aseries of medical knowledge inventories, and programs submitted in-training examscores.Results: A total of 221 fellows (39%) and 17 PDs (89%)completed the precurriculum surveys, and 38 (12%) fellows and 10(53%) PDs completed postcurriculum surveys. Before curriculumimplementation, only 34.4% of fellows rated the quality of theirambulatory education as good or outstanding compared with 57.9% at theend of the study. Eighty-five percent of faculty and 89% of PDs rated thecurriculum as good or excellent. Faculty believed that the teaching scripts wereeasy to use (78.4%), were factually accurate (86.3%), and providedhigh-yield information (82.1%). The majority of PDs indicated that thecurriculum positively impacted patient care (78%) and fulfilled an unmeteducational need (100%), and most planned to continue the curriculumafter the study (78%). Feedback surrounded the need for updated contentbased on recently published guidelines and studies.Conclusion: The curriculum is a standardized and feasible way toaddress a previously unmet need in PCCM fellowship education. PDs rated thecurriculum highly and most plan to continue it in the future. Our limited dataset suggests that the curriculum was well received by fellows and faculty andpositively impacted perceptions of ambulatory education and preparedness forindependent practice. Future study with a larger sample of fellows is needed tobetter understand the generalizability of these findings.

Editorial introductions

Background: In July of 2013, the University of Maryland launched MarylandCCProject.com. This free-access educational website delivers asynchronous high-quality multidisciplinary critical care education targeted at critical care trainees. The lectures, presented in real time on-site, are recorded and available on the website or as a podcast on iTunes or Android. Thus, the curriculum can be easily accessed around the world.Objective: We sought to identify the impact this website has on current and former University of Maryland critical care trainees.Methods: A 32-question survey was generated using a standard survey generation tool. The survey was e-mailed in the fall of 2019 to the University of Maryland Multi-Departmental Critical Care current and graduated trainees from the prior 7 years. Survey data were collected through December 2019. The questions focused on user demographics, overall experience with the website, scope of website use, and clinical application of the content. Anonymous responses were electronically gathered.Results: A total of 186 current trainees and graduates were surveyed, with a 39% (n = 72) response rate. Of responders, 76% (55) use the website for ongoing medical education. The majority use the website at least monthly. Most users (63%, n = 35) access the lectures directly through the website. All 55 current users agree that the website has improved their medical knowledge and is a useful education resource. Platform use has increased and includes users from around the world.Conclusion: Based on our current data, the MarylandCCProject remains a valuable and highly used educational resource, impacting patient care both during and after critical care fellowship training.

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

The management of neurologic emergencies is an important component of critical care fellowship training. Additional training in neurocritical care has been demonstrated to improve clinical outcomes, though exposure to these emergencies during training can be limited. Three simulation cases are presented as part of a comprehensive neurologic emergencies curriculum for critical care trainees. The cases represent neurologic catastrophes encountered in the intensive care unit consisting of symptomatic hyponatremia, severe alcohol withdrawal syndrome, and brain herniation syndrome. The case descriptions are complete with learning objectives, critical actions checklists, and debriefing material for facilitators, as well as all necessary personnel briefs and required equipment. The scenarios were completed over the course of the 2016-2017 academic year by first-year critical care fellows. Following curriculum implementation, there was an improvement in self-perceived confidence of fellows in neurologic emergency management skills. The cases were felt to be realistic and beneficial and led to perceived improvement in management of neurologic emergencies and leadership during clinical crises.

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.

Editorial introductions