Critical Care Medicine Fellowship Research Articles

Survey of Clinical Knowledge and Procedural Readiness of Pulmonary Fellows to Start Interventional Pulmonary Fellowship: A Survey of Interventional Pulmonary Fellowship Directors.

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.

Multiple Goals Theory and Communication Quality Analysis for Fellows Communication Training.

End-of-life communication skills are vital to high-quality critical care. Patients and families often report deficiencies in end-of-life communication by providers. However, formalized training is difficult to implement and study on a large scale. Furthermore, curricula are often designed with early-stage clinical trainees in mind and are not tailored to advanced clinician learners. The goal of this pilot study was to explore educational and practical implications of using Multiple Goals Theory (MGT), Communication Quality Analysis (CQA), and communication logs as a three-pronged, reflective communication curriculum for advanced trainees. We describe design and qualitative evaluation of a novel, pilot, longitudinal curricular intervention for pulmonary and critical care fellows and program directors at a tertiary academic medical center. The 2-year longitudinal communication curriculum incorporates 1) a theoretical framework from communication science (MGT), with 2) a novel training modality of analyzing audio-recorded intensive care unit family meetings (CQA), and 3) written communication logs after an intensive care unit family meeting. The sample included 13 pulmonary and critical care medicine fellows and two program directors. Qualitative thematic analysis was conducted on seven fellow interviews and on 23 communication logs completed. Four themes emerged from interviews: 1) fellows incorporated the skills into real-life practice and found the curriculum useful and valuable; 2) a key takeaway from MGT was the deemphasis of task goals; 3) CQA was an engaging opportunity for self-reflection and learning; and 4) written communication logs were perceived as helpful in theory but too burdensome in practice. Findings from analyses of the communication logs included that most fellows' writing was brief and without substantial reflection. Many scholars have argued that communication theory can impact practice, but few have recognized the potential of theory and methods, such as MGT and CQA, as educational tools. Our findings demonstrate that MGT is a feasible and useful theoretical framework for improving communication skills among advanced trainees, and CQA fosters meaningful self-reflection about practice. Communication logs were not feasible or useful training tools in this context, but CQA workshops helped fulfill the goals of narrative reflection. Next steps are to implement this curriculum in more programs and measure changes in behavior acquisition and clinical care.

Impact of Ambulatory Blocks on Pulmonary Critical Care Fellow Outpatient Training Experience.

The Accreditation Council for Graduate Medical Education requires Pulmonary and Critical Care Medicine (PCCM) fellows spend a minimum of 7% of their time in the outpatient setting over 3 years of training. In a multi-institutional survey, only 47% of PCCM fellows rated their ambulatory training as adequate. Internal medicine residencies previously adopted the "x + y" scheduling model, which separates inpatient ("x") and outpatient ("y") rotations to provide focused ambulatory experiences, to address similar concerns. To observe the effects of dedicated ambulatory blocks at a single academic PCCM fellowship on fellow exposure to outpatient pulmonary medicine, and on fellow and faculty perceptions of education. In the 2021-2022 academic year, PCCM fellows of all class years in a single academic fellowship program in the northeast United States rotated through four 2-week ambulatory blocks that included longitudinal clinics, themed subspecialty clinics, and a dedicated educational half-day for small group learning. Before the intervention, fellow ambulatory clinics were scheduled longitudinally one-half day per week during inpatient and research blocks. Both fellows and faculty were surveyed before and after the intervention; fellows were also interviewed via focus groups at the conclusion of the intervention. The degree of subspecialty clinic exposure was compared before and after intervention. There was an increase in the quantity and variety of pulmonary subspecialty clinics per fellow when compared with preintervention years (P < 0.01). After intervention, we observed increased fellow satisfaction with ambulatory education, perceived preparedness for independent practice, and satisfaction with subspecialty clinic exposure (P < 0.05). Faculty satisfaction with fellow ambulatory pulmonary education also increased (P < 0.05). Thematic analysis from focus groups highlighted focused topical learning, exposure to the breadth of pulmonary medicine, career development, interaction with engaged faculty experts, and enhanced interprofessional competence. The ambulatory block structure provides a potential model to expand PCCM fellow outpatient pulmonary training through increased exposure to ambulatory pulmonology and dedicated ambulatory teaching. Important features of the ambulatory block structure include separation of outpatient clinics from competing responsibilities, expansion of fellow pulmonary exposure, opportunities for deliberate practice, and faculty engagement in fellow education.

Development of a Simulation-Based Mastery Learning Curriculum for Late Goals of Care Discussions

IntroductionFellows in critical care medicine (CCM) routinely help patients and families navigate complex decisions near the end of life. These “late goals of care” (LGOC) discussions require rigorous skills training and impact patient care. Innovation is needed to ensure that fellow training in leading these discussions is centered on reproducible competency-based standards. The aims of this study were to (1) describe the development of a simulation-based mastery learning (SBML) curriculum for LGOC discussions and (2) set a defensible minimum passing standard (MPS) to ensure uniform skill acquisition among learners. InnovationWe developed an SBML curriculum for CCM fellows structured around REMAP, a mnemonic outlining foundational components of effective communication around serious illness. A multidisciplinary expert panel iteratively created an LGOC discussion assessment tool. Pilot testing was completed to refine the checklist, set the MPS, and assess skill acquisition. OutcomesThe LGOC discussion assessment tool included an 18-item checklist and 6 scaled items. The tool produced reliable data (k ≥ 0.7 and ICC of ≥ 0.7). Using the Mastery Angoff method, the panel set the MPS at 87%. Ten CCM fellows participated in the pilot study. Performance on the checklist significantly improved from a median score of 52% (IQR 44%–72%) at pretest to 96% (IQR 82%–97%) at post-test (P = 0.005). The number of learners who met the MPS similarly improved from 10% during pre-testing to 70% during post-testing (P = 0.02). CommentWe describe the development of a LGOC SBML curriculum for CCM fellows which includes a robust communication skills assessment and the delineation of a defensible MPS.

Development and Implementation of a Microlearning Curriculum of Physiology Formulas for Postgraduate Clinical Fellows in Pediatric Critical Care Medicine.

Postgraduate medical education in clinical settings poses many challenges secondary to the large volume of knowledge to be acquired, competing clinical responsibilities, and fatigue. To address these challenges, a microlearning curriculum using flipped classroom methodologies was created to facilitate the mastering of fundamental physiology formulas by pediatric critical care medicine fellows. Forty physiology formulas were distilled into 5-minute microlearning sessions. Fellows were provided the weekly formula and encouraged to self-study prior to the face-to-face learning. The 5-minute session took place at the beginning of a regularly scheduled clinical care conference where normal values, explanatory diagrams, and board-like questions were discussed. A faculty or fellow facilitator then provided a more in-depth explanation and shared clinical pearls related to the formula. Following the session, an e-mail summarizing the learning points was sent. The curriculum was well received by fellows and faculty. Over 5 years, the curriculum evolved through phases of active development, implementation, minor modifications, transition to a virtual platform, shift to senior fellow-led instruction, and harmonization with other curricular activities. Engagement and sustainability were addressed with a fully flipped classroom, where senior fellows served as teachers to junior fellows. Microlearning in a multimodal manner is an excellent method for teaching busy postgraduate clinical trainees fundamental physiology formulas that underpin pediatric critical care decision-making. The gradual transition from individual learning to a flipped classroom taught by peers with faculty support was well tolerated and consistent with adult learning theories. The transition was essential to ensure the sustainability of the curriculum.

Survey of Pediatric Critical Care Fellows on Postresuscitation Debriefing.

Current guidelines recommend debriefing following medical resuscitations to improve patient outcomes. The goal of this study was to describe national trends in postresuscitation debriefing practices among pediatric critical care medicine (PCCM) fellows to identify potential gaps in fellow education. A 13-item survey was distributed to fellows in all 76 ACGME-accredited PCCM programs in the United States in the spring of 2021. The online survey addressed frequency and timing of debriefings following medical resuscitations, whether formal training is provided, which medical professionals are present, and providers' comfort level leading a debriefing. Results were analyzed using descriptive statistics. A total of 102 responses (out of a possible N of 536) were gathered from current PCCM fellows. All fellows (100%) reported participation in a medical resuscitation. Only 21% stated that debriefings occurred after every resuscitation event, and 44% did not follow a structured protocol for debriefing. While 66% reported feeling very or somewhat comfortable leading the debriefing, 19% felt either somewhat uncomfortable or very uncomfortable. A vast majority (92%) of participating fellows believed that debriefing would be helpful in improving team member performance during future resuscitations, and 92% expressed interest in learning more about debriefing. The majority of PCCM fellows do not receive formal training on how to lead a debriefing. Given that 74% of fellows in our study did not feel very comfortable leading a debriefing but almost universally expressed that this practice is useful for provider well-being and performance, there is a clear need for increased incorporation of debriefing training into PCCM curricula across the United States.

Variable Practice, Variable Results: Impact of Postinterview Communication Practices Among Critical Care Medicine/Pulmonary and Critical Care Medicine Fellowship Applicants and Program Directors

BackgroundWhile post-interview communication (PIC) guidelines exist, adherence is voluntary. There are no studies of PIC practices in Critical Care Medicine (CCM) and Pulmonary and Critical Care Medicine (PCCM) fellowship recruitment. Research QuestionWhat is the frequency, format, goals, and content of PIC between CCM/PCCM applicants and program directors (PD)? What is the impact of PIC on applicant and program rank order lists (ROL)? Study Design and MethodsCCM/PCCM applicants and PDs were separately surveyed after the 2022-2023 National Resident Matching Program Specialty Match. Surveys included multiple-choice, Likert-scale, and two free text questions. Thematic content analysis of free text responses was performed. ResultsOne-third of eligible participants responded (applicants: n=373, 34%; PDs: n=86, 32%). Applicant respondents applied to CCM (19%), PCCM (69%), or both (12%). PDs represented CCM (17%), PCCM (57%), or both (26%) programs. Applicant (66%) and PD (49%) respondents reported initiating PIC. PIC did not impact ROL decision for most applicants (73%) or PDs (83%), though 21% of applicants and 17% of PDs moved programs or applicants up on their ROL in response to PIC. A quarter (23%) of applicants strongly agreed or agreed that PIC was helpful in creating their ROL, 27% strongly disagreed or disagreed, and 29% were neutral. PIC challenges identified by both groups included time, lack of uniformity, peer pressure, misleading language, and uncertainty about motives, rules, and response protocols. InterpretationPIC is common among CCM/PCCM applicants and PDs. About 50% of applicants and 20% of PDs share ranking intentions via PIC. While PIC did not impact ROL for most applicants and PDs, a minority of applicants and PDs moved programs up on their ROL after receiving PIC from the other party. Applicants have mixed perspectives on PIC value. Applicants and PDs alike desire clear guidance on PIC to minimize ambiguous and misleading communication.

Overnight staffing in Canadian neonatal and pediatric intensive care units.

Infants and children who require specialized medical attention are admitted to neonatal and pediatric intensive care units (ICUs) for continuous and closely supervised care. Overnight in-house physician coverage is frequently considered the ideal staffing model. It remains unclear how often this is achieved in both pediatric and neonatal ICUs in Canada. The aim of this study is to describe overnight in-house physician staffing in Canadian pediatric and level-3 neonatal ICUs (NICUs) in the pre-COVID-19 era. A national cross-sectional survey was conducted in 34 NICUs and 19 pediatric ICUs (PICUs). ICU directors or their delegates completed a 29-question survey describing overnight staffing by resident physicians, fellow physicians, nurse practitioners, and attending physicians. A comparative analysis was conducted between ICUs with and without in-house physicians. We obtained responses from all 34 NICUs and 19 PICUs included in this study. A total of 44 ICUs (83%) with in-house overnight physician coverage provided advanced technologies, such as extracorporeal life support, and included all ICUs that catered to patients with cardiac, transplant, or trauma conditions. Residents provided the majority of overnight coverage, followed by the Critical Care Medicine fellows. An attending physician was in-house overnight in eight (15%) out of the 53 ICUs, seven of which were NICUs. Residents participating in rotations in the ICU would often have rotation durations of less than 6 weeks and were often responsible for providing care during shifts lasting 20-24 h. Most PICUs and level-3 NICUs in Canada have a dedicated in-house physician overnight. These physicians are mainly residents or fellows, but a notable variation exists in this arrangement. The potential effects on patient outcomes, resident learning, and physician satisfaction remain unclear and warrant further investigation.

Massive Hemoptysis Simulation Curriculum Improves Performance

Massive hemoptysis is a rare, high-acuity presentation, which requires the integration of both cognitive and procedural skills. Simulation has been recommended to improve preparation for high-acuity, low-occurrence procedures; however, the effect of a simulation curriculum for massive hemoptysis management has never been investigated. Does simulation for hemoptysis management improve competence? Kern's six steps for medical education curriculum design were used iteratively to develop a simulation curriculum for the management of massive hemoptysis. Pulmonary and critical care medicine fellows from the University of Colorado participated in a local needs assessment and a massive hemoptysis simulation curriculum. Using a manikin-based massive hemoptysis simulator developed for this curriculum, the simulation session used repetitive practice, clinical variation, a range of difficulties, and directed feedback in a group practice setting. Time to management and performance were assessed for each management attempt; competence was assessed using a combined metric of management-related priorities and global entrustment. During the needs assessment, fellows viewed massive hemoptysis management skills as important, while expressing their current confidence as low. Nineteen fellows participated in a 90-min case-based hemoptysis simulation during which each was exposed to five different cases and acted as the primary manager for two cases. There was significant improvement in performance from the first to final simulation attempts measured by time to successful management (14.24 vs10.26 min, P= .0067) and entrustment (Global Assessment Scale, 1 [should not perform] to 5 [independent]; 4.11 vs4.61; P= .015). Fellow self-assessed knowledge and confidence in hemoptysis management and endobronchial blocker placement improved significantly after the simulation. Hemoptysis simulation experience improves fellow confidence and skill for management of this high-acuity, low-occurrence presentation.

Central Venous Catheter Placement Skill Acquisition Through Apprenticeship Training in Clinical Context during Pediatric Critical Care Medicine Fellowship: A Longitudinal Study

AbstractPediatric critical care medicine (PCCM) fellows must develop competence in central venous catheter (CVC) placement. The impact of experiential learning opportunities in the clinical context on PCCM fellow CVC placement skill acquisition remains unknown. We sought to measure femoral CVC placement skill acquisition during fellowship and compare fellow to attending skill. We performed a prospective observational cohort study of PCCM fellows at the University of Colorado from 2019 to 2021. Femoral CVC placement skill was measured by attending evaluation of level of the supervision (LOS) required for the fellow, and hand motion analysis (HMA) on simulation task trainer. Competence in femoral CVC placement was defined as LOS ≥ 4 (can perform this skill independently) on a 5-point Likert scale. We compared fellow skill in femoral CVC placement to years of training and number of femoral CVCs placed. We also compared third-year fellow and attending HMA measurements. We recruited 13 fellows and 6 attendings. Fellows placed a median of 8 (interquartile range 7, 11) femoral CVCs during the study period. All fellows who reached third-year of fellowship during the study period achieved competence. Longitudinal analysis demonstrated improvement in CVC placement skill by both LOS and HMA as years of fellowship and number of femoral CVCs placed increased. Few third-year fellows achieved attending level skill in femoral CVC placement as measured by HMA. PCCM fellows acquired skill in CVC placement during fellowship and achieved competence in the procedure, but most did not reach attending level of skill.

The Quality Improvement Fellow: Educating on Making the Difference.

The critical care medicine (CCM) fellowship is an opportunity for advanced anesthesiology trainees to refine their quality improvement (QI) skills. However, the short training period and inconsistent curricula make this challenging. The QI fellow (QIF) is described as an education program to provide consistent QI training during the CCM fellowship. The QIF is a mentored position to help manage data review, QI conferences, and improvement efforts within the CCM Division. The curriculum is focused on a QI education framework and mentored experiential learning. The QIF program is an opportunity for education and mentorship in the role of a CCM operational leader.

Financial Education in U.S. Pulmonary and Critical Care Medicine Fellowship Programs.

Financial Education in U.S. Pulmonary and Critical Care Medicine Fellowship Programs.

Mechanical Ventilation Training Curriculum for Pulmonary Critical Care Fellows during the COVID-19 Pandemic.

Mechanical ventilation (MV) management is an essential skill for pulmonary and critical care medicine (PCCM) fellows to master during training. The unprecedented emergence of the coronavirus disease (COVID-19) pandemic highlighted the need for advanced operator competency in MV to improve patients' outcomes. We aimed to create a standardized case-based curriculum using a blended approach of high-fidelity simulation, rapid-cycle deliberate practice, video didactics, and hands-on small group sessions for rapid accumulation of knowledge and hands-on skills for PCCM fellows before caring for critically ill patients during the COVID-19 pandemic. The MV curriculum consisted of the following steps: 1) baseline written knowledge test with 15 multiple-choice questions covering MV, the latest evidence-based practices, and pathophysiology of COVID-19; 2) baseline confidence survey using a 5-point Likert scale; 3) a one-on-one session using a high-fidelity simulation manikin, a lung simulator, and a mechanical ventilator to test baseline competencies; 4) a structured debriefing tailored per fellow's 50-point competency assessment checklist from the simulation using rapid-cycle deliberate practice; 5) video didactics; 6) a hands-on session in small groups for basic knobology, waveforms, and modes of MV; 7) a one-on-one simulation reassessment session; 8) a written knowledge posttest; and 9) a post-training confidence survey using a 5-point Likert scale. Eight PCCM fellows completed the training. The mean multiple-choice question score increased from 7.4 ± 2.9 to 10.4 ± 2.4 (P < 0.05), and the simulation scores increased from 17.1 ± 4.4 to 30.8 ± 3.7 (P < 0.05). Comparing the simulation reassessment to the baseline, fellows showed significant improvement (P < 0.05) in assessing indications for MV; implementing rapid sequence intubation for patients with COVID-19; initiating MV and ventilator bundle per best practices; recognizing and managing mucous plugging, ventilator dyssynchrony, and evidence-based treatments for acute respiratory distress syndrome; and developing a care plan for proning. The post-training survey revealed improved learner confidence in all competencies. This pilot MV curriculum using a blended approach was feasible and allowed PCCM fellows to significantly improve their knowledge and hands-on skills, allowing for the appropriate use of MV during the pandemic. Self-reported improvement scores further reinforced this. The emergent need for novice learners may again be necessary for future pandemic settings where standard training models requiring extensive training time are limited.

A Pilot Standardized Simulation-Based Mechanical Ventilation Curriculum Targeting Pulmonary and Critical Care Medicine and Critical Care Medicine Fellows.

Introduction The mastery of mechanical ventilation (MV) management is challenging, as it requires the integration of physiological and technological knowledge with critical thinking. Our aim was to create a standardized curriculum with assessment tools based on evidence-based practices to identify the skill deficit and improve knowledge in MV management. Methods For 3 years, 3 hours of standardized curriculum for each first-year pulmonary critical care medicine (PCCM) and critical care medicine (CCM) fellows was integrated into the orientation (chronologically): (1) a baseline knowledge pretest; (2) a 1-hour one-on-one case-based simulation session with debriefing. A 34-item competency checklist was used to assess critically thinking and skills and guide the debriefing; (3) a 1-hour group didactic on respiratory mechanics and physiology; (4) a 45-minute hands-on session in small groups of one to three fellows for basic knobology, waveforms, and various modes of mechanical ventilators; (5) a 15-minute group bedside teaching of vented patients covering topics such as techniques to alleviate dyssynchrony and advanced ventilator modes; (6) a one-on-one simulation reassessment session; (7) a knowledge posttest. Fellows' performances at baseline, 1-month posttest, and end-of-first year post-test were compared. Results Fellows ( n = 24) demonstrated significant improvement at 1-month posttest in knowledge (54.2% ± 11.0 vs. 76.6 ± 11.7%, p < 0.001) and MV competency (40.7 ± 11.0% vs. 69.7 ± 9.3%, p < 0.001), compared with pretest. These improvements were retained at the end-of-year reassessments (knowledge 75.1 ± 14.5% and MV competency 85.5 ± 8.7%; p < 0.001). Conclusion Standardized simulation-based MV curriculum may improve the medical knowledge competency, and confidence of first-year PCCM and CCM fellows toward MV management before encountering actual ventilated patients.

Critical care medicine training in the age of COVID-19.

The COVID-19 pandemic caused the largest disruption to graduate medical education in modern history. The danger associated with SARS-CoV-2 necessitated a paradigm shift regarding the fundamental approach to the education of medical residents and fellows. Whereas prior work has examined the effect of the pandemic on residents' experiences during training, the effect of the pandemic on academic performance of critical care medicine (CCM) fellows is not well understood. This study examined the relationship between CCM fellow's lived experiences during the COVID-19 pandemic and performance on in-training examinations. This mixed-methods study consisted of a quantitative retrospective analysis of critical care fellows' in-training examination scores and a qualitative, interview-based phenomenological examination of fellows' experiences during the pandemic while training in a single large academic hospital in the American Midwest. Quantitative: Prepandemic (2019 and 2020) and intrapandemic (2021 and 2022) in-training examination scores were analyzed utilizing an independent samples t test to determine whether a significant change occurred during the pandemic. Qualitative: Individual semi-structured interviews were conducted with CCM fellows exploring their lived experiences during the pandemic and their perception of the effect on their academic performance. Transcribed interviews were analyzed for thematic patterns. These themes were coded and categorized, and subcategories were developed as indicated during the analysis. The identified codes were then analyzed for thematic connections and apparent patterns. Relationships between themes and categories were analyzed. This process was continued until a coherent picture could be assembled from the data to answer the research questions. Analysis was performed from a phenomenological perspective with an emphasis on interpretation of the data from the participants' perspectives. Quantitative: Fifty-one in-training examination scores from 2019 to 2022 were obtained for analysis. Scores from 2019 to 2020 were grouped as prepandemic scores, while scores from 2021 to 2022 were grouped as intrapandemic scores. Twenty-four prepandemic and 27 intrapandemic scores were included in the final analysis. A significant difference was found between mean total prepandemic and intrapandemic in-service examination scores (t 49=2.64, p=0.01), with mean intrapandemic scores being 4.5 points lower than prepandemic scores (95 % CI, 1.08-7.92). Qualitative: Interviews were conducted with eight CCM fellows. Thematic analysis of the qualitative interviews revealed three main themes: psychosocial/emotional effects, effects on training, and effects on health. The factors that most effected participants' perceptions of their training were burnout, isolation, increased workload, decreased bedside teaching, decreased formal academic training opportunities, decreased procedural experience, a lack of an external reference point for normal training in CCM, fear of spreading COVID-19, and neglect of personal health during the pandemic. In-training examination scores decreased significantly during the COVID-19 pandemic for CCM fellows in this study. The fellows in this study reported perceived effects of the pandemic on their psychosocial/emotional well-being, medical training, and health.

End-of-Life Care Education in Pediatric Critical Care Medicine Fellowship Programs: Exploring Fellow and Program Director Perspectives.

Background/Objectives: The aim of this study is to describe the current state of end-of-life (EOL) care education within pediatric critical care medicine (PCCM) fellowship programs and explore potential differences in beliefs on EOL care education between program directors (PDs) and fellows. Design: A mixed-methods study based on data obtained through a nationally distributed, web-based cross-sectional survey of PCCM fellowship PDs and PCCM fellows was performed. Setting: Accreditation Council for Graduate Medical Education (ACGME)-accredited PCCM fellowships in the United States. Subjects: PCCM fellows and PDs participated in this study. Measurements and Results: The total number of survey respondents was 124 (94/654 fellows and 30/96 PDs), representing 39% of ACGME-accredited PCCM programs. Bedside teaching and lecture-based modalities were the most commonly used methods to teach EOL care. Most fellows and PDs reported a perceived need for additional EOL education within their respective training programs (fellows 91%, n = 86/94; PDs 67%, n = 20/30). A thematic analysis of curriculum structure questions revealed significant similarities between PDs and fellows, including the perceived need for education in communication, medical management, and cultural awareness. Dealing with uncertainty and resiliency were identified as themes among PDs only, and emotional/moral and legal issues were identified as themes solely by fellows. Conclusions: Our study describes the current state of EOL care education within a sample of PCCM fellowship programs. We highlight the perceived need for additional EOL education and identify areas within EOL care that deserve more focus by PCCM fellows and PDs. Future studies with focus on EOL curriculum development in PCCM EOL training are needed.

Meet the First Authors.

HomeCirculation ResearchVol. 132, No. 6Meet the First Authors Free AccessIn BriefPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessIn BriefPDF/EPUBMeet the First Authors Originally published16 Mar 2023https://doi.org/10.1161/RES.0000000000000603Circulation Research. 2023;132:672–673is related toGJA1-20k Rescues Cx43 Localization and Arrhythmias in Arrhythmogenic CardiomyopathySmooth Muscle MR in Post-Preeclampsia Hypertension (p 674)Download figureDownload PowerPointDr Lauren Biwer is a postdoctoral researcher in Dr Iris Jaffe’s lab at Tufts Medical Center. She became passionate about research in Dr Taben Hale’s lab at the University of Arizona and completed her PhD in Molecular Physiology at the University of Virginia with Dr Brant Isakson. When her sister developed preeclampsia, she became interested in mitigating future cardiovascular disease in women with complicated pregnancies. Lauren received a K99 grant to pursue this work and is thrilled to start her independent laboratory in the Yale Vascular Biology and Therapeutics program in November 2023. She enjoys traveling, outdoor activities, college sports and reading non-fiction. She can be found on Twitter @DrLaurenBiwer.Endosomal PI3Kγ Regulates Hypoxia Sensing (p 690)Download figureDownload PowerPointDr Yu Sun (Cynthia) earned her MD in Pathology from Shanghai Medical College at Fudan University in 2014. Following her clinical training, Cynthia joined the lab of Dr Naga Prasad in 2017 as a postdoctoral fellow to understand the mechanisms regulating βAR function in hypoxia. Unexpectedly, she found that hypoxia regulates endosomal βAR function by inhibition of resensitization through PI3K. Her current work focuses on dissecting the agonist-independent endosomal regulation of βARs, as acute hypoxia is the initial stress following ischemia. During her free time Cynthia enjoys reading and watching movies.Download figureDownload PowerPointKate Stenson is currently Senior Laboratory Technologist in the Department of Cardiovascular and Metabolic Sciences at Lerner Research Institute, Cleveland Clinic. She earned her undergraduate degrees in Marine Biology and Psychobiology from the University of New England in Maine. She joined Cleveland Clinic to further extend her hands-on approach from her undergraduate education to the mouse models of pathology, specifically heart failure. She is passionate about unraveling scientific discoveries through the use of animal models and during her spare time, when she is not imaging mice, she likes to play with her kids and take them to musicals.Dectin-1 Mediates Ang II Action in Heart (p 707)Download figureDownload PowerPointDr Shiju Ye earned his MS in Cardiovascular Disease at the Wenzhou Medical University, China, in 2019, and is now pursing his Cardiovascular Disease PhD at Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, China. Dr Ye’s recent research interests include Ang II related cardiac inflammation, heart failure, and the crosstalk between the cardiomyocytes and macrophages. Outside of the laboratory, he not only maintains an active social life and studies, but also focuses on learning clinical knowledge of cardiovascular disease.GJA1-20k Reduces Arrhythmias in ACM (p 744)Download figureDownload PowerPointDr Joseph Palatinus is an Assistant Professor of Medicine at the Nora Eccles Harrison Cardiovascular Research and Training Institute at the University of Utah and Critical Care Cardiologist at Intermountain Medical Center. He completed his residency at Beth Israel Deaconess Medical Center and cardiology and critical care medicine fellowships at Cedars Sinai Medical Center. His postdoctoral work focused on gap junction trafficking in the laboratory of Dr Robin Shaw. The Palatinus Lab is focused on mechanisms contributing to disease progression in arrhythmogenic cardiomyopathy. Dr Palatinus’s clinical interests are focused on the care of patients with cardiogenic shock in the CCU. Previous Back to top Next FiguresReferencesRelatedDetailsRelated articlesGJA1-20k Rescues Cx43 Localization and Arrhythmias in Arrhythmogenic CardiomyopathyJoseph A. Palatinus, et al. Circulation Research. 2023;132:744-746 March 17, 2023Vol 132, Issue 6 Advertisement Article InformationMetrics © 2023 American Heart Association, Inc.https://doi.org/10.1161/RES.0000000000000603PMID: 36927179 Originally publishedMarch 16, 2023 PDF download Advertisement

Differences in international medical graduates’ letters of recommendation by gender in pulmonary and critical care medicine: a cohort analysis

BackgroundInternational Medical Graduates (IMGs) encounter barriers as they seek to match into fellowship programs in the United States (US). This study’s objective is to determine if there are differences in letters of recommendation written for IMGs compared to U.S. Medical Graduates (USMGs) applying to pulmonary and critical care medicine (PCCM) fellowship programs.MethodsAll applications submitted to a PCCM fellowship program in 2021 were included in this study. The applicant demographics and accomplishments were mined from applications. The gender of letter writers was identified by the author’s pronouns on professional websites. Word count and language differences in the letters were analyzed for each applicant using the Linguistic Inquiry and Word Count (LWIC2015) program. Multivariable linear regressions were performed controlling for applicant characteristics to identify if IMG status was associated with total word count and degree of support, measured by a composite outcome encompassing several categories of adjectives, compared to USMG status.ResultsOf the 573 applications, most of the applicants were USMGs (72%, N = 334/573). When adjusting for applicant characteristics, IMG applicants had shorter letters of recommendation (87.81 total words shorter 95% CI: − 118.61, − 57.00, p-value < 0.01) and less supportive letters (4.79 composite words shorter 95% CI: − 6.61, − 2.97, p-value < 0.01), as compared to USMG applicants. Notably, female IMG applicants had the biggest difference in their word counts compared to USMG applicants when the letter writer was a man.ConclusionsIMG applicants to a PCCM fellowship received shorter and less supportive letters of recommendation compared to USMG applicants.

Year two of virtual interviews: longitudinal changes and diverse perspectives

BackgroundThe coronavirus disease (COVID-19) pandemic brought the virtual interview (VI) format to graduate medical education (GME) and the trainee recruitment process. It is unclear if applicants’ VI experience is consistent across all demographic groups. Our group collected 2 years of survey data to assess longitudinal changes in applicants’ attitudes towards the VI format. In addition, demographic data were collected, and analyses were performed to identify if between-group differences were present amongst a diverse applicant population.MethodsWe distributed an anonymous electronic survey to applicants to the pulmonary disease and critical care medicine fellowship programs at Case Western Reserve University/University Hospitals Cleveland Medical Center and MetroHealth Medical Center for the 2021 and 2022 appointment years.ResultsWe received 112 responses (20% response rate) for our surveys. Although there was an overall stability of responses between the first 2 years, there were significant gender differences with applicants identifying as female more likely to recommend VI as a future model. Similarly, there were a significant difference in factor importance based on underrepresented minority (URM) status with applicants identifying as URM placing more emphasis on programs’ social media presence.ConclusionsThere were no significant change in the responses of applicants between the first 2 years of VI. However, subset analyses revealed multiple significant findings. These differences have implications for future iterations of the VI format.

Primary Intensivists and Nurses for Long-Stay Patients: A Survey of Practices and Perceptions at Academic PICUs.

To determine the prevalence of the utilization of primary intensivists and primary nurses for long-stay patients in large, academic PICU and ascertain how these practices are operationalized and perceived. A cross-sectional survey. U.S. PICUs with accredited Pediatric Critical Care Medicine fellowships. One senior physician and one senior nurse at each institution. None. Separate but largely analogous questionnaires for intensivists and nurses were created using an iterative process to enhance content/face validity and readability. Sixty-seven intensivists (representing 93% of the 72 institutions with fellowship programs and their PICUs) and 59 nurses (representing 82%) responded. Twenty-four institutions utilize primary intensivists; 30 utilize primary nurses; and 13 utilize both. Most institutions use length of stay and/or other criteria (e.g., medical complexity) for eligibility. Commonly, not all patients that meet eligibility criteria receive primaries. Primary providers are overwhelmingly volunteers, and often only a fraction of providers participate. Primary intensivists at a large majority (>75%) of institutions facilitate information sharing and decision-making, attend family/team meetings, visit patients/families regularly, and are otherwise available upon request. Primary nurses at a similar majority of institutions provide consistent bedside care, facilitate information sharing, and attend family/team meetings. A large majority of respondents thought that primary intensivists increase patient/family satisfaction, reduce their stress, improve provider communication, and reduce conflict, whereas primary nurses similarly increase patient/family satisfaction. More than half of respondents shared that these practices can sometimes require effort (e.g., time and emotion), complicate decision-making, and/or reduce staffing flexibility. Primary practices are potential strategies to augment rotating PICU care models and better serve the needs of long-stay and other patients. These practices are being utilized to varying extents and with some operationalization uniformity at large, academic PICUs.