Critical Care Medicine Program Directors Research Articles

Perspectives on Using Race in Pulmonary Function Testing: A National Survey Fellows and Program Directors.

Pulmonary function tests (PFTs) have historically used race-specific prediction equations. The recent American Thoracic Society guidelines recommend the use of a race-neutral approach in prediction equations. There are limited studies centering the opinions of practicing pulmonologists on the use of race in spirometry. Provider opinion will impact adoption of the new guideline. The aim of this study was to ascertain the beliefs of academic pulmonary and critical care providers regarding the use of race as a variable in spirometry prediction equations. We report data from 151 open-ended responses from a voluntary, nationwide survey (distributed by the Association of Pulmonary Critical Care Medicine Program Directors) of academic pulmonary and critical care providers regarding the use of race in PFT prediction equations. Responses were coded using inductive and deductive methods, and a thematic content analysis was conducted. There was a balanced distribution of opinions among respondents supporting, opposing, or being unsure about the incorporation of race in spirometry prediction equations. Responses demonstrated a wide array of understanding related to the concept and definition of race and its relationship to physiology. There was no consensus among providers regarding the use of race in spirometry prediction equations. Concepts of race having biologic implications persist among pulmonary providers and will likely affect the uptake of the Global Lung Function Initiative per the American Thoracic Society guidelines.

Self-Assessment of Research Skills and Barriers to Research Careers among Pulmonary and Critical Care Fellows.

Recruitment and retention of Pulmonary and Critical Care Medicine (PCCM) trainees into academic research positions remain difficult. Factors influencing graduates, like salary and personal circumstances, remain unchangeable. However, some program-level factors, like research skill acquisition and mentorship, may be modifiable to encourage matriculation into academic research positions. We aim to identify proficiency in research-specific skills in PCCM trainees and barriers to careers as research-focused academic faculty. We surveyed PCCM fellows in a nationwide cross-sectional analysis including demographics, research intent, research skills self-assessment, and academic career barriers. The Association of Pulmonary and Critical Care Medicine Program Directors approved and disseminated the survey. Data were collected and stored using the REDCap database. Descriptive statistics were used to assess survey items. 612 fellows received the primary survey with 112 completing the survey for a response rate of 18.3%. A majority were male (56.2%) and training at university-based medical centers (89.2%). Early fellowship trainees (first-/second-year fellows) comprised 66.9% of respondents with 33.1% being late fellowship trainees (third-/fourth-year fellows). Most early trainees (63.2%) indicated they intended to incorporate research into their careers. A chi-square testing of independence was performed to examine the relationship between training level and perceived proficiency. Significant relationships in perceived proficiency were identified between early and late fellowship trainees with an absolute difference of 25.3% (manuscript writing), 18.7% (grant writing), 21.6% (study design), and 19.5% (quantitative/qualitative methodology). The most prevalent barriers were unfamiliarity with grant writing (59.5%) and research funding uncertainty (56.8%). With an ongoing need for academic research faculty, this study identifies self-perceived gaps in research skills including grant writing, data analytics, and study conception and design. These skills map to fellow-identified barriers to careers in academics. Mentorship and innovative curriculum focusing on the development of key research skills may enhance academic research faculty recruitment.

Impact of Risk and Volume on Procedural Traning of Pulmonary and Critical Care Fellows.

Background: Invasive procedures are a core aspect of pulmonary and critical care practice. Procedures performed in the intensive care unit can 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 blocker placement. LRHV procedures include arterial line placement, central venous catheter placement, thoracentesis, and flexible bronchoscopy. Despite the frequency and importance of procedures in critical care medicine, little is known about the similarities and differences in procedural training between different Pulmonary and Critical Care Medicine (PCCM) and Critical Care Medicine (CCM) training programs. Furthermore, differences in procedural training practices for HRLV and LRHV procedures have not previously been described.Objective: To assess procedural training practices in PCCM and CCM fellowship programs in the United States, and compare differences in training between HRLV and LRHV procedures.Methods: A novel survey instrument was developed and disseminated to PCCM and CCM program directors and associate program directors at PCCM and CCM fellowship programs in the United States to assess procedural teaching practices for HRLV and LRHV procedures.Results: The survey was sent to 221 fellowship programs, 168 PCCM and 34 CCM, with 70 unique respondents (31.7% response rate). Of the procedural educational strategies assessed, each strategy was used significantly more frequently for LRHV versus HRLV procedures. The majority of respondents (51.1%) report having no dedicated training for HRLV procedures versus 6.9% reporting no dedicated training for any LRHV procedure (P < 0.001). For HRLV procedures, 76.9% of respondents indicated that there was no set number of procedures required to determine competency, versus 25.3% for LRHV procedures (P < 0.001). For LRHV procedures, fellows were allowed to perform procedures independently without supervision 21.7% of the time versus 3.9% for HRLV procedures (P = 0.004). Program directors’ confidence in their ability to determine fellows’ competence in performing procedures was significantly lower for HRLV versus LRHV versus HRLV procedures (P < 0.001).Conclusion: Significant differences exist in procedural training education for PCCM and CCM fellows for LRHV versus HRLV procedures, and awareness of this discrepancy presents an opportunity to address this educational gap in PCCM and CCM fellowship training.

IMPACT OF INTERVENTIONAL PULMONOLOGY FELLOWSHIPS ON THE PROCEDURAL TRAINING OF PCCM FELLOWS

SESSION TITLE: Education, Research, and Quality Improvement Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: There has been an increase in the number of interventional pulmonology (IP) fellowships, raising concern about their impact on the procedural training of PCCM fellows due to potential competition for procedures. We aim to conduct a survey of PCCM program directors (PD) to determine their expectations in procedural training for their fellows and to assess the impact of IP fellowships on that training. METHODS: An online survey was distributed to members of the Association of Pulmonary and Critical Care Medicine Program Directors in May 2020. PCCM PDs were invited to complete a survey. Data was collected using the Beth Israel Deaconess Medical Center REDCap database, and descriptive analysis was performed. RESULTS: Forty-nine of 173 PDs completed the survey (28.3% response rate). 82% of respondents have an interventional pulmonologist on faculty while 31% host a formal IP fellowship. The majority of PCCM programs have pulmonology as the team primarily responsible for performing thoracentesis, pigtail chest tube insertion, bronchoscopy with BAL, and bronchoscopy with transbronchial biopsy (collectively, “standard pulmonary procedures”). Thoracic surgery is most commonly responsible for surgical chest tube insertion, and IP, for performing endobronchial ultrasound (EBUS). When asked which team should be primarily responsible, the responses were congruent with the reported services currently in place with the exception for EBUS. 55% of respondents reported that pulmonology should be the primary service responsible for EBUS. More than 90% of programs expect their PCCM fellows to be fully competent and independent in performing standard pulmonary procedures while 76% expect this for EBUS. 27% of respondents reported that the presence of an IP fellowship does/would affect the procedural training of PCCM fellows neither negatively nor positively; 25%, somewhat negatively; 21%, very positively. 69% of respondents reported that the presence of an interventional pulmonologist on faculty very positively affected the procedural training of PCCM fellows. CONCLUSIONS: Almost all PCCM PDs expect their fellows to demonstrate competence in standard pulmonary procedures. Accordingly, the pulmonology service is the primary team responsible for these procedures at many institutions. From the PD perspective, there is significant variation in how the presence of an IP fellowship affects the procedural training of PCCM fellows; however, the presence of IP faculty is very valuable. These results are similar to that reported in a survey of PCCM fellows. A substantial number of PDs expect their fellows to achieve competency in performing EBUS, a procedure usually performed by IP. CLINICAL IMPLICATIONS: Thus, there are opportunities for further collaboration between PCCM and IP PDs to optimize the training and educational experience of PCCM fellows, particularly in performing EBUS. DISCLOSURES: No relevant relationships by Alex Chee, source=Web Response No relevant relationships by Van Holden, source=Web Response no disclosure on file for Fayez Kheir; Consultant relationship with Boston Scientific Please note: $1001 - $5000 by Adnan Majid, source=Web Response, value=Consulting fee Consultant relationship with olympus Please note: $5001 - $20000 by Adnan Majid, source=Web Response, value=Consulting fee Consultant relationship with pinacle biologics Please note: $1001 - $5000 by Adnan Majid, source=Web Response, value=Consulting fee Consultant relationship with cook medical Please note: $1001 - $5000 by Adnan Majid, source=Web Response, value=Consulting fee No relevant relationships by Mihir Parikh, source=Web Response Consultant relationship with Medtronic Please note: $1001 - $5000 Added 06/11/2020 by Edward Pickering, source=Web Response, value=Consulting fee Consultant relationship with Merit Endotek Please note: $1-$1000 Added 04/06/2020 by Ashutosh Sachdeva, source=Web Response, value=Consulting fee Consultant relationship with Medtronic Please note: $1001 - $5000 Added 04/06/2020 by Ashutosh Sachdeva, source=Web Response, value=Consulting fee Speaker/Speaker's Bureau relationship with COOK Please note: $1001 - $5000 Added 04/06/2020 by Ashutosh Sachdeva, source=Web Response, value=Honoraria Consultant relationship with Medtronic Please note: $1001 - $5000 by Ashutosh Sachdeva, source=Web Response, value=Consulting fee Unrestricted education grant relationship with Olympus Please note: $1001 - $5000 by Ashutosh Sachdeva, source=Web Response, value=Grant/Research Support Consultant relationship with COOK Please note: $1001 - $5000 Added 04/27/2020 by Ashutosh Sachdeva, source=Web Response, value=Honoraria

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

The prevalence of burnout and depressive symptoms is high among physician trainees. What is the burden of burnout and depressive symptoms among fellows training in pulmonary and critical care medicine (PCCM) and what are associated individual fellow, program, and institutional characteristics? We conducted a cross-sectional electronic survey of fellows enrolled in pulmonary, PCCM, and critical care medicine training programs in the United States to assess burnout and depressive symptoms. Burnout symptoms were measured using the Maslach Burnout Index two-item measure. The two-item Primary Care Evaluation of Mental Disorders Procedure was used to screen for depressive symptoms. For each of the two outcomes (burnout and depressive symptoms), we constructed three multivariate logistic regression models to assess individual fellow characteristics, program structure, and institutional polices associated with either burnout or depressive symptoms. Five hundred two of the 976 fellows who received the survey completed it-including both outcome measures-giving a response rate of 51%. Fifty percent of fellows showed positive results for either burnout or depressive symptoms, with 41%showing positive results for depressive symptoms, 32%showing positive results for burnout, and 23%showing positive results for both. Reporting a coverage system in the case of personal illness or emergency (adjusted OR [aOR], 0.44; 95%CI, 0.26-0.73) and access to mental health services (aOR, 0.14; 95%CI, 0.04-0.47) were associated with lower odds of burnout. Financial concern was associated with higher odds of depressive symptoms (aOR, 1.13; 95%CI, 1.05-1.22). Working more than 70 hours in an average clinical week and the burdens of electronic health record (EHR) documentation were associated with a higher odds of both burnout and depressive symptoms. Given the high prevalence of burnout and depressive symptoms among fellows training in PCCM, an urgent need exists to identify solutions that address this public health crisis. Strategies such as providing an easily accessible coverage system, access to mental health resources, reducing EHR burden, addressing work hours, and addressing financial concerns among trainees may help to reduce burnout or depressive symptoms and should be studied further by the graduate medical education community.

Virtually Hosting a National Medical Society Conference. Lessons Learned from the 2020 Association of Pulmonary and Critical Care Medicine Program Directors Conference.

The coronavirus pandemic forced the Association of Pulmonary and Critical Care Medicine Program Directors to change the 2020 annual conference to a virtual format with relatively short notice. Using the experience of the planning committee and survey feedback from attendees, we describe the steps taken to implement a virtual conference and lessons learned in the process. The lessons described include frequent and concise communication, establishment of roles within a discrete production team, preparing speakers with a protocolized training session, active moderation of the chat box, using interactive polling and online documents to improve interactivity, a shorter agenda with more frequent breaks, encouraging “virtual happy hours” to connect with colleagues, and establishing facilitators for breakout rooms.

Establishing the Knowledge and Skills Necessary in Pediatric Critical Care Medicine: A Systematic Approach to Practice Analysis.

To describe the practice analysis undertaken by a task force convened by the American Board of Pediatrics Pediatric Critical Care Medicine Sub-board to create a comprehensive document to guide learning and assessment within Pediatric Critical Care Medicine. An in-depth practice analysis with a mixed-methods design involving a descriptive review of practice, a modified Delphi process, and a survey. Not applicable. Seventy-five Pediatric Critical Care Medicine program directors and 2,535 American Board of Pediatrics Pediatric Critical Care Medicine diplomates. A practice analysis document, which identifies the full breadth of knowledge and skill required for the practice of Pediatric Critical Care Medicine, was developed by a task force made up of seven pediatric intensivists and a psychometrician. The document was circulated to all 75 Pediatric Critical Care Medicine fellowship program directors for review and comment and their feedback informed modifications to the draft document. Concurrently, data from creation of the practice analysis draft document were also used to update the Pediatric Critical Care Medicine, was developed by a task force made up of seven pediatric intensivists and a psychometrician. The document was circulated to all 75 Pediatrics Pediatric Critical Care Medicine fellowship program directors for review and comment and their feedback informed modifications to the draft document. Concurrently, data from creation of the practice analysis draft document were also used to update the Pediatric Critical Care Medicine content outline, which was sent to all 2,535 American Board of Pediatrics Pediatric Critical Care Medicine diplomates for review during an open-comment period between January 2019 and February 2019, and diplomate feedback was used to make updates to both the content outline and the practice analysis document. After review and comment by 25 Pediatric Critical Care Medicine program directors (33.3%) and 619 board-certified diplomates (24.4%), a comprehensive practice analysis document was created through a two-stage process. The final practice analysis includes 10 performance domains which parallel previously published Entrustable Professional Activities in Pediatric Critical Care Medicine. These performance domains are made up of between three and eight specific tasks, with each task including the critical knowledge and skills that are necessary for successful completion. The final practice analysis document was also used by the American Board of Pediatrics Pediatric Critical Care Medicine Sub-board to update the Pediatric Critical Care Medicine content outline. A systematic approach to practice analysis, with stakeholder engagement, is essential for an accurate definition of Pediatric Critical Care Medicine practice in its totality. This collaborative process resulted in a dynamic document useful in guiding curriculum development for training programs, maintenance of certification, and lifetime professional development to enable safe and efficient patient care.

352 Critical Care Fellowship Program Directors’ Opinions of Emergency Medicine Applicants

Over the past decade, emergency physicians have secured formal pathways to board certification in Critical Care Medicine (CCM) through internal medicine, anesthesia, and surgery. It is unclear how EM applicants are perceived by CCM fellowship program directors and how these perceptions may affect the advancement of emergency physicians in the field of CCM. The objective of this study was to explore the opinions and attitudes that CCM program directors have toward emergency medicine applicants and to identify potentially modifiable factors to increase emergency physician acceptance into CCM programs.

Assessing Competence in Central Venous Catheter Placement by Pediatric Critical Care Fellows: A National Survey Study.

To describe the current approach to initial training, ongoing skill maintenance, and assessment of competence in central venous catheter placement by pediatric critical care medicine fellows, a subset of trainees in whom this skill is required. Cross-sectional internet-based survey with deliberate sampling. United States pediatric critical care medicine fellowship programs. Pediatric critical care medicine program directors of Accreditation Council for Graduate Medical Education-accredited fellowship programs. None. A working group of the Education in Pediatric Intensive Care Investigators research collaborative conducted a national study to assess the degree of standardization of training and competence assessment of central venous catheter placement across pediatric critical care medicine fellowship programs. After piloting, the survey was sent to all program directors (n = 67) of Accreditation Council for Graduate Medical Education-accredited pediatric critical care medicine programs between July 2017 and September 2017. The response rate was 85% (57/67). Although 98% of programs provide formalized central venous catheter placement training for first-year fellows, only 42% of programs provide ongoing maintenance training as part of fellowship. Over half (55%) of programs use a global assessment tool and 33% use a checklist-based tool when evaluating fellow central venous catheter placement competence under direct supervision. Only two programs (4%) currently use an assessment tool previously published and validated by the Education in Pediatric Intensive Care group. A majority (82%) of responding program directors believe that a standardized approach to assessment of central venous catheter competency across programs is important. Despite national mandates for skill competence by many accrediting bodies, no standardized system currently exists across programs for assessing central venous catheter placement. Most pediatric critical care medicine programs use a global assessment and decisions around the ability of a fellow to place a central venous catheter under indirect supervision are largely based upon subjective assessment of performance. Further investigation is needed to determine if this finding is consistent in other specialties/subspecialties, if utilization of standardized assessment methods can improve program directors' abilities to ensure trainee competence in central venous catheter insertion in the setting of variable training approaches, and if these findings are consistent with other procedures across critical care medicine training programs, adult and pediatric.

Pulmonary and Critical Care Medicine Program Directors’ Attitudes toward Training in Medical Education. A Nationwide Survey Study

Many pulmonary and critical care medicine (PCCM) fellows are interested in improving their teaching skills as well as learning about careers as clinician educators. Educational opportunities in PCCM fellowship programs designed to address these interests have not been well characterized in U.S. training programs. We aimed to characterize educational content and structure for training fellows to teach in PCCM fellowship programs. We evaluated three major domains: (1) existing educational opportunities, (2) PCCM program directors' attitudes toward the importance of teaching fellows how to teach, and (3) potential components of an optimal teaching skills curriculum for PCCM fellows. We surveyed program and associate program directors who were members of the Association of Pulmonary and Critical Care Medicine Program Directors in 2014. Survey domains included existing teaching skills content and structure, presence of a formal medical education curriculum or clinician educator track, perceived barriers to teaching fellows teaching skills, and open-ended qualitative inquiries about the ideal curricula. Data were analyzed both quantitatively and qualitatively. Of 158 invited Association of Pulmonary and Critical Care Medicine Program Directors members, 85 program directors and associate directors responded (53.8% response rate). Annual curricular time dedicated to teaching skills varied widely (median, 3 h; mean, 5.4 h; interquartile range, 2.0-6.3 h), with 17 respondents (20%) allotting no time to teaching fellows to teach and 14 respondents (17%) dedicating more than 10 hours. Survey participants stated that the optimal duration for training fellows in teaching skills was significantly less than what they reported was actually occurring (median optimal duration, 1.5 h/yr; mean, 2.1 h/yr; interquartile range, 1.5-3.5 h/yr; P < 0.001). Only 28 (33.7%) had a formal curriculum for teaching medical education skills. Qualitative analyses identified several barriers to implementing formal teaching skills curricula, including "time," "financial resources," "competing priorities," and "lack of expert faculty." While prior work has demonstrated that fellows are interested in obtaining medical education skills, PCCM program directors and associate directors noted significant challenges to implementing formal educational opportunities to teach fellows these skills. Effective strategies are needed to design, implement, sustain, and assess teaching skills curricula for PCCM fellowships.

Entrustable professional activities and curricular milestones for fellowship training in pulmonary and critical care medicine: executive summary from the Multi-Society Working Group.

Assessment of graduate medical trainee progress via the accomplishment of competency milestones is an important element of the Next Accreditation System of the Accreditation Council for Graduate Medical Education. This article summarizes the findings of a multisociety working group that was tasked with creating the entrustable professional activities and curricular milestones for fellowship training in pulmonary medicine, critical care medicine, and combined programs. Using the Delphi process, experienced medical educators from the American College of Chest Physicians, American Thoracic Society, Society of Critical Care Medicine, and Association of Pulmonary and Critical Care Medicine Program Directors reached consensus on the detailed curricular content and expected skill set of graduates of these programs. These are now available to trainees and program directors for the purposes of curriculum design, review, and trainee assessment.

Entrustable Professional Activities and Curricular Milestones for Fellowship Training in Pulmonary and Critical Care Medicine: Report of a Multisociety Working Group

This article describes the curricular milestones and entrustable professional activities for trainees in pulmonary, critical care, or combined fellowship programs. Under the Next Accreditation System of the Accreditation Council for Graduate Medical Education (ACGME), curricular milestones compose the curriculum or learning objectives for training in these fields. Entrustable professional activities represent the outcomes of training, the activities that society and professional peers can expect fellowship graduates to be able to perform unsupervised. These curricular milestones and entrustable professional activities are the products of a consensus process from a multidisciplinary committee of medical educators representing the American College of Chest Physicians (CHEST), the American Thoracic Society, the Society of Critical Care Medicine, and the Association of Pulmonary and Critical Care Medicine Program Directors. After consensus was achieved using the Delphi process, the document was revised with input from the sponsoring societies and program directors. The resulting lists can serve as a roadmap and destination for trainees, program directors, and educators. Together with the reporting milestones, they will help mark trainees' progress in the mastery of the six ACGME core competencies of graduate medical education.

Perceived effects of attending physician workload in academic medical intensive care units

Increases in the size and number of American intensive care units have not been accompanied by a comparable increase in the critical care physician workforce, raising concerns that intensivists are becoming overburdened by workload. This is especially concerning in academic intensive care units where attending physicians must couple teaching duties with patient care. We performed an in-person and electronic survey of the membership of the Association of Pulmonary and Critical Care Medicine Program Directors, soliciting information about patient workload, other hospital and medical education duties, and perceptions of the workplace and teaching environment of their intensive care units. Eighty-four out of a total 121 possible responses were received from program directors or their delegates, resulting in a response rate of 69%. The average daily (SD) census (as perceived by the respondents) was 18.8 ± 8.9 patients, and average (SD) maximum service size recalled was 24.1 ± 9.9 patients. Twenty-seven percent reported no policy setting an upper limit for the daily census. Twenty-eight percent of respondents felt the average census was "too many" and 71% felt the maximum size was "too many." The median (interquartile range) patient-to-attending physician ratio was 13 (10-16). When categorized according to this median, respondents from intensive care units with high patient/physician ratios (n = 31) perceived significantly more time constraints, more stress, and difficulties with teaching trainees than respondents with low patient/physician ratios (n = 40). The total number of non-nursing healthcare workers per patient was similar in both groups, suggesting that having more nonattending physician staff does not alleviate perceptions of overwork and stress in the attending physician. Academic intensive care unit physicians that direct fellowship programs frequently perceived being overburdened in the intensive care unit. Understaffing intensive care units with attending physicians may have a negative impact on teaching, patient care, and workforce stability.

Barriers to ultrasound training in critical care medicine fellowships: A survey of program directors

Ultrasonography is an effective tool for making quick diagnoses and guiding therapeutic procedures. National organizations have advocated increasing the use of critical care ultrasonography. The purpose of this study was to investigate the prevalence of teaching of critical care ultrasonography in fellowship programs. In addition, we hoped to identify barriers to establishment of ultrasound training programs. All pulmonary/critical care and critical care medicine (CCM) program directors in the United States were invited to participate in an online survey. We asked respondents for demographic information about their programs and perceived barriers to training, as well as current training opportunities for their fellows in five aspects of critical care ultrasonography. A five-point Likert scale was used for survey answers. Web-based survey. Pulmonary/critical care and CCM program directors in the United States. Web-based survey. Ninety (66%) of 136 program directors responded. Ultrasonography training was offered by fellowship programs in the following areas: vascular access (98%), lung and pleural (74%), cardiac (55%), vascular diagnostic (33%), and abdominal (37%). Ninety-two percent of respondents agreed or strongly agreed that ultrasound training is useful, and 80% were interested in getting their fellows trained. Forty-one percent indicated that they lacked sufficient faculty trained in ultrasound use. Eighty-four percent agreed or strongly agreed that fellow turnover was an impediment to training. Forty-eight percent believed that cardiac echocardiography required a long training time. Although ultrasound training in vascular access was nearly universal, training in other aspects of ultrasound was less prevalent. We identified several barriers, including fellow turnover, insufficient faculty training, and perceived length of time required for echocardiography training.