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The development of core entrustable professional activities (EPA) for entering residency and Accreditation Council for Graduate Medical Education's milestones have spurred thinking about the fourth year of medical school as a transition to residency. In this monograph, we layout our specialty focused post-clerkship curriculum and report learner and residency director perceptions over the first three years of implementation. Ongoing curricular monitoring has reinforced core principles but has also informed actionable quality improvement efforts. EPA-focused learning experiences, integration of specialty-specific milestones, addition of the feedforward process, and accessible mentorships have been key curricular elements to guide the transition to residency.

Background The prevalence of burnout and depressive symptoms is high among physician trainees. Research Question 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? Study Design and Methods 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. Results 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. Interpretation 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.

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.

Background: All applicants to accredited training programs must write a personal statement as part of the application process. This may provoke anxiety on the part of the applicant and can result i...

Background Teaching rounds are an important component of the learning environment for residents in the intensive care unit (ICU). Retrieval practice is a cognitive learning tool that helps learners consolidate information and might improve the quality and culture of teaching rounds. Objective We performed a feasibility study from October 2018 to June 2019 to investigate the incorporation of retrieval practice into ICU rounds. Methods Participants included internal medicine and family medicine residents and pulmonary and critical care medicine fellows and faculty on medical ICU (MICU) teams at a tertiary care academic medical center. For 1-week periods, residents were asked to use retrieval practice after rounds, sharing one learning point. Participants were anonymously surveyed about the feasibility and acceptability of this strategy and perceptions of the educational value of ICU rounds before and after incorporating retrieval practice. Results We enrolled 9 MICU teams, including 31 residents, 8 fellows, and 8 attendings. Pre- and postsurvey response rates were 89% and 91% (42 and 43 of 47, respectively). Sixty-nine percent of respondents (30 of 43) reported sharing learning points on at least 3 days of the intervention week. Eighty-six percent of respondents (37 of 43) said retrieval practice did not adversely affect the workflow at the end of rounds. The perception that teaching on rounds was a priority increased after the intervention (3.93 versus 4.28 on 1–5 Likert scale, P = .047). Conclusions Using retrieval practice on MICU rounds was feasible and acceptable and was associated with an increase in the perceived priority given to teaching on rounds.

Background Pulmonary medicine specialists find themselves responsible for the diagnosis and management of patients with sleep disorders. Despite the increasing prevalence of many of these conditions, many sleep medicine fellowship training slots go unfilled, leading to a growing gap between the volume of patients seeking care for sleep abnormalities and the number of physicians formally trained to manage them. To address this need, we convened a multisociety panel to develop a list of curricular recommendations related to sleep medicine for pulmonary fellowship training programs. Methods Surveys of pulmonary and pulmonary/critical care fellowship program directors and recent graduates of these programs were performed to assess the current state of sleep medicine education in pulmonary training, as well as the current scope of practice of pulmonary specialists. These data were used to inform a modified Delphi process focused on developing curricular recommendations relevant to sleep medicine. Results Surveys confirmed that pulmonary medicine specialists are often responsible for the diagnosis and treatment of a number of sleep conditions, including several that are not traditionally considered related to respiratory medicine. Through five rounds of voting, the panel crafted a list of 52 curricular competencies relevant to sleep medicine for recommended inclusion in pulmonary training programs. Conclusions Practicing pulmonary specialists require a broad knowledge of sleep medicine to provide appropriate care to patients they will be expected to manage. Training program directors may use the list of competencies as a framework to ensure adequate mastery of important content by graduating fellows.

Background: Interpersonal and communication skills are essential for physicians practicing in critical care settings. Accordingly, demonstration of these skills has been a core competency of the Accreditation Council for Graduate Medical Education since 2014. However, current practices regarding communication skills training in adult and pediatric critical care fellowships are not well described. Objective: To describe the current state of communication curricula and training methods in adult and pediatric critical care training programs as demonstrated by the published literature. Methods: We performed a systematic review of the published literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Three authors reviewed a comprehensive set of databases and independently selected articles on the basis of a predefined set of inclusion and exclusion criteria. Data were independently extracted from the selected articles. Results: The 23 publications meeting inclusion criteria fell into the following study classifications: intervention (n = 15), cross-sectional survey (n = 5), and instrument validation (n = 3). Most interventional studies assessed short-term and self-reported outcomes (e.g., learner attitudes and perspectives) only. Fifteen of 22 publications represented pediatric subspecialty programs. Conclusion: Opportunities exist to evaluate the influence of communication training programs on important outcomes, including measured learner behavior and patient and family outcomes, and the durability of skill retention.

Background: Pulmonary and critical care medicine (PCCM) fellowship requires a high degree of medical knowledge and procedural competency. Gaps in fellowship readiness can result in significant trainee anxiety related to starting fellowship training. Objective: To improve fellowship readiness and alleviate anxiety for PCCM-bound trainees by improving confidence in procedural skills and cognitive domains. Methods: Medical educators within the American Thoracic Society developed a national resident boot camp (RBC) to provide an immersive, experiential training program for physicians entering PCCM fellowships. The RBC curriculum is a 2-day course designed to build procedural skills, medical knowledge, and clinical confidence through high-fidelity simulation and active learning methodology. Separate programs for adult and pediatric providers run concurrently to provide unique training objectives targeted to their learners’ needs. Trainee assessments include multiple-choice pre- and post-RBC knowledge tests and confidence assessments, which are scored on a four-point Likert scale, for specific PCCM-related procedural and cognitive skills. Learners also evaluate course material and educator effectiveness, which guide modifications of future RBC programs and provide feedback for individual educators, respectively. Results: The American Thoracic Society RBC was implemented in 2014 and has grown annually to include 132 trainees and more than 100 faculty members. Mean knowledge test scores for participants in the 2019 RBC adult program increased from 55% (±14% SD) on the pretest to 72% (±11% SD; P

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.

Despite the increasing proportion of women in U.S. medical schools, there are relatively few women in leadership positions, and a number of recent publications have highlighted many factors that could contribute to gender inequity and inequality in medicine. The Association of Pulmonary, Critical Care, and Sleep Division Directors, an organization of Division Directors from across the United States, convened a workshop to review data and obtain input from leaders on the state of gender equity in our field. The workshop identified a number of factors that could contribute to gender inequality and inequity: gender climate (including implicit and perceived biases); disproportionate family responsibilities; lack of women in leadership positions; poor retention of women; and lack of gender equality in compensation. The panel members developed a roadmap of concrete recommendations for societies, leaders, and individuals that should promote gender equity to achieve gender equality and improve retention of women in the field of pulmonary, critical care, and sleep medicine.

Rationale: Few data have been published regarding scoring tools for selection of postgraduate medical trainee candidates that have wide applicability.Objectives: The authors present a novel scoring tool developed to assist postgraduate programs in generating an institution-specific rank list derived from selected elements of the U.S. Electronic Residency Application System (ERAS) application.Methods: The authors developed and validated an ERAS and interview day scoring tool at five pulmonary and critical care fellowship programs: the ERAS Application Scoring Tool–Interview Scoring Tool. This scoring tool was then tested for intrarater correlation versus subjective rankings of ERAS applications. The process for development of the tool was performed at four other institutions, and it was performed alongside and compared with the “traditional” ranking methods at the five programs and compared with the submitted National Residency Match Program rank list.Results: The ERAS Application Scoring Tool correlated h...

Author(s): Leung, Cynthia G; Thompson, Laura; McCallister, Jennifer W; Way, David P; Kman, Nicholas E

Background Video is an increasingly popular medium for consuming online content, and video-based education is effective for knowledge acquisition and development of technical skills. Despite the increased interest in and use of video in medical education, there remains a need to develop accurate and trusted collections of peer-reviewed videos for medical learners. Objective We developed the first professional society-based, open-access library of crowd-sourced and peer-reviewed educational videos for medical learners and health care providers. Methods A comprehensive peer-review process of medical education videos was designed, implemented, reviewed, and modified using a plan-do-study-act approach to ensure optimal accuracy and effective pedagogy, while emphasizing modern teaching methods and brevity. The number of submissions and views were tracked as metrics of interest and engagement of medical learners and educators. Results The Best of American Thoracic Society Video Lecture Series (BAVLS) was launched in 2016. Total video submissions for 2016, 2017, and 2018 were 26, 55, and 52, respectively. Revisions to the video peer-review process were made after each submission cycle. By 2017, the total views of BAVLS videos on www.thoracic.org and YouTube were 9100 and 17 499, respectively. By 2018, total views were 77 720 and 152 941, respectively. BAVLS has achieved global reach, with views from 89 countries. Conclusions The growth in submissions, content diversity, and viewership of BAVLS is a result of an intentional and evolving review process that emphasizes creativity and innovation in video-based pedagogy. BAVLS can serve as an example for developing institutional or society-based video platforms.

Recent discussions have sparked a debate about the purpose and function of the fourth year of medical school and the transition from undergraduate to graduate medical education. Our institution recently reformed our medical school curriculum into a three-part, competency-based curriculum that spans for 4 years, called Lead, Serve, Inspire (LSI). We present a novel way to structure the fourth year of medical school to better prepare our students for the next phase of their education in two ways, the development of Clinical Tracks and Advanced Competencies. The Clinical Tracks form individualized specialty-specific educational plans for students, preparing them to obtain the skills needed to be proficient interns in the specialty in which they hope to match. The Advanced Competencies are experiences that offer enhanced content that map to one of the Core Educational Objectives of the College of Medicine. They are often interdisciplinary and generalizable to multiple practice areas in both clinical and non-clinical activities. Ultimately, the goal of this revision is to create a competency-based, specialty-specific curriculum during the fourth year that will allow students to obtain the skills needed to function as interns on the first day of their postgraduate year 1 (PGY-1) of residency.

Fellows in pulmonary and critical care medicine are required to show competency in facilitating family meetings for critically ill patients. There are many assessment measures available for evaluating physician-patient communication (e.g., the SEGUE Framework [Set the stage, Elicit information, Give information, Understand the patient's perspective, End the encounter]) and some designed for family meetings. However, no validated measure exists that is specifically designed to assess communication skills during family meetings with surrogate decision makers in intensive care settings.We developed the Family Meeting Behavioral Skills Checklist (FMBSC) to measure advanced communication skills of fellows in family meetings of critically ill patients based on a literature review and consensus of an interdisciplinary group of communications experts. We evaluated the psychometric properties of the FMBSC.We digitally recorded 16 pulmonary/critical care fellows performing a simulated family meeting for a critically ill patient at the end of 1 year of fellowship training. Two clinical health psychologists evaluated each recording independently using the FMBSC Rating Scale and the SEGUE Framework. Judges recorded the number of skills performed using the checklist and employed a summary rating scale to judge the level of performance for each of nine subsets of skills. Each instrument was scored and converted to percentage scores. The FMBSC and SEGUE Framework items were summed and converted to percentage scores for each category and as a total for each instrument. The rating scale items on the FMBSC were also summed and converted to a percentage score. Four primary analyses were conducted to evaluate interjudge reliability, internal consistency, and concurrent validity.Interrater reliability was higher for the FMBSC (intraclass correlation [ICC2,2] = 0.57) than for the SEGUE instrument (ICC2,2 = 0.32) or the FMBSC Rating Scale (ICC2,2 = 0.23). The FMBSC demonstrated evidence of concurrent validity through high positive correlations with both the FMBSC Rating Scale and the SEGUE instrument (r = +0.83, P ≤ 0.01; r = +0.65, P ≤ 0.01 respectively). All but one of the nine subscales on the FMBSC showed adequate internal consistency (reliabilities ranged from 0.18 to 0.68). Interjudge reliability was higher for the FMBSC (ICC2,2 = 0.57) than for the SEGUE instrument (ICC2,2 = 0.32) or the FMBSC Rating Scale (ICC2,2 = 0.23).The FMBSC demonstrated internal consistency and structural validity in assessing advanced communication skills of fellows in facilitating family meetings of critically ill patients in the ICU. Interjudge reliability was better for the FMBS Checklist than it was for the other measures.

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; P0.001). 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.

This paper outlines specific tips for those applying to pulmonary and/or critical care medicine fellowship training in the United States using the PAIR-Match steps: preparation, application, interview, ranking, and match. Preparation for fellowship begins long before the application process with an assessment of one's long-term goals (to the extent that these are known). The cornerstone of the application is the curriculum vitae, which should highlight applicants' pulmonary and critical care-related experiences and scholarly work. Applicants should obtain letters of recommendation from faculty members who know them well and can write a letter that speaks to their strengths in clinical, scholarly, or leadership areas. The personal statement is an opportunity to share experiences not otherwise shared in the application and is an opportunity to explain any breaks in training or performance lapses. When selecting programs to which they will apply, applicants should pay close attention to the areas of education and curriculum, clinical experience, scholarly opportunity, and personal factors. Preparing for interviews should include a review of the program at which one is interviewing and development of relevant questions regarding details of the program. The interview day is the applicant's opportunity to see the "personality" of the program by meeting with the program director, faculty, and current fellows and to assess whether the program is a good fit for their goals. Applicants should only rank those programs they are willing to attend, in order of preference; they should be aware that the match process is binding.

The Accreditation Council for Graduate Medical Education requires physicians training in pulmonary and critical care medicine to demonstrate competency in interpersonal communication. Studies have shown that residency training is often insufficient to prepare physicians to provide end-of-life care and facilitate patient and family decision-making. Poor communication in the intensive care unit (ICU) can adversely affect outcomes for critically ill patients and their family members. Despite this, communication training curricula in pulmonary and critical care medicine are largely absent in the published literature.We evaluated the effectiveness of a communication skills curriculum during the first year of a pulmonary and critical care medicine fellowship using a family meeting checklist to provide formative feedback to fellows during ICU rotations. We hypothesized that fellows would demonstrate increased competence and confidence in the behavioral skills necessary for facilitating family meetings.We evaluated a 12-month communication skills curriculum using a pre-post, quasiexperimental design. Subjects for this study included 11 first-year fellows who participated in the new curriculum (intervention group) and a historical control group of five fellows who had completed no formal communication curriculum. Performance of communication skills and self-confidence in family meetings were assessed for the intervention group before and after the curriculum. The control group was assessed once at the beginning of their second year of fellowship.Fellows in the intervention group demonstrated significantly improved communication skills as evaluated by two psychologists using the Family Meeting Behavioral Skills Checklist, with an increase in total observed skills from 51 to 65% (P ≤ 0.01; Cohen's D effect size [es], 1.13). Their performance was also rated significantly higher when compared with the historical control group, who demonstrated only 49% of observed skills (P ≤ 0.01; es, 1.55). Fellows in the intervention group also showed significantly improved self-confidence scores upon completion of the curriculum, with an increase from 77 to 89% (P ≤ 0.01; es, 0.87) upon completion of the curriculumA structured curriculum that includes abundant opportunities for fellows to practice and receive feedback using a behavioral checklist during their ICU rotations helps to develop physicians with advanced communication skills.

SummaryObjectiveImportant differences between men and women with asthma have been demonstrated, with women describing more symptoms and worse asthma-related quality of life (QOL) despite having similar or better pulmonary function. While current guidelines focus heavily on assessing asthma control, they lack information about whether sex-specific approaches to asthma assessment should be considered. We sought to determine if sex differences in asthma control or symptom profiles exist in the well-characterized population of participants in the American Lung Association Asthma Clinical Research Centers (ALA-ACRC) trials.MethodsWe reviewed baseline data from four trials published by the ALA-ACRC to evaluate individual item responses to three standardized asthma questionnaires: the Juniper Asthma Control Questionnaire (ACQ), the multi-attribute Asthma Symptom Utility Index (ASUI), and Juniper Mini Asthma Quality of Life Questionnaire (mini-AQLQ).ResultsIn the poorly-controlled population, women reported similar overall asthma control (mean ACQ 1.9 vs. 1.8; p = 0.54), but were more likely to report specific symptoms such as nocturnal awakenings, activity limitations, and shortness of breath on individual item responses. Women reported worse asthma-related QOL on the mini-AQLQ (mean 4.5 vs. 4.9; p

PURPOSE OF REVIEW Asthma is one of the most prevalent chronic medical conditions to complicate pregnancy. With approximately one-third of women experiencing a worsening of control during the course of their pregnancy, identifying those at greatest risk has the potential to improve maternal and fetal outcomes for a large number of pregnancies. Similarly, active management strategies that prioritize asthma control in this vulnerable population can have a far-reaching impact. RECENT FINDINGS Demographic characteristics and patient noncompliance place certain populations of pregnant women at increased risk of poor asthma control during pregnancy. In addition, undertreatment and disparities in care of acute exacerbations during pregnancy likely contribute. Targeted educational interventions and treatment algorithms using objective markers of disease activity have shown improved outcomes in asthma control. SUMMARY Active management strategies which focus on identifying patient-specific risk factors, patient and provider education, and targeted treatment interventions can improve asthma care for women during pregnancy.

Summary Objective Asthma is one of the most common medical conditions complicating pregnancy. Despite the presence of published guidelines outlining the care of the pregnant patient with asthma, disparities in the treatment of acute asthma exacerbations in the emergency department related to pregnancy status are known to exist. We sought to determine if pregnancy status affected the treatment of women presenting to a tertiary emergency department for care of acute asthma exacerbations. Methods We retrospectively compared the emergency department treatment of acute asthma exacerbations in 123 pregnant women to 123 non-pregnant controls. Asthma exacerbations were classified by severity according to pre-determined criteria. Results In the emergency department (ED), pregnant women were significantly less likely to be treated with systemic corticosteroids than non-pregnant controls (50.8% versus 72.4%, p = 0.001). Similarly, 41% of pregnant women received prescriptions for prednisone at the time of discharge from the ED compared to 69.2% of non-pregnant women ( p Conclusions In this population of asthmatics presenting to a tertiary emergency department with acute asthma exacerbations, pregnant women were less likely to receive appropriate therapy with systemic corticosteroids.

Asthma and gastroesophageal reflux disease (GERD) are both common conditions and, hence, they often coexist. However, asthmatics have been found to have a much greater prevalence of GERD symptoms than the general population. There remains debate regarding the underlying physiologic mechanism(s) of this relationship and whether treatment of GERD actually translates into improved asthma outcomes. Based on smaller trials with somewhat conflicting results regarding improved asthma control with treatment of GERD, current guidelines recommend a trial of GERD treatment for symptomatic asthmatics even without symptoms of GERD. However, recently a large multicenter trial demonstrated that the treatment of asymptomatic GERD with proton-pump inhibitors did not improve asthma control in terms of pulmonary function, rate of asthma exacerbations, asthma-related quality of life, or asthma symptom frequency. These data suggest empiric treatment of asymptomatic GERD in asthmatics is not a useful practice. This review article provides an overview of the epidemiology and pathophysiologic relationships between asthma and GERD as well as a summary of current data regarding links between treatment of GERD with asthma outcomes.

This article was migrated. The article was not marked as recommended. Background: Educational handoffs between medical schools and residency may facilitate the transition into graduate medical education. Attitudes of residency program directors about handoffs are largely unknown. Objective: This study assessed the opinions of residency program directors from four specialties, regarding information sharing between medical schools and residencies, and whether they desire student performance data post-match, including milestones, competency and entrustable professional activity (EPA) achievement, and capstone or boot camp-based performance data. Methods: In 2017 a thirteen question survey was sent to program directors from internal medicine, pediatrics, emergency medicine, and obstetrics/gynecology. Responses were anonymous and data was analyzed using descriptive statistics and thematic analysis. Results: Twenty percent of program directors surveyed submitted a survey (187 out of 950). Fifty-nine percent reported that unexpected remedial issues often arise within the first 6 months of internship. Twenty-four percent stated that information currently received is adequate to structure the learning environment of individual residents. Seventy-seven percent responded that they desire access to EPA-based information; seventy-four percent to milestone or competency-based data; eighty-two percent to performance data from fourth-year capstone courses or boot camps. No significant differences were found between specialties. Concerns were raised by respondents about the validity and reliability of performance metrics that would be shared with program directors. Conclusions: The majority of the program directors who responded to this survey indicated that they desire access to and would utilize medical student performance data post-match, though concerns were raised about the validity and reliability of proposed metrics.

Lecturing is an essential teaching skill for scientists and health care professionals in pulmonary, critical care, and sleep medicine. However, few medical or scientific educators have received training in contemporary techniques or technology for large audience presentation. Interactive lecturing outperforms traditional, passive-style lecturing in educational outcomes, and is being increasingly incorporated into large group presentations. Evidence-based techniques range from the very simple, such as inserting pauses for audience discussion, to more technologically advanced approaches such as electronic audience response systems. Alternative software platforms such as Prezi can overcome some of the visual limits that the ubiquitous PowerPoint imposes on complex scientific narratives, and newer technology formats can help foster the interactive learning environment. Regardless of the technology, adherence to good principles of instructional design, multimedia learning, visualization of quantitative data, and informational public speaking can improve any lecture. The storyline must be clear, logical, and simplified compared with how it might be prepared for scientific publication. Succinct outline and summary slides can provide a roadmap for the audience. Changes of pace, and summaries or other cognitive breaks inserted every 15-20 minutes can renew attention. Graphics that emphasize clear, digestible data graphs or images over tables, and simple, focused tables over text slides, are more readily absorbed. Text slides should minimize words, using simple fonts in colors that contrast to a plain background. Adherence to these well-established principles and addition of some new approaches and technologies will yield an engaging lecture worth attending.

This article was migrated. The article was marked as recommended. In this Personal View article we discuss the limitations of the summative medical student data currently received by residencies pre-match (such as transcripts, the Dean's Letter and letters of recommendation) to adequately communicate a student's strengths, weaknesses, and learning needs as they begin internship. We briefly summarize the evolution of medical student and resident performance evaluation, and discuss the role that educational handoffs may play in the future as students transition to internship. We then consider emerging questions about the feasibility and mechanics of educational handoffs and discuss possible steps forward.

Purpose The safety of single-bolus etomidate to facilitate intubation in septic patients is controversial due to its potential to suppress adrenal steroidogenesis. The purpose of this study was to evaluate the effects of etomidate on the development of shock when used as an induction agent to facilitate intubation in septic patients. Methods A multicenter, retrospective, propensity-matched cohort study comparing patients with sepsis or severe sepsis who either received etomidate or did not receive etomidate for intubation was conducted. The primary outcome was the difference in the need for vasopressor support within 72 hours after intubation. Secondary outcomes included the use of multiple vasopressors, intensive care unit length of stay, and in-hospital mortality. Results A total of 411 patients were analyzed. Eighty-three patients were matched by propensity score. There was no difference in the matched cohort in regards to vasopressor use within 72 hours of intubation (odds ratio, 0.95; 95% confidence interval, 0.52-1.76; P = .88). Furthermore, there were no significant differences observed with regard to secondary outcomes, including in-hospital mortality (P = .76). Conclusions The use of etomidate for intubation in septic patients did not increase vasopressor requirements within 72 hours after intubation.

Objectives 1. Develop an observed structured clinical examination (OSCE) to assess and give feedback to residents on their ability to provide prognostic information and recommend hospice as part of an existing required palliative care curriculum in our institution’s internal medicine residency program. Background. Over the past decade, late referral to hospice has become an increasing problem in the United States. Barriers to hospice referral are not well understood, but the lack of residency training in essential generalist palliative care competencies, such as giving prognostic information and recommending hospice, is a potential barrier to improving hospice utilization. Using observed structured clinical examinations (OSCEs) to improve trainees’ interpersonal and communication skills may address this barrier. Methods. The OSCE case was developed by an expert palliative care educator and modified though an iterative process consisting of 22 pilot OSCEs. An extensive literature review informed the development of the OSCE assessment tool, and items were reviewed and revised by six palliative and geriatric medicine experts. The assessment tool was revised in an iterative process over the course of 16 OSCEs with internal medicine residents. One standardizedpatient was used for all OSCEs. Results. The final OSCE assessment tool consists of a 20-item behavior checklist. Preliminary results suggest high interrater reliability (K1⁄40.97). Pilot assessment of 13 internal medicine residents found that the most frequently missed behaviors were assessing a patient’s desire for prognostic information, identifying social workers or chaplains as part of the hospice team, and describing the hospice team’s role after the patient dies (pronouncement, post-mortem care, and bereavement care). Of participants who evaluated the OSCE, all reported that the exercise was useful and ‘‘better than average’’ compared with other residency educational activities. Common ‘‘take home’’ points for residents included identifying members of the hospice team and asking patientswhat they understand and want to know about their prognosis. Results from an additional 20 OSCEs will be reported using the final assessment tool. Discussion. This OSCE offers an opportunity for standardized assessment and individualized feedback to improve internal medicine residents’ medical knowledge and skills related to the essential generalist palliative care competencies discussing prognosis and recommending hospice. Although originally developed for internal medicine residents, this tool could be readily applied to other specialties. Conclusion. The Discussing Prognosis and Recommending Hospice OSCE is a useful and effective tool for identifying and addressing residents’ gaps in knowledge and communication skills around discussing prognosis and recommending hospice.

PURPOSE OF REVIEW asthma is a common chronic disease with significant clinical impact worldwide. Sex-related disparities in asthma epidemiology and morbidity exist but debate continues regarding the mechanisms for these differences. There is a need to review the recent findings for asthma care providers and to highlight areas in need of additional research. RECENT FINDINGS recent data illustrate striking sex-related differences in asthma epidemiology and disease expression. Studies show an increased incidence of asthma in women. Data demonstrate that asthmatic women have a poorer quality of life and increased utilization of healthcare compared to their male counterparts despite similar medical treatment and baseline pulmonary function. Research continues to explore hypotheses for these differences including the potential influences of the female sex hormones, altered perception of airflow obstruction, increased bronchial hyper-responsiveness, and medication compliance and technique. However, no single explanation has been able to fully explain the disparities. SUMMARY women are more likely to be diagnosed with asthma and suffer greater morbidity than men. The physiologic mechanisms for these differences are not well understood. Understanding sex-related differences in asthma and providing patients with education geared toward these disparities are important in establishing effective, individualized asthma management strategies for all patients.

Fluticasone propionate is approved for the long-term maintenance therapy of persistent asthma of all severities, and its safety and efficacy has been well established in clinical trials and practice. With the need to phase out chlorofluorocarbons (CFCs) as propellants in pressurized metered-dose inhalers (pMDIs), hydrofluoroalkane (HFA) propellants have been introduced as a safer, environmentally friendly alternative. A HFA formulation of fluticasone propionate has been developed as a microgram-equivalent replacement for the traditional CFC pMDI. Clinical trials have demonstrated that the fluticasone propionate HFA pMDI is an acceptable clinical alternative for the CFC pMDI with similar safety and efficacy.