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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.

Issue: Life-long learning is a skill that is central to competent health professionals, and medical educators have sought to understand how adult professionals learn, adapt to new information, and independently seek to learn more. Accrediting bodies now mandate that training programs teach in ways that promote self-directed learning (SDL) but do not provide adequate guidance on how to address this requirement. Evidence: The model for the SDL mandate in physician training is based mostly on early childhood and secondary education evidence and literature, and may not capture the unique environment of medical training and clinical education. Furthermore, there is uncertainty about how medical schools and postgraduate training programs should implement and evaluate SDL educational interventions. The Shapiro Institute for Education and Research, in conjunction with the Association of American Medical Colleges, convened teams from eight medical schools from North America to address the challenge of defining, implementing, and evaluating SDL and the structures needed to nurture and support its development in health professional training. Implications: In this commentary, the authors describe SDL in Medical Education, (SDL-ME), which is a construct of learning and pedagogy specific to medical students and physicians in training. SDL-ME builds on the foundations of SDL and self-regulated learning theory, but is specifically contextualized for the unique responsibilities of physicians to patients, inter-professional teams, and society. Through consensus, the authors offer suggestions for training programs to teach and evaluate SDL-ME. To teach self-directed learning requires placing the construct in the context of patient care and of an obligation to society at large. The SDL-ME construct builds upon SDL and SRL frameworks and suggests SDL as foundational to health professional identity formation.KEYWORDSself-directed learning; graduate medical education; undergraduate medical education; theoretical frameworksSupplemental data for this article is available online at https://doi.org/10.1080/10401334.2021.1938074 .

Background Although it is well known that the coronavirus disease (COVID-19) pandemic has had a profound effect on health care, its impact on fellowship training in Pulmonary and Critical Care Medicine (PCCM) has not been well described. Objective We conducted an anonymous survey of PCCM program directors (PDs) to assess the impact of the COVID-19 pandemic on PCCM fellowship training across the United States. Methods We developed a 30-question web-based survey that was distributed to U.S. PCCM PDs through the Association of Pulmonary and Critical Care Medicine Program Directors. Results The survey was sent to 242 PDs, of whom 28.5% responded. Most of the responses (76.8%) came from university-based programs. Almost universally, PDs reported a decrease in the number of pulmonary function tests (100%), outpatient visits (94.1%), and elective bronchoscopies (96%). Three-quarters (77.6%) of the PDs reported that their PCCM fellows spent more time in the intensive care unit than originally scheduled. Conclusion The COVID-19 pandemic has had a variable impact on different aspects of fellowship training. PDs reported a significant decrease in the core components of pulmonary training, whereas certain aspects of critical care training increased. It is likely that targeted mitigation strategies will be needed to ensure no gaps in PCCM training while optimizing well-being.

Introduction Given barriers to learner assessment in the authentic clinical environment, simulated patient encounters are gaining attention as a valuable opportunity for competency assessment across the health professions. Simulation-based assessments offer advantages over traditional methods by providing realistic clinical scenarios through which a range of technical, analytical, and communication skills can be demonstrated. However, simulation for the purpose of assessment represents a paradigm shift with unique challenges, including preservation of a safe learning environment, standardization across learners, and application of valid assessment tools. Our goal was to create an interactive workshop to equip educators with the knowledge and skills needed to conduct assessments in a simulated environment. Methods Participants engaged in a 90-minute workshop with large-group facilitated discussions and small-group activities for practical skill development. Facilitators guided attendees through a simulated grading exercise followed by in-depth analysis of three types of assessment tools. Participants designed a comprehensive simulation-based assessment encounter, including selection or creation of an assessment tool. Results We have led two iterations of this workshop, including an in-person format at an international conference and a virtual format at our institution during the COVID-19 pandemic, with a total of 93 participants. Survey responses indicated strong overall ratings and impactfulness of the workshop. Discussion Our workshop provides a practical, evidence-based framework to guide educators in the development of a simulation-based assessment program, including optimization of the environment, design of the simulated case, and utilization of meaningful, valid assessment tools.

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.

Simulation is a popular and effective training modality in medical education across a variety of domains. Central venous catheterization (CVC) is commonly undertaken by trainees, and carries significant risk for patient harm when carried out incorrectly. Multiple studies have evaluated the efficacy of simulation-based training programs, in comparison with traditional training modalities, on learner and patient outcomes. In this review, we discuss relevant adult learning principles that support simulation-based CVC training, review the literature on simulation-based CVC training, and highlight the use of simulation-based CVC training programs at various institutions.

Objectives: We present a pilot study exploring the effects of a brief, 30-minute educational intervention targeting resident communication surrounding dying in the intensive care unit (ICU). We sought to determine whether simulation or didactic educational interventions improved resident-reported comfort, preparation, and skill acquisition. We also sought to identify resident barriers to using the word “dying.” Methods: In this mixed-methods prospective study, second- and third-year medical residents were randomized to participate in a simulation-based communication training or a didactic session. Residents completed a pre–post survey after the sessions evaluating the sessions and reflecting on their use of the word “dying” in family meetings. Results: Forty-five residents participated in the study. Residents reported increases in comfort (Mean [M]-pre = 3.3 [standard deviation: 0.6], M-post = 3.7 [0.7]; P < .01, Cohen d = 0.75) and preparation (M-pre = 3.4 [0.7], M-post = 3.9 [0.6]; P < .01, d = 1.07) using the word “dying” after both the simulation and didactic versions. Residents randomized to the simulation reported they were more likely to have learned new skills as compared to residents in the didactic (M-simulation = 2.2 [0.4], M-didactic = 1.9 [0.3]; P = .015, d = 0.80). They estimated that they used the word “dying” in 50% of their end-of-life (EOL) conversations and identified uncertain prognosis as the main barrier to explicitly stating the word “dying.” Conclusion: A 30-minute educational intervention improves internal medicine residents’ self-reported comfort and preparation in talking about death and dying in the ICU. Residents in simulation-based training were more likely to report they learned new skills as compared to the didactic session. Residents report multiple barriers to using the word “dying” EOL conversations.

Dynamic hyperinflation is a common cause of dyspnea and functional limitation in patients with emphysema. Dynamic hyperinflation occurs in individuals with air-flow limitation when expiratory time is decreased during periods of relative tachypnea (such as during exercise or agitation, for example). In this setting, patients with emphysema develop lung hyperinflation, impairment of inspiratory respiratory muscles, and an increase in work of breathing. The associated decrease in inspiratory capacity results in the stimulation of several receptors, including chemoreceptors and pulmonary receptors, which signal the brain to increase tidal volume. The inability of the respiratory system to respond to signals of increased demand (eg, by enlarging tidal volume and increasing inspiratory flow) results in a dissociation between afferent and efferent signaling thereby intensifying breathing discomfort, or what clinicians term dyspnea. A thorough understanding of the physiology of dyspnea and pathophysiology of dynamic hyperinflation informs the interventions used to mitigate sensations of dyspnea and the physiologic effects of dynamic hyperinflation, respectively. Pharmacotherapy, pulmonary rehabilitation, breathing techniques, positive airway pressure, and lung volume reduction are well-studied interventions that target pathways to dyspnea in patients with dynamic hyperinflation.

We evaluated the effects of myocardial perfusion after primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) on gender-based mortality rates. Research has demonstrated a gender-specific response of cardiomyocytes to ischemia and a potential increase in myocardial salvage in women compared with men. Myocardial blush grade (MBG), an angiographic surrogate of myocardial perfusion, is an independent predictor of early and late survival after AMI. Whether the incidence and prognosis of myocardial perfusion differs according to gender among patients with AMI undergoing PCI is unknown. MBG and short- and long-term mortality were evaluated in 1,301 patients (male = 935; female = 366) with AMI randomized to primary angioplasty ± abciximab versus stent ± abciximab. Following PCI, >96% of patients achieved final Thrombolysis In Myocardial Infarction 3 flow, of which MBG 2/3 was present in 58.3% of women versus 51.1% of men (p = 0.02). Worse MBG was an independent predictor of mortality in women at 30 days (7.4% for MBG 0/1 vs 2.4% for MBG 2/3, p = 0.04) and at 1-year (11.0% for MBG 0/1 vs 3.4% for MBG 2/3, p = 0.01); however, MBG was not associated with differences in mortality for men. In conclusion, impaired myocardial perfusion following PCI for AMI, indicated by worse MBG, is an independent predictor of early and late mortality in women but not in men. These findings imply an enhanced survival benefit from restoring myocardial perfusion for women compared with men during primary angioplasty and may have clinical implications for interventional strategies in women.

Background Only a small fraction of acute chest pain in the emergency department (ED) is due to obstructive coronary artery disease (CAD). ED chest pain remains associated with high rates of recidivism, often in the presence of nonobstructive CAD. Psychological states such as depression, anxiety, and elevation of perceived stress may account for this finding. The objective of the study was to determine whether psychological states predict recurrent chest pain (RCP). Methods We conducted a prospective cohort study of low– to moderate–cardiac risk ED patients admitted to the Yale Chest Pain Center with acute chest pain. Depression, anxiety, and perceived stress were assessed in each patient using multistudy-validated screening scales: Patient Health Questionnaire (PHQ8), Clinical Anxiety Scale (CAS), and Perceived Stress Scale (PSS), respectively. All patients ruled out for infarction underwent appropriate cardiac stress testing. Primary outcome was RCP at 30 days evaluated by phone follow-up and medical record. The relationship between each psychological scale and RCP was evaluated using ordinal logistic regressions, controlling for known sociodemographic and cardiac risk factors. Depression (PHQ8 ≥ 10), anxiety (CAS ≥ 30), and perceived stress (PSS ≥ 15) were considered positive. Results Between August 2013 and May 2015, 985 patients were screened at the Yale Chest Pain Center. Of 500 enrolled patients, 483 patients had complete data and 365 (76%) patients completed follow-up. Thirty-six percent (n = 131) had RCP within 1 month. On multivariable regression models, depression (odds ratio [OR] = 2.11, 95% CI 1.18-3.79) was a significant independent predictor of 30-day chest pain recurrence after adjustment, whereas PSS (OR = 0.96, 95% CI 0.60-1.53) and anxiety (OR = 1.59, 95% CI 0.80-3.20) were not. Similarly, there was a direct relationship between psychometric evaluation of depression (via PHQ8) and the frequency of chest pain. Conclusions Depression is independently associated with RCP regardless of significant cardiac ischemia on stress testing. Identification and targeted interventions may curtail recidivism with RCP.

There is growing need for the identification of novel non-invasive methodologies for the identification of individuals at risk for adverse cardiovascular (CV) events. We examined whether endothelial dysfunction, as detected by non- invasive peripheral arterial tonometry (EndoPAT), can predict late CV events. Methods and results Reactive hyperaemia (RH) was induced following upper arm occlusion of systolic blood pressure in 270 outpatients (54+ 12 years, 48% female). The natural logarithmic scaled RH index (L_RHI) was calculated from the ratio between the digital pulse volume during RH and at baseline. The patients were followed for CV adverse events (AE: cardiac death, myocardial infarction, revascularization or cardiac hospitalization) during a 7-year follow-up (inter-quartile range ¼ 4.4-8). Cox models were used to estimate the association of EndoPAT results with AE adjusted for age. During the follow-up, AE occurred in 86 patients (31%). Seven-year AE rate was 48% in patients with L_RHI , 0.4 vs. 28% in those with L_RHI � 0.4 (P ¼ 0.03). Additional univariate predictors of AE were advancing age (P ¼ 0.02) and prior coronary bypass surgery (P ¼ 0.01). The traditional Framingham risk score was not higher in patients with AE. Multivariate analysis identified L_RHI , 0.4 as an independent predictor of AE (P ¼ 0.03). Conclusion A low RH signal detected by EndoPAT, consistent with endothelial dysfunction, was associated with higher AE rate during follow-up. L_RHI was an independent predictor of AE. Non-invasive assessment of peripheral vascular func- tion may be useful for the identification of patients at risk for cardiac AEs.

Endothelial dysfunction is an important component in the pathogenesis of atherosclerosis. The ability to assess the endothelium in a meaningful manner has been the subject of intense investigation over decades. Since the function of endothelial cells is a gauge of vascular health, assessment of vascular function is emerging as a useful tool for predicting cardiovascular risk and as a surrogate outcome measure for cardiovascular reduction intervention studies. This review highlights techniques for assessing endothelial function, focusing on a novel method of determining peripheral vascular reactivity via arterial tonometry.