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

BACKGROUND

Although postinterview communication (PIC) guidelines exist, adherence is voluntary. There are no studies of PIC practices in critical care medicine (CCM) and pulmonary and critical care medicine (PCCM) fellowship recruitment.

RESEARCH QUESTION

What is the frequency, format, goals, and content of PIC between CCM/PCCM applicants and program directors? What is the impact of PIC on applicant and program rank order lists (ROLs)?

STUDY DESIGN AND METHODS

CCM/PCCM applicants and program directors were separately surveyed after the 2022-2023 National Resident Matching Program Specialty Match. Surveys included multiple-choice, Likert-scale, and two free text questions. Thematic content analysis of free text responses was performed.

RESULTS

One-third of eligible participants responded (applicants: n = 373 [34%]; program directors: n = 86 [32%]). Applicant respondents applied to CCM (19%), PCCM (69%), or both (12%). Program directors represented CCM (17%), PCCM (57%), or both (26%) programs. Applicant (66%) and program director (49%) respondents reported initiating PIC. PIC did not impact ROL decision for most applicants (73%) or program directors (83%), though 21% of applicants and 17% of program directors moved programs or applicants up on their ROL in response to PIC. One-quarter (23%) of applicants strongly agreed or agreed that PIC was helpful in creating their ROL, 27% strongly disagreed or disagreed, and 29% were neutral. PIC challenges identified by both groups included time; lack of uniformity; peer pressure; misleading language; and uncertainty about motives, rules, and response protocols.

INTERPRETATION

PIC is common among CCM/PCCM applicants and program directors. About 50% of applicants and 20% of program directors share ranking intentions via PIC. Although PIC did not impact ROL for most applicants and program directors, a minority of applicants and program directors moved programs up on their ROL after receiving PIC from the other party. Applicants have mixed perspectives on PIC value. Applicants and program directors alike desire clear guidance on PIC to minimize ambiguous and misleading communication.

The effect of in-person primary and secondary school instruction on county-level SARS-CoV-2 spread in Indiana

Objective

To determine the county-level effect of in-person primary and secondary school reopening on daily cases of SARS-CoV-2 in Indiana.

Methods

This is a county-level population-based study using a panel data regression analysis of the proportion of in-person learning to evaluate an association with community-wide daily new SARS-CoV-2 cases. The study period was July 12-October 6, 2020. We included 73 out of 92 (79.3%) Indiana counties in the analysis, accounting for 85.7% of school corporations and 90.6% of student enrollment statewide. The primary exposure was the proportion of students returning to in-person instruction. The primary outcome was the daily new SARS-CoV-2 cases per 100,000 residents at the county level.

Results

There is a statistically significant relationship between the proportion of students attending K-12 schools in-person and the county level daily cases of SARS-CoV-2 28 days later. For all ages, the coefficient of interest (β) is estimated at 3.36 (95% CI: 1.91—4.81; p < 0.001). This coefficient represents the effect of a change the proportion of students attending in-person on new daily cases 28 days later. For example, a 10 percentage point increase in K-12 students attending school in-person is associated with a daily increase in SARS-CoV-2 cases in the county equal to 0.336 cases/100,000 residents of all ages.

Conclusion

In-person primary and secondary school is associated with a statistically significant but proportionally small increase in the spread of SARS-CoV-2 cases.

Balancing Demands: Determinants of Burnout Reported by Fellows in Pulmonary and Critical Care Medicine

Background: Burnout is common among physicians who care for critically ill patients and is known to contribute to worse patient outcomes. Fellows training in pulmonary and critical care medicine (PCCM) have risk factors that make them susceptible to burnout; for example, clinical environments that require increased intellectual and emotional demands with long hours. The Accreditation Council for Graduate Medical Education has recognized the increasing importance of trainee burnout and encourages training programs to address burnout. Objective: To assess factors related to training and practice that posed a threat to the well-being among fellows training in PCCM and to obtain suggestions regarding how programs can improve fellow well-being. Methods: We conducted a qualitative content analysis of data collected from a prior cross-sectional electronic survey with free-response questions of fellows enrolled in pulmonary, PCCM, and critical care medicine training programs in the United States. Fellows were asked what factors posed a threat to their well-being and what changes their training program could implement. Responses were qualitatively coded and categorized into themes using thematic analysis. Results: A total of 427 fellows (44% of survey respondents) completed at least one free-response question. The majority of respondents (60%) identified as male and white/non-Hispanic (59%). The threats to well-being and burnout were grouped into five themes: clinical burden, individual factors, team culture, limited autonomy, and program resources. Clinical burden was the most common threat discussed by fellows. Fellows highlighted factors contributing to burnout that specifically pertained to trainees including challenging interpersonal relationships with attending physicians and limited protected educational time. Fellows proposed solutions addressing clinical care, changes at the program or institution level, and organizational culture changes to improve well-being. Conclusion: This study provides insight into factors fellows report as contributors to burnout and decreased well-being in addition to investigating fellow-driven solutions toward improving well-being. These solutions may help pulmonary, PCCM, and critical care medicine program directors better address fellow well-being in the future.

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

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.

Social complexity negatively influences lung function in cystic fibrosis after transfer to adult care

BACKGROUND

Several nongenetic factors, such as socioeconomic status, environmental exposures, and adherence have been described to have an impact on outcomes in cystic fibrosis (CF).

OBJECTIVE

To determine the effect of social complexity on the % predicted forced expiratory volume (ppFEV₁ ) before and after transfer to adult care among adolescents with CF.

METHODS

Retrospective, single center, cohort study included all patients with CF who were transitioned into adult care between 2005 and 2015 at Indiana University. Social complexity (Bob's level of social support, [BLSS]) was collected at transfer. Linear mixed regression models assessed the relationship between ppFEV₁ decline over time and BLSS with other covariates.

RESULTS

The median age of the patients (N = 133) at the time of transfer was 20 years (interquartile range: 19-23). Overall, there was a decline in lung function over time in our population (ppFEV₁ at 24 months pretransfer 77 ± 20%, ppFEV₁ at 24 months, posttransfer 66 ± 24%; P < .001). The relationship between BLSS and ppFEV₁ became more negative over time, even after adjusting for other covariates.

CONCLUSION

Social complexity is strongly associated with lung function decline after transfer to adult care.

When Adolescent and Parents Disagree on Medical Plan, Who Gets to Decide?

An adolescent with Duchenne Muscular Dystrophy wants a life-extending tracheostomy whereas parents do not want this for him.

Aligning use of intensive care with patient values in the USA: past, present, and future

For more than three decades, both medical professionals and the public have worried that many patients receive non-beneficial care in US intensive care units during their final months of life. Some of these patients wish to avoid severe cognitive and physical impairments, and protracted deaths in the hospital setting. Recognising when intensive care will not restore a person's health, and helping patients and families embrace goals related to symptom relief, interpersonal connection, or spiritual fulfilment are central challenges of critical care practice in the USA. We review trials from the past decade of interventions designed to address these challenges, and present reasons why evaluating, comparing, and implementing these interventions have been difficult. Careful scrutiny of the design and interpretation of past trials can show why improving goal concordant care has been so elusive, and suggest new directions for the next generation of research.

What Should We Learn From Early Hemodialysis Allocation About How We Should Be Using ECMO?

Early hemodialysis allocation deliberations should inform our current considerations of what constitutes reasonable uses of extracorporeal membrane oxygenation. Deliberative democracy can be used as a strategy to gather a plurality of views, consider criteria, and guide policy making.

Impact of social complexity on outcomes in cystic fibrosis after transfer to adult care

OBJECTIVE

This study evaluates the roles of medical and social complexity in health care use outcomes in cystic fibrosis (CF) after transfer from pediatric to adult care.

METHODS

Retrospective cohort design included patients with CF who were transitioned into adult care at Indiana University from 2005 to 2015. Predictor variables included demographic and comorbidity data, age at transition, treatment complexity score (TCS), and an objective scoring measure of their social complexity (Bob's Level of Social Support, BLSS). Outcome variables included outpatient visit rates and hospitalization rates. Pearson's correlations and linear regression were used to analyze the data.

RESULTS

The median age of the patients (N = 133) at the time of transition was 20 (IQR 19-23) years. The mean FEV₁ % predicted at transition was 69 ± 24%. TCS correlated with outpatient visit rates (r = 0.3, P = 0.003), as well as hospitalization rates (r = 0.4, P < 0.001); while the BLSS only correlated with hospitalization rates (r = 0.7, P < 0.001). After adjusting for covariates, the strongest predictors of post-transfer hospitalizations are BLSS (P < 0.0001) and pre-transfer hospitalization rate (P < 0.0001).

CONCLUSION

Greater treatment complexity is associated with greater healthcare utilization overall, while greater social complexity is associated with increased hospitalizations (but not outpatient visits). Screening young adults for social complexity may identify high-risk subpopulations and allow for patient centered interventions to support them and prevent avoidable health care use.

Resolving Family-Clinician Disputes in the Context of Contested Definitions of Futility

The word futile has been a touchstone in debates regarding resolution of disputes regarding life-prolonging treatments since the 1980s. Here, we respond to several criticisms of the Multiorganization Policy Statement, "An Official ATS/AACN/ACCP/ESICM/SCCM Policy Statement: Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units" (Bosslet et al. 2015). This response highlights the need for a strict definition of the word futile in order to avoid undue treatment differences when end-of-life interventions are contested. We also reply to several criticisms of this policy statement that are formulated upon fundamental misunderstandings of the statement and its assertions.

The Family Navigator: A Pilot Intervention to Support Intensive Care Unit Family Surrogates

BACKGROUND

Communication problems between family surrogates and intensive care unit (ICU) clinicians have been documented, but few interventions are effective. Nurses have the potential to play an expanded role in ICU communication and decision making.

OBJECTIVES

To conduct a pilot randomized controlled trial of the family navigator (FN), a distinct nursing role to address family members' unmet communication needs early in an ICU stay.

METHODS

An interprofessional team developed the FN protocol. A randomized controlled pilot intervention trial of the FN was performed in a tertiary referral hospital's ICU to test the feasibility and acceptability of the intervention. The intervention addressed informational and emotional communication needs through daily contact by using structured clinical updates, emotional and informational support modules, family meeting support, and follow-up phone calls.

RESULTS

Twenty-six surrogate/patient pairs (13 per study arm) were enrolled. Surrogates randomized to the intervention had contact with the FN on 90% or more of eligible patient days. All surrogates agreed that they would recom mend the FN to other families. Open-ended comments from both surrogates and clinicians were uniformly positive.

CONCLUSIONS

Having a fully integrated nurse empowered to facilitate decision making is a feasible intervention in an ICU and is well-received by ICU families and staff. A larger randomized controlled trial is needed to demonstrate impact on important outcomes, such as surrogates' well-being and decision quality.

The Effect of Paging Reminders on Fellowship Conference Attendance: A Multi-Program Randomized Crossover Study

BACKGROUND

Educational conferences have long served as a foundation of medical education. Sending reminder text pages prior to the start of conferences is a method that may be employed to enhance conference attendance.

OBJECTIVE

The goal of our study was to determine if routine text paging before regularly scheduled conferences improves attendance among fellows in 3 internal medicine programs.

METHODS

A prospective, randomized, crossover study included 3 fellowship programs: pulmonary and critical care, cardiovascular disease, and hematology-oncology. The study was performed between October 2014 and March 2015. All fellows were included and randomized to 1 of 2 groups (with subsequent crossover to opposite group): Pages or No Pages. Paging reminders, which included conference title, location, and time, were sent 30 minutes prior to every conference for those in the intervention arm. Attendance was collected through a standard attendance log using self-registration.

RESULTS

A total of 46 fellows and 156 conferences were included for analysis, with 75 during the first 3 months and 81 during the second 3 months. There were no differences in individual overall attendance between randomized groups for the entire study period (42.9% versus 46.5%, P = .46). Paging reminders had no effect on overall individual attendance (43.7% versus 45.6%, P = .50). In addition, no significant differences were identified for individuals within each fellowship and training year.

CONCLUSIONS

Paging reminders prior to a regularly scheduled conference had no effect on overall attendance in this study. Fellows reported that clinical obligations were a major barrier to conference attendance.

Smoking-Related Home Oxygen Burn Injuries: Continued Cause for Alarm

BACKGROUND

Home oxygen therapy is a mainstay of treatment for patients with various cardiopulmonary diseases. In spite of warnings against smoking while using home oxygen, many patients sustain burn injuries.

OBJECTIVES

We aimed to quantify the morbidity and mortality of such patients admitted to our regional burn unit over a 6-year period.

METHODS

A retrospective chart review of all patients admitted to a regional burn center from 2008 through 2013 was completed. Admitted patients sustaining burns secondary to smoking while using home oxygen therapy were selected as the study population to determine morbidity.

RESULTS

Fifty-five subjects were admitted to the burn unit for smoking-related home oxygen injuries. The age range was 40-84 years. Almost all subjects were on home oxygen for chronic obstructive pulmonary disease (96%). Seventy-two percent of burns involved <5% of the total body surface area, 51% of patients were intubated, and of those 33% had evidence of inhalation injury. The hospital mortality rate was 14.5%. The mean length of hospital stay was 8.6 days, and 54.5% were discharged to a nursing home or another advanced facility. Finally, concomitant substance abuse was found in 27%, and a previous history of injury from smoking while on home oxygen was discovered in 14.5%.

CONCLUSIONS

This single-center analysis is one of the largest describing burn injuries stemming from smoking while using home oxygen therapy. We identified the morbidity and mortality associated with these injuries. Ongoing education and careful consideration of prescribing home oxygen therapy for known smokers is highly encouraged.

The influence of the residency application process on the online social networking behavior of medical students: a single institutional study

PURPOSE

To evaluate medical students' behavior regarding online social networks (OSNs) in preparation for the residency matching process. The specific aims were to quantify the use of OSNs by students to determine whether and how these students were changing OSN profiles in preparation for the residency application process, and to determine attitudes toward residency directors using OSNs as a screening method to evaluate potential candidates.

METHOD

An e-mail survey was sent to 618 third- and fourth-year medical students at Indiana University School of Medicine over a three-week period in 2012. Statistical analysis was completed using nonparametric statistical tests.

RESULTS

Of the 30.1% (183/608) who responded to the survey, 98.9% (181/183) of students reported using OSNs. More than half, or 60.1% (110/183), reported that they would (or did) alter their OSN profile before residency matching. Respondents' opinions regarding the appropriateness of OSN screening by residency directors were mixed; however, most respondents did not feel that their online OSN profiles should be used in the residency application process.

CONCLUSIONS

The majority of respondents planned to (or did) alter their OSN profile in preparation for the residency match process. The majority believed that residency directors are screening OSN profiles during the matching process, although most did not believe their OSN profiles should be used in the residency application process. This study implies that the more medical students perceive that residency directors use social media in application screening processes, the more they will alter their online profiles to adapt to protect their professional persona.

The patient-doctor relationship and online social networks: results of a national survey

BACKGROUND

The use of online social networks (OSNs) among physicians and physicians-in-training, the extent of patient-doctor interactions within OSNs, and attitudes among these groups toward use of OSNs is not well described.

OBJECTIVE

To quantify the use of OSNs, patient interactions within OSNs, and attitudes toward OSNs among medical students (MS), resident physicians (RP), and practicing physicians (PP) in the United States.

DESIGN/SETTING

A random, stratified mail survey was sent to 1004 MS, 1004 RP, and 1004 PP between February and May 2010.

MEASUREMENTS

Percentage of respondents reporting OSN use, the nature and frequency of use; percentage of respondents reporting friend requests by patients or patients' family members, frequency of these requests, and whether or not they were accepted; attitudes toward physician use of OSNs and online patient interactions.

RESULTS

The overall response rate was 16.0% (19.8% MS, 14.3% RP, 14.1% PP). 93.5% of MS, 79.4% of RP, and 41.6% of PP reported usage of OSNs. PP were more likely to report having visited the profile of a patient or patient's family member (MS 2.3%, RP 3.9%, PP 15.5%), and were more likely to have received friend requests from patients or their family members (MS 1.2%, RP 7.8%, PP 34.5%). A majority did not think it ethically acceptable to interact with patients within OSNs for either social (68.3%) or patient-care (68.0%) reasons. Almost half of respondents (48.7%) were pessimistic about the potential for OSNs to improve patient-doctor communication, and a majority (79%) expressed concerns about maintaining patient confidentiality.

CONCLUSION

Personal OSN use among physicians and physicians-in-training mirrors that of the general population. Patient-doctor interactions take place within OSNs, and are more typically initiated by patients than by physicians or physicians-in-training. A majority of respondents view these online interactions as ethically problematic.

Parental procreative obligation and the categorisation of disease: the case of cystic fibrosis

The advent of prenatal genetic diagnosis has sparked debates among ethicists and philosophers regarding parental responsibility towards potential offspring. Some have attempted to place moral obligations on parents to not bring about children with certain diseases in order to prevent harm to such children. There has been no rigorous evaluation of cystic fibrosis in this context. This paper will demonstrate cystic fibrosis to have unique properties that make it difficult to categorize among other diseases with the goal of promulgating a reproductive rule. Once this is established, it will be demonstrated that procreative rules that appeal to future health are inadequate in the era of advancing genetic knowledge. Utilising a specification of Joel Feinberg's 'open future' concept outlined by Matteo Mameli, it will offer an analysis of parental obligation that does not constrain parents of potential children with cystic fibrosis with a moral obligation not to bring them about.

Nurse-administered propofol sedation: feasibility and safety in bronchoscopy

BACKGROUND

Propofol is a fast-acting intravenous sedative that has advantages as a procedural sedative over traditional regimens. It has been shown to have a similar safety profile to traditional sedating medications in the setting of gastroenterologic endoscopy. Nurse-administered propofol sedation is given by a specially-trained nurse, without anesthesiologist involvement.

OBJECTIVES

We have used nurse-administered propofol sedation in our bronchoscopy suite for several years. In this report, we summarize our experience with nurse-administered propofol sedation, and demonstrate it to be feasible and safe for bronchoscopic procedures.

METHODS

Procedure reports and nursing notes for 588 bronchoscopic procedures performed between July 2006 and June 2008 were retrospectively reviewed. Patient demographics, procedure type and indication, procedure time, medication doses, and adverse events were noted and analyzed.

RESULTS

Nurse-administered propofol sedation was used in 498/588 (85%) procedures. Patients utilizing nurse-administered propofol sedation had an average age of 53 years (range 18-86) with an average weight of 80 kg. 56% of the patients were male, and 57% of the procedures were performed on outpatients. Average procedure duration was 25 min (range 3-123). The average propofol dose was 3.13 mg/kg (range 0.12-20 mg/kg). Adverse events attributable to sedation were noted in 33 (6.6%) procedures. Of the 14 (2.8%) major adverse events (death, need for intubation, ICU stay, or hospitalization), only 6 (1.2%) were potentially attributable to the sedation regimen. There were 2 deaths, neither of which was related to sedation.

CONCLUSIONS

Nurse-administered propofol sedation is a feasible and safe sedation method for bronchoscopic procedures.