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Background: Conflict is inevitable on healthcare teams, yet few professional school curricula teach or assess conflict resolution skills. Little is known about the variation in conflict resolution styles across medical students and how these styles might impact conflict resolution skills.Methods: Graduating medical students completed a mandatory conflict resolution session with standardized patients acting as nurses during a transition to residency course. Coaches reviewed videotapes of simulated student-nurse encounters, focusing on students’ conflict resolution style (assessed with the Thomas-Kilman Instrument (TKI)) and student skills with negotiation and emotional intelligence. We also assessed the impact of knowing one’s conflict resolution style, student gender, race and intended field of practice on conflict resolution skills.Results: One hundred and eight students completed the simulated conflict session. Sixty-seven students completed the TKI before the simulated patient (SP) encounter and 41 after. The most common conflict resolution style was accommodating (n=40). Knowing one’s conflict resolution style in advance of the simulation and one’s identified race/ethnicity did not impact skill as assessed by faculty coaches. Students pursuing diagnosis-based specialties had higher negotiation (p=0.04) and emotional quotient (p=0.006) scores than those pursuing procedural specialties. Females had higher emotional quotient scores (p=0.02). Conclusions: Conflict resolution styles vary among medical students. Male gender and future practice in a procedural specialty impacted conflict resolution skills, but knowing conflict resolution style did not.

Purpose When the Centers for Medicare and Medicaid Services (CMS) changed policies about medical student documentation, students with proper supervision may now document their history, physical exam, and medical decision-making in the electronic health record (EHR) for billable encounters. Since documentation is a core entrustable professional activity for medical students, the authors sought to evaluate student opportunities for documentation and feedback across and between clerkships. Method In February 2018, a multidisciplinary workgroup was formed to implement student documentation at Duke University Health System, including educating trainees and supervisors, tracking EHR usage, and enforcing CMS compliance. From August 2017 to August 2018, locations and types of student-involved services (student-faculty, or student-resident-faculty) were tracked using billing data from attestation statements. Student end-of-clerkship evaluations included opportunity for documentation and receipt of feedback. Since documentation was not allowed prior to August 2018 it was not possible to compare to prior student experiences. Results In the first half of the academic year, 6,972 patient encounters were billed as student-involved services, 52% (n = 3,612) in the inpatient setting and 47% (n = 3,257) in the outpatient setting. Most (74%) of the inpatient encounters also involved residents and most (92%) of outpatient encounters were student-teaching physician only.Approximately 90% of students indicated having had opportunity to document in the EHR across clerkships, except for procedure-based clerkships such as surgery and obstetrics. Receipt of feedback was present along with opportunity for documentation more than 85% of the time on services using evaluation and management coding. Most students (>90%) viewed their documentation as having a moderate or high impact on patient care. Conclusions Changes to student documentation were successfully implemented and adopted; changes met both compliance and education needs within the health system without resulting in potential abuses of student work for service.

Background: After critical illness, new or worsening impairments in physical, cognitive, and/or mental health function are common among patients who have survived. Who should be screened for long-term impairments, what tools to use, and when remain unclear. Objectives: Provide pragmatic recommendations to clinicians caring for adult survivors of critical illness related to screening for postdischarge impairments. Participants: Thirty-one international experts in risk-stratification and assessment of survivors of critical illness, including practitioners involved in the Society of Critical Care Medicine’s Thrive Post-ICU Collaboratives, survivors of critical illness, and clinical researchers. Design: Society of Critical Care Medicine consensus conference on post-intensive care syndrome prediction and assessment, held in Dallas, in May 2019. A systematic search of PubMed and the Cochrane Library was conducted in 2018 and updated in 2019 to complete an original systematic review and to identify pre-existing systematic reviews. Meeting Outcomes: We concluded that existing tools are insufficient to reliably predict post-intensive care syndrome. We identified factors before (e.g., frailty, preexisting functional impairments), during (e.g., duration of delirium, sepsis, acute respiratory distress syndrome), and after (e.g., early symptoms of anxiety, depression, or post-traumatic stress disorder) critical illness that can be used to identify patients at high-risk for cognitive, mental health, and physical impairments after critical illness in whom screening is recommended. We recommend serial assessments, beginning within 2–4 weeks of hospital discharge, using the following screening tools: Montreal Cognitive Assessment test; Hospital Anxiety and Depression Scale; Impact of Event Scale-Revised (post-traumatic stress disorder); 6-minute walk; and/or the EuroQol-5D-5L, a health-related quality of life measure (physical function). Conclusions: Beginning with an assessment of a patient’s pre-ICU functional abilities at ICU admission, clinicians have a care coordination strategy to identify and manage impairments across the continuum. As hospital discharge approaches, clinicians should use brief, standardized assessments and compare these results to patient’s pre-ICU functional abilities (“functional reconciliation”). We recommend serial assessments for post-intensive care syndrome-related problems continue within 2–4 weeks of hospital discharge, be prioritized among high-risk patients, using the identified screening tools to prompt referrals for services and/or more detailed assessments.

Prerecorded video content in medical education has become more common. Increasingly accessible technology coupled with the COVID-19 pandemic and subsequent need for distanced learning has greatly increased the interest in and need for high-quality video content. The use of short educational videos to augment other teaching methods has been shown to improve learners' experiences, knowledge retention, and understanding of content. Multiple studies have demonstrated that video education can be a highly effective tool for learning, particularly for hard-to-visualize processes and for procedural education. Videos allow learners to view content at their own pace and revisit materials on demand. In addition, well-designed videos can be repurposed by educators, ultimately reducing time needed to create high-quality educational content. Currently available technology allows educators to create high-quality videos at minimal cost and with a modest investment of time. This article details practical tips for creating high-yield educational videos.

Background Observation of student skills is essential for accurate assessment of entrustment and competence. Time spent directly observing students in patient care must balance with the need to serve adequate numbers of patients and, in some instances, revenue generation. Clinical education may also be hampered by a negative learning climate. The authors created a Direct Observation Clinical Experience with feedback iN real Time (DOCENT) clinic with patients from the Emergency Department (ED) to provide care for low-acuity patients while observing student care to determine the best location for the clinic and interprofessional education opportunities. Methods Patient number, chief complaints, estimated severity of illness (ESI), and use of radiology resources were logged. ESI, length of stay (LOS), and satisfaction were monitored for non-inferiority to ED patients. Student evaluations collected information on amount of direct observation, quality of feedback, learning climate and both peer-to-peer and interprofessional teaching. Results Musculoskeletal (MSK) complaints were the most common category of complaints. Patient LOS in DOCENT was shorter than for ED patients (mean 4.5 vs. 6.4 hours, p

Background Clinical education across the professions is challenged by a lack of recognition for faculty and pressure for patient throughput and revenue generation. These pressures may reduce direct observation of patient care provided by students, a requirement for both billing student-involved services and assessing competence. These same pressures may also limit opportunities for interprofessional education and collaboration. Methods An interprofessional group of faculty collaborated in a sequential quality improvement project to identify the best patients and physical location for a student teaching clinic. Patient chief complaint, use of resources, length of stay, estimated severity of illness and student participation and evaluation of the clinic was tracked. Results Clinic Optimization and Patient Care: Five hundred and thirty-two emergency department (ED) patients were seen in the first 19 months of the clinic. A clinic located near the ED allowed for patients with higher emergency severity index and greater utilization of imaging. Patients had similar or lower lengths of stay and higher satisfaction than patients who remained in the ED (p Student Interprofessional Experience: A total of 991 students participated in the clinic: 68.3% (n = 677) medical students, 10.1% (n = 100) physician assistant students, 9.7% (n = 96) undergraduate nursing students, 9.1% (n = 90) physical therapy students, and 2.8% (n = 28) nurse practitioner students. The majority (74.5%, n = 738) of student participants worked with students from other professions. More than 90% of students reported that faculty set a positive learning environment respectful of students. However, 20% of students reported that faculty could improve provision of constructive feedback. Direct Observation: Direct observation of core entrustable professional activities for medical students was possible. Senior medical students were more likely to be observed generating a differential diagnosis or management plan than first year medical students. Conclusions Creation of a DOCENT clinic in the emergency department provided opportunities for interprofessional education and observation of student clinical skills, enriching student experience without compromising patient care.

Purpose The Accreditation Council for Graduate Medical Education (ACGME) milestones were implemented across medical subspecialties in 2015. Although milestones were proposed as a longitudinal assessment tool potentially providing opportunities for early implementation of individualized learning plans in fellowship, the association of subspecialty fellowship ratings with prior residency ratings remains unclear. This study aimed to assess the relationship between internal medicine (IM) residency milestones and pulmonary-critical care medicine (PCCM) fellowship milestones. Method A multicenter retrospective cohort analysis was conducted for all PCCM trainees enrolled in ACGME-accredited PCCM fellowship programs in 2017-2018 who had complete prior IM milestone ratings from 2014-2017. Only professionalism and interpersonal and communication skills (ICS) were included based on shared anchors between IM and PCCM milestones. Using a generalized estimating equations model, the association of PCCM milestones ≤ 2.5 during the first year of fellowship with corresponding IM subcompetencies was assessed at each time-point, nested by program. Statistical significance was determined using logistic regression. Results The study included 354 unique PCCM fellows. For both ICS and professionalism subcompetencies, fellows with higher IM ratings were less likely to obtain PCCM ratings ≤ 2.5 during the first fellowship year. Each ICS subcompetency was significantly associated with future lapses in fellowship (ICS01: β = -0.67, P = 0.003; ICS02: β = -0.70, P = 0.001; ICS03: β = -0.60, P = 0.004) at various residency timepoints. Similar associations were noted for PROF03 (β = -0.57, P = 0.007). Conclusions Findings demonstrated an association between IM milestone ratings and low milestone ratings during PCCM fellowship. IM trainees with low ratings in several professionalism and ICS subcompetencies were more likely to be rated ≤ 2.5 during their first year in PCCM fellowship. This highlights a potential use of longitudinal milestones to target educational gaps at the beginning of PCCM fellowship.

Introduction The AAMC has recognized the importance of effective teamwork and collaboration. One core Entrustable Professional Activity emphasizes creating a climate of mutual respect and trust and prioritizing team needs over personal needs, which leads to safe, timely, effective, efficient, and equitable patient care. Relationship conflicts, specifically, are associated with decreased productivity, complex information processing, and work satisfaction. Given the prevalence of conflict and its impact on health care workers, the lack of conflict resolution curricula in undergraduate medical education is surprising. We developed a curriculum formally introducing these skills and allowing practice in a simulated environment before students entered residency. Methods Fourth-year medical students completed a conflict resolution exercise in a mandatory transition-to-residency course. Students completed online prework including reflection on teamwork and information on conflict resolution styles, participated in a simulated conflict with a standardized patient acting as a nurse, and afterward completed a self-evaluation with video review by the students' assigned coach and feedback on the session. Results We collected complete responses from 108 students. We evaluated the curriculum for feasibility and acceptability by faculty and students. Most students agreed with faculty on their entrustment and milestone levels. Students found that the session prompted self-reflection and was a good review of conflict resolution. The standardized patient and faculty feedback was found to be the most useful by the students. Discussion We successfully implemented a simulated but realistic conflict resolution exercise. Students found the exercise helpful in their preparation for residency.

Problem Many medical schools now incorporate meaningful clinical experiences for first-year medical students (MS1s). However, these clinical placements often fail to teach components of the physician experience, including health care logistics, cost-conscious care, longitudinal patient care, and interaction with an interprofessional team. The Duke Hotspotting Initiative (DHSI) is a student-led elective longitudinal experience for MS1s to serve as a patient's health care liaison to encourage proactive health management and efficient use of resources. Approach DHSI is a combined didactic-clinical experience at Duke University School of Medicine. Students complete a didactic curriculum to develop relevant skills and maintain weekly contact with a patient in Durham, North Carolina, for the duration of the academic year. In their meetings with patients, students help them set and monitor health goals, identify and address barriers to health resources, and efficiently access primary care. Across 2 academic years (2017-2018 and 2018-2019), 54 MS1s were surveyed electronically before and after their participation in DHSI. They were asked about their comfort navigating various patient management scenarios, using communication tools, and assuming clinical responsibilities. Outcomes DHSI offers MS1s a unique immersive opportunity to gain experience applying the clinical skills they will need in their future careers. Based on comparisons of responses from the 48 students (89%) who completed the pre-DHSI survey and 40 students (74%) who completed the post-DHSI survey, there was a significant increase in comfort with communication and patient advising, managing common chronic diseases, using interview skills, and assuming clinical responsibilities. Next steps DHSI continues to expand in both size and scope, with the goal of incorporating team members from other health professions training programs at multiple institutions. Future analysis will investigate the longer-term impact of the program on students' professional development, objective changes in clinical skills, and outcomes for patients involved with DHSI.

BACKGROUND Resident physicians at teaching hospitals write many discharge summaries (DCSs), but receive little formal training or feedback. Poor DCS quality poses a potential patient safety risk. METHODS We developed a curriculum to train fourth-year medical students (MS4s) how to write DCSs and integrated this curriculum into a transition-to-residency course. An inpatient attending physician (IPA) and non-inpatient physician (coach) used structured tools to assess for the presence of key elements within the DCS, evaluate the overall quality of the DCS, and judge the student's progression towards entrustable professional activities and transitional year milestones. We identified overall areas of weakness and correlated scores between IPAs and coaches. Improvements in student knowledge and DCS writing confidence were determined using pre- and post-curriculum surveys. RESULTS Of 102 eligible students, 78 completed the assignment, 61 wrote a new DCS and 17 reviewed previously written DCSs. Patient condition at discharge was missing in more than 20.0% of DCSs. Coaches were less likely than IPAs to assess students as entrustable (58.3% versus 95.8%; p = 0.0027). IPAs assigned higher overall quality ratings than coaches (8.0 versus 6.0 out of 10.0, p< 0.0001). Post-intervention, 82.2% of students reported they learned how to write high-quality DCSs and 93.3% of students reported they would change the way they write DCSs. CONCLUSIONS Graduating medical students have limited skill and comfort in writing DCSs. Structured training on how to write DCSs before postgraduate residency training is a key step towards ultimately improving transitions of care. Training should teach learners to write high-quality DCSs that serve the needs of both inpatient and outpatient providers. Resident physicians at teaching hospitals are expected to independently author [discharge summaries] DCSs, yet few receive formal training.

Health systems, granting agencies, and professional societies are increasingly involving patients and their family members in the delivery of health care and the improvement of health sciences. This is a laudable advance toward fully patient-centered medicine. However, patient engagement is not a simple matter, either practically or ethically. The complexities include (1) the physical limitations that patients and their family members may have, from traveling to meetings to special dietary needs; (2) the emotional sensitivities patients and their families might experience-from distress at discussions of disease prognosis, outcomes, and therapies to being inexperienced at public speaking; and (3) the fact that advocacy efforts by patients and family members, which may be encouraged at the national level, may threaten individual professionals providing care to individual patients and may result in risk to patients. In this article, a patient-physician and patient-bioethicist set out the obstacles, including ones that they have encountered in their own advocacy efforts. The aim is to survey the practical and ethical landscape so that solutions to various problems may be identified and solved as we move forward in our efforts to involve patients and their families in research, policy, and quality improvement in critical care medicine.

Academic physicians encounter many demands on their time including patient care, quality and performance requirements, research, and education. In an era when patient volume is prioritized and competition for research funding is intense, there is a risk that medical education will become marginalized. Bedside teaching, a responsibility of academic physicians regardless of professional track, is challenged in particular out of concern that it generates inefficiency, and distractions from direct patient care, and can distort physician-patient relationships. At the same time, the bedside is a powerful location for teaching as learners more easily engage with educational content when they can directly see its practical relevance for patient care. Also, bedside teaching enables patients and family members to engage directly in the educational process. Successful bedside teaching can be aided by consideration of four factors: climate, attention, reasoning, and evaluation. Creating a safe environment for learning and patient care is essential. We recommend that educators set expectations about use of medical jargon and engagement of the patient and family before they enter the patient room with trainees. Keep learners focused by asking relevant questions of all members of the team and by maintaining a collective leadership style. Assess and model clinical reasoning through a hypothesis-driven approach that explores the rationale for clinical decisions. Focused, specific, real-time feedback is essential for the learner to modify behaviors for future patient encounters. Together, these strategies may alleviate challenges associated with bedside teaching and ensure it remains a part of physician practice in academic medicine.

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.

Background Undergraduate medical education (UME) follows the lead of graduate medical education (GME) in moving to competency-based assessment. The means for and the timing of competency-based assessments in UME are unclear. Objective We explored the feasibility of using the Accreditation Council for Graduate Medical Education Transitional Year (TY) Milestones to assess student performance during a mandatory, fourth-year capstone course. Methods Our single institution, observational study involved 99 medical students who completed the course in the spring of 2014. Students' skills were assessed by self, peer, and faculty assessment for 6 existing course activities using the TY Milestones. Evaluation completion rates and mean scores were calculated. Results Students' mean milestone levels ranged between 2.2 and 3.6 (on a 5-level scoring rubric). Level 3 is the performance expected at the completion of a TY. Students performed highest in breaking bad news and developing a quality improvement project, and lowest in developing a learning plan, working in interdisciplinary teams, and stabilizing acutely ill patients. Evaluation completion rates were low for some evaluations, and precluded use of the data for assessing student performance in the capstone course. Students were less likely to complete separate online evaluations. Faculty were less likely to complete evaluations when activities did not include dedicated time for evaluations. Conclusions Assessment of student competence on 9 TY Milestones during a capstone course was useful, but achieving acceptable evaluation completion rates was challenging. Modifications are necessary if milestone scores from a capstone are intended to be used as a handoff between UME and GME.

Problem Interprofessional curricula on patient safety do not acknowledge the culture and vulnerabilities of the student experience and often do not engage students. Methods We describe a patient safety collaboration between graduating nursing and medical students during their Capstone courses that fostered conversations about the similarities and differences in professional school experiences around patient safety. Students wrote reflections about an unanticipated patient outcome. Qualitative content analysis was used to characterize themes within student reflections, and to create audience response system questions to highlight differences in each profession's reflections and to facilitate discussion about those differences during the collaboration. Findings Medical students identified events in which perceived patient outcomes were worse than events identified by nursing students. Nursing students identified more near-miss events. Nursing students positively impacted the event and attributed action to the presence of a clinical instructor and personal responsibility for patient care. Medical students described themselves as "only a witness" and attributed inaction to hierarchy and concern about grades. Conclusions Students felt the session would change their future attitudes and behaviors. Stevenson Chudgar Molloy Phillips Engle Clay.

Background Although many Americans utilize complementary and alternative medicine (CAM) services and products, few medical school curricula consistently provide instruction in counseling patients on the use of CAM or strategies for identifying credible evidence on the safety and effectiveness of CAM therapies. Methods This is a mixed methods study. A sustainable, mandatory, half-day CAM immersion curriculum for graduating medical students is described. Student comfort talking with patients about CAM, their willingness to refer patients to a CAM provider, and adequacy of the CAM curriculum was assessed. Results Students who participated in this mandatory curriculum, rated the medical school curriculum in CAM as more adequate than students at other medical schools without a mandatory curriculum. Students' narrative comments indicate the curriculum impacts students knowledge about CAM, patient use of CAM, and personal practice with CAM in the future. Conclusions The timing of the CAM curriculum near to graduation, students' personal exploration of several CAM modalities through immersion, and student interaction with community CAM providers are aspects of the curriculum that make the curriculum successful and memorable.

Objectives To determine the emotional responses to patient care activities described by fourth year medical students. Methods Qualitative content analysis for emerging themes in letters written by graduating medical students to patients during a Capstone Course. The patient need not be alive and the letter would never be sent. Results Six themes emerged from student letters: (1) Sorrow for the depths of patient suffering; (2) Gratitude towards patients and their families; (3) Personal responsibility for care provided to patients; (4) Regret for poor care provided by the student or student's team; (5) Shattered expectations about medicine and training; and (6) Anger towards patients. Students expressed sensitivity to vulnerable patients, including those who were alone, unable to communicate, or for whom care was biased. Students’ expressed powerlessness (inability to cure, managing a work–life balance, and challenges with hierarchy) in some essays. Conclusion At graduation, medical students describe strong emotions about previous patient care experiences, including difficulty witnessing suffering, disappointment with medicine, and gratitude to patients and their families Practice implications Providing regular opportunities for writing throughout medical education would allow students to recognize their emotions, reflect upon them and promote wellness that would benefit students and their patients.

Background: Interprofessional education (IPE) is a “core” competency in professional school education. Challenges to successful collaboration include: aligning student abilities/experience, providing meaningful clinically-based interaction, and the need for extensive planning. Methods: Curriculum. A 3-1/2 hour IPE patient safety experience for final-semester medical and nursing students was developed. The content included an introduction, small-group low-fidelity simulation, and a large-group discussion of patient safety events observed by students during clinical rotations. Logistics. A planning committee met monthly to plan the curriculum and train faculty facilitators. Four sessions were held, accommodating 92 medical and 82 nursing students. Thirty faculty facilitators and 10 support personnel were needed for each session. Results: Over 70% students reported that the experience resulted in new learning and prompted self-reflection; 57% said it would change their practice. Students confirmed that the experience taught them about the importance of patient involvement in the team, the development of a shared mental model, and the importance of everyone’s role on the team. Conclusions: This collaboration successfully aligned students with similar levels of clinical experience, involved many faculty from both professional schools, and gave students opportunities to discuss differences in their roles and responsibilities, while highlighting patient-centered care.

Care in the hospital is hazardous. Harm in the hospital may prolong hospitalization, increase suffering, result in death, and increase costs of care. Although the interprofessional team is critical to eliminating hazards that may result in adverse events to patients, professional students' formal education may not prepare them adequately for this role.To determine if medical and nursing students can identify hazards of hospitalization that could result in harm to patients and to detect differences between professions in the types of hazards identified.Mixed-methods observational study of graduating nursing (n = 51) and medical (n = 93) students who completed two "Room of Horrors" simulations to identify patient safety hazards. Qualitative analysis was used to extract themes from students' written hazard descriptions. Fisher's exact test was used to determine differences in frequency of hazards identified between groups.Identification of hazards by students was low: 66% did not identify missing personal protective equipment for a patient on contact isolation, and 58% did not identify a medication administration error (medication hanging for a patient with similar name). Interprofessional differences existed in how hazards were identified: medical students noted that restraints were not indicated (73 vs. 2%, P 0.001), whereas nursing students noted that there was no order for the restraints (58.5 vs. 0%, P 0.0001). Nursing students discovered more issues with malfunctioning or incorrectly used equipment than medical students. Teams performed better than individuals, especially for hazards in the second simulation that were similar to those in the first: need to replace a central line with erythema (73% teams identified) versus need to replace a peripheral intravenous line (10% individuals, P 0.0001). Nevertheless, teams of students missed many intensive care unit-specific hazards: 54% failed to identify the presence of pressure ulcers; 85% did not notice high tidal volumes on the ventilator; and 90% did not identify the absence of missing spontaneous awakening/breathing trials and absent stress ulcer prophylaxis.Graduating nursing and medical students missed several hazards of hospitalization, especially those related to the intensive care unit. Orientation for residents and new nurses should include education on hospitalization hazards. Ideally, this orientation should be interprofessional to allow appreciation for each other's roles and responsibilities.

Despite the importance of self-directed learning (SDL) in the field of medicine, individuals are rarely taught how to perform SDL or receive feedback on it. Trainee skill in SDL is limited by difficulties with self-assessment and goal setting.Ninety-two graduating fourth-year medical students from Duke University School of Medicine completed an individualized learning plan (ILP) for a transition-to-residency Capstone course in spring 2015 to help foster their skills in SDL. Students completed the ILP after receiving a personalized report from a designated faculty coach detailing strengths and weaknesses on specific topics (e.g., pulmonary medicine) and clinical skills (e.g., generating a differential diagnosis). These were determined by their performance on 12 Capstone Problem Sets of the Week (CaPOWs) compared with their peers. Students used transitional-year milestones to self-assess their confidence in SDL.SDL was successfully implemented in a Capstone course through the development of required clinically oriented problem sets. Coaches provided guided feedback on students' performance to help them identify knowledge deficits. Students' self-assessment of their confidence in SDL increased following course completion. However, students often chose Capstone didactic sessions according to factors other than their CaPOW performance, including perceived relevance to planned specialty and session timing.Future Capstone curriculum changes may further enhance SDL skills of graduating students. Students will receive increased formative feedback on their CaPOW performance and be incentivized to attend sessions in areas of personal weakness.

Numerous accrediting organizations are calling for competency-based medical education that would help define specific specialties and serve as a foundation for ongoing assessment throughout a practitioner's career. Pulmonary Medicine and Critical Care Medicine are two distinct subspecialties, yet many individual physicians have expertise in both because of overlapping content. Establishing specific competencies for these subspecialties identifies educational goals for trainees and guides practitioners through their lifelong learning.To define specific competencies for graduates of fellowships in Pulmonary Medicine and Internal Medicine-based Critical Care.A Task Force composed of representatives from key stakeholder societies convened to identify and define specific competencies for both disciplines. Beginning with a detailed list of existing competencies from diverse sources, the Task Force categorized each item into one of six core competency headings. Each individual item was reviewed by committee members individually, in group meetings, and conference calls. Nominal group methods were used for most items to retain the views and opinions of the minority perspective. Controversial items underwent additional whole group discussions with iterative modified-Delphi techniques. Consensus was ultimately determined by a simple majority vote.The Task Force identified and defined 327 specific competencies for Internal Medicine-based Critical Care and 276 for Pulmonary Medicine, each with a designation as either: (1) relevant, but competency is not essential or (2) competency essential to the specialty.Specific competencies in Pulmonary and Critical Care Medicine can be identified and defined using a multisociety collaborative approach. These recommendations serve as a starting point and set the stage for future modification to facilitate maximum quality of care as the specialties evolve.

Total parenteral nutrition (TPN) offers a method for ensuring adequate nutritional intake in patients whose eating is compromised; for reasons related to treatment side effects and their disease itself, end-stage cancer patients comprise a significant proportion of patients on TPN. In patients with advanced life-limiting cancer, at or near the end of life, the benefit of TPN is unclear. Conflicting research evidence spanning several decades both supports and refutes the use of TPN. In this paper, we suggest one approach to TPN at the end of life, acknowledging that there are many unresolved medical, ethical, and moral issues surrounding the use of TPN in palliative/end-of-life patients. We encourage the field of palliative medicine to use the TPN controversy as a forum in which to discuss the challenges of applying evidence-based practice principles to palliative medicine.

Patients experiencing acute elevations of ammonia present to the ICU with encephalopathy, which may progress quickly to cerebral herniation. Patient survival requires immediate treatment of intracerebral hypertension and the reduction of ammonia levels. When hyperammonemia is not thought to be the result of liver failure, treatment for an occult disorder of metabolism must begin prior to the confirmation of an etiology. This article reviews ammonia metabolism, the effects of ammonia on the brain, the causes of hyperammonemia, and the diagnosis of inborn errors of metabolism in adult patients.

This article illustrates the creation of a specialty specific portfolio that can be used by several different residency programs to document resident competence during a given rotation.Three different disciplines (anesthesiology, surgery and medicine) worked together to create a critical care medicine portfolio. We began by reviewing the curriculum requirements for critical care medicine and organized these requirements into the six ACGME core competencies. We then developed learner led exercises in each core competency that were specific to critical care. Each exercise includes assessment of resident knowledge and application, an evaluation of the exercise, a learner self-assessment of skill, and a review of performance by a faculty member. Portfolio entries are highlighted in a multi-disciplinary weekly conference and posted on a critical care web site at our University.Creation of specialty specific portfolio reduces redundancy between disciplines, allows for increased time to be spent on the development of exercises specific to rotation objectives, and aids program directors in the collection of portfolio entries for each resident over the course of a residency.

Introduction The emotional and psychological costs of frontline medicine can be profound. This small-group session uses letters written by practicing physicians to prepare rising first-year residents to examine the toll of medical mistakes, problems in hierarchy, witnessing tragedy, and other issues. Methods This workshop is a 2-hour small-group discussion session led by faculty. Students participate in groups of about eight students with one faculty facilitator per group. Students have 15 minutes to write to a patient about an unresolved issue. They then share either their letter or a sample letter written by another physician. The group discusses the impacts these events have on the students as providers and ways to appropriately deal with emotions without putting themselves at risk for burnout. Results Students were required to complete an anonymous evaluation within 48 hours of the completion of the exercise. We report evaluation data from 96 students who participated in this workshop in 2014. More than 90% thought the session should be mandatory the following year, and over 80% stated that it resulted in significant individual reflection. Comments from students indicated that the session normalized their experiences and allowed them to move forward as they were starting their residency. Discussion We have implemented this session for the past 8 years at the Duke University School of Medicine with graduating fourth-year medical students. Themes frequently encountered in students' letters include regret for care provided, the difficulty students have in witnessing suffering, and gratitude towards patients and their families for the learning experiences.

Errors can happen in the most accomplished of systems, and healthcare providers need a better understanding of what effect these errors have on patients, what we must do to respond to errors, and what we can do to prevent them. The authors describe a medical error from the perspectives of both physician-patient and physician-friend, identifying key “lessons learned” and strategies for preventing similar errors from occurring in other healthcare settings.

(CHEST 2005; 128:1028–1031) A 50-year-old, white woman presented with a 5-month history of failure to thrive and hoarseness. The patient described a progressive decline in her voice, resulting in inability to speak. Concurrently, dysphagia, nausea, and alternating episodes of diarrhea and constipation developed, which resulted in the loss of 35 lb. Vertigo and dizziness became so severe that the patient was eventually unable to stand without falling. She also described headaches, anxiety attacks, an inability to move her eyes, and loss of visual acuity. The patient presented to an outside hospital where otolaryngologic evaluation revealed bilateral vocal cord paralysis. The patient underwent tracheostomy, and a gastrostomy tube was placed for severe weight loss. The patient was transferred to our institution for further evaluation. During the 4 years prior to her hospitalization, the patient had been seen for multiple somatic and psychiatric complaints, including paresthesias, intermittent vertigo, anxiety, and depression. Based on serologic markers and the presence of mediastinal adenopathy on chest radiography, the patient received a diagnosis of sarcoidosis and/or lupus. The patient’s other medical history was significant for congestive heart failure, hypertension, and gastroesophageal reflux disease. The patient had a 100-pack-year history of tobacco use. She had no occupational exposures or pets. The patient’s family history was remarkable for a mother with breast cancer and a grandfather with colon cancer. On physical examination, the patient’s supine BP was 114/74 mm Hg with a pulse of 74 beats/min. Her upright BP was 90/62 mm Hg, with a pulse rate of 85 beats/min. Her temperature was 37.2°C, respiratory rate was 16 breaths/min, and oxygen saturation was 92% on 1Lo foxygen. Generally, the patient appeared cachectic, chronically ill, and older than her stated age. The pupils were accommodating but nearly unreactive to light. There were three to four beats of vertical nystagmus. The patient had marked temporal wasting and tongue fasciculations. There were no oral lesions or cervical, occipital, or supraclavicular lymphadenopathy. A tracheostomy was in place. The lung fields had poor air exchange, and occasional wheezes were heard. The heart examination revealed regular rate and rhythm without murmurs, rubs, or gallops. The abdomen was remarkable for the presence of a gastrostomy tube and was diffusely tender and slightly distended without hepatomegaly. Neurologic examination was remarkable for global proximal muscle weakness (4/5) and pathologically brisk patellar, biceps, and brachioradialis reflexes. The patient had mild dysmetria. She had normal tone, normal sensation to pin prick, and down-going toes bilaterally. Laboratory examination revealed a hemoglobin of 9.9 g/dL (normal range, 12.0 to 15.5 g/dL), mean cell volume of 100 femtoliters (normal, 80 to 98 femto

Resident physicians play an essential role as teachers, but time to learn to teach effectively during residency is limited. Targeted education prior to beginning residency may help combat this problem. We successfully implemented a highly rated Effective Clinical Teaching course for graduating medical students that improved confidence in teaching skills.

The clinical spectrum of mitochondrial diseases has expanded dramatically in the last decade. Abnormalities of mitochondrial function are now thought to participate in a number of common adult diseases, ranging from exercise intolerance to aging. This review outlines the common presentations of mitochondrial disease in ICUs and in the outpatient setting and discusses current diagnostic and therapeutic options as they pertain to the pulmonary and critical-care physician.

A 55-year-old man with diabetes mellitus was in his usual state of health until the day before admission, when he experienced severe abdominal pain that was relieved by a bowel movement several hours later. The following day, he developed excruciating right hip pain while driving. He presented to an emergency department with a temperature of 40°C (104°F) and no focal signs. He was given a dose of IV ceftriaxone. The patient was transferred to our institution for further care. The patient denied trauma to the extremity, fevers, chills, or numbness or tingling in his extremities. His medical history was significant for chronic renal insufficiency (baseline creatinine, 2.5 mg/dL) due to his type II diabetes, previous osteomyelitis, hypertension, and peripheral vascular disease with a past revascularization of the right leg.

Background: Growing numbers of critically ill patients receive prolonged mechanical ventilation. Little is known about the patterns of care as patients transition from acute care hospitals to postacute care facilities or about the associated resource utilization. Objective: To describe 1-year trajectories of care and resource utilization for patients receiving prolonged mechanical ventilation. Design: 1-year prospective cohort study. Setting: 5 intensive care units at Duke University Medical Center, Durham, North Carolina. Participants: 126 patients receiving prolonged mechanical ventilation (defined as ventilation for ≥4 days with tracheostomy placement or ventilation for ≥21 days without tracheostomy), as well as their 126 surrogates and 54 intensive care unit physicians, enrolled consecutively over 1 year. Measurements: Patients and surrogates were interviewed in the hospital, as well as 3 and 12 months after discharge, to determine patient survival, functional status, and facility type and duration of postdischarge care. Physicians were interviewed in the hospital to elicit prognoses. Institutional billing records were used to assign costs for acute care, outpatient care, and interfacility transportation. Medicare claims data were used to assign costs for postacute care. Results: 103 (82%) hospital survivors had 457 separate transitions in postdischarge care location (median, 4 transitions [interquartile range, 3 to 5 transitions]), including 68 patients (67%) who were readmitted at least once. Patients spent an average of 74% (95% CI, 68% to 80%) of all days alive in a hospital or postacute care facility or receiving home health care. At 1 year, 11 patients (9%) had a good outcome (alive with no functional dependency), 33 (26%) had a fair outcome (alive with moderate dependency), and 82 (65%) had a poor outcome (either alive with complete functional dependency [4 patients; 21 %] or dead [56 patients; 44%]). Patients with poor outcomes were older, had more comorbid conditions, and were more frequently discharged to a postacute care facility than patients with either fair or good outcomes (P < 0.05 for all). The mean cost per patient was $306 135 (SD, $285 467), and total cohort cost was $38.1 million, for an estimated $3.5 million per independently functioning survivor at 1 year. Limitation: The results of this single-center study may not be applicable to other centers. Conclusion: Patients receiving prolonged mechanical ventilation have multiple transitions of care, resulting in substantial health care costs and persistent, profound disability. The optimism of surrogate decision makers should be balanced by discussions of these outcomes when considering a course of prolonged life support. Primary Funding Source: None.

Objective To characterize the effects of critical illness in the daily lives and functioning of acute respiratory distress syndrome survivors. Survivors of acute respiratory distress syndrome, a systemic critical illness, often report poor quality of life based on responses to standardized questionnaires. However, the experiences of acute respiratory distress syndrome survivors have not been reported. Design We conducted semistructured interviews with 23 acute respiratory distress syndrome survivors and 24 caregivers 3 to 9 mos after intensive care unit admission, stopping enrollment after thematic saturation was reached. Transcripts were analyzed, using Colaizzi's qualitative methodology, to identify significant ways in which survivors' critical illness experience impacted their lives. Setting Medical and surgical intensive care units of an academic medical center and a community hospital. Patients We recruited consecutively 31 acute respiratory distress syndrome survivors and their informal caregivers. Eight patients died before completing interviews. Interventions None. Measurements and main results Participants related five key elements of experience as survivors of acute respiratory distress syndrome: 1) pervasive memories of critical care; 2) day-to-day impact of new disability; 3) critical illness defining the sense of self; 4) relationship strain and change; and 5) ability to cope with disability. Survivors described remarkable disability that persisted for months. Caregivers' interviews revealed substantial strain from caregiving responsibilities as well as frequent symptom minimization by patients. Conclusions The diverse and unique experiences of acute respiratory distress syndrome survivors reflect the global impact of severe critical illness. We have identified symptom domains important to acute respiratory distress syndrome patients who are not well represented in existing health outcomes measures. These insights may aid the development of targeted interventions to enhance recovery and return of function after acute respiratory distress syndrome.

To compare prolonged mechanical ventilation decision-makers' expectations for long-term patient outcomes with prospectively observed outcomes and to characterize important elements of the surrogate-physician interaction surrounding prolonged mechanical ventilation provision. Prolonged mechanical ventilation provision is increasing markedly despite poor patient outcomes. Misunderstanding prognosis in the prolonged mechanical ventilation decision-making process could provide an explanation for this phenomenon.Prospective observational cohort study.Academic medical center.A total of 126 patients receiving prolonged mechanical ventilation.None.Participants were interviewed at the time of tracheostomy placement about their expectations for 1-yr patient survival, functional status, and quality of life. These expectations were then compared with observed 1-yr outcomes measured with validated questionnaires. The 1-yr follow-up was 100%, with the exception of patient death or cognitive inability to complete interviews. At 1 yr, only 11 patients (9%) were alive and independent of major functional status limitations. Most surrogates reported high baseline expectations for 1-yr patient survival (n = 117, 93%), functional status (n = 90, 71%), and quality of life (n = 105, 83%). In contrast, fewer physicians described high expectations for survival (n = 54, 43%), functional status (n = 7, 6%), and quality of life (n = 5, 4%). Surrogate-physician pair concordance in expectations was poor (all kappa =0.08), as was their accuracy in outcome prediction (range = 23%-44%). Just 33 surrogates (26%) reported that physicians discussed what to expect for patients' likely future survival, general health, and caregiving needs.One-year patient outcomes for prolonged mechanical ventilation patients were significantly worse than expected by patients' surrogates and physicians. Lack of prognostication about outcomes, discordance between surrogates and physicians about potential outcomes, and surrogates' unreasonably optimistic expectations seem to be potentially modifiable deficiencies in surrogate-physician interactions.

Objective To determine the impact of the Accreditation Council for Graduate Medical Education mandates for duty hours and competencies on instruction, evaluation, and patient care in intensive care units in the United States. Design A Web-based survey was designed to determine the current methods of teaching and evaluation in the intensive care unit, barriers to changing methods of teaching and evaluation, and the impact of Accreditation Council for Graduate Medical Education regulations on teaching and patient care. Setting An anonymous Web-based survey was used; cumulative data were analyzed. Subjects A total of 125 of 380 program directors (33%) for pediatric critical care, pulmonary critical care, anesthesiology critical care, and surgery critical care fellowship programs completed questionnaires. Measurements and main results Bedside case-based teaching and standardized lectures are the most common methods of education in the intensive care unit. Patient safety and resident demands are two factors most likely to result in changes in instruction in the intensive care unit. Barriers to changes in education include clinical workload and lack of protected time and funding. Younger respondents viewed influences to change differently than older respondents. Respondents felt that neither education nor patient care had improved as a result of the Accreditation Council for Graduate Medical Education mandates. Conclusions Medical education teaching methods and assessment in the intensive care unit have changed little since the initiation of the Accreditation Council for Graduate Medical Education regulations despite respondents' self-report of a willingness to change. Instead, the Accreditation Council for Graduate Medical Education regulations are thought to have negatively impacted resident attitudes, continuity of care, and even availability for teaching. These concerns, coupled with lack of protected time and funding, serve as barriers toward changes in critical care graduate medical education.

High practice variability in critical care medicine contributes to medical errors and the high cost of ICU care. Clinical guidelines and protocol-based strategies can reduce the variation and cost of ICU medicine, increase adherence to evidence-based interventions, and reduce error, thereby improving the morbidity and mortality of critically ill patients. There are various barriers to guideline adherence, and protocols often are more successful when implemented by nonphysicians. However, this has potential consequences for house-staff knowledge and education. This article discusses the implications of mechanical ventilation protocols on patient care and medical education, and this article offers suggestions for synchronizing the processes for improving patient care to improve medical education.

Objective: To develop an assessment tool for bedside teaching in the intensive care unit (ICU) that provides feedback to residents about their performance compared with clinical best practices. Method: We reviewed the literature on the assessment of resident clinical performance in critical care medicine and summarized the strengths and weaknesses of these assessments. Using debriefing after simulation as a model, we created five checklists for different situations encountered in the ICU—areas that encompass different Accreditation Council for Graduate Medical Education core competencies. Checklists were designed to incorporate clinical best practices as defined by the literature and institutional practices as defined by the critical care professionals working in our ICUs. Checklists were used at the beginning of the rotation to explicitly define our expectations to residents and were used during the rotation after a clinical encounter by the resident and supervising physician to review a resident’s performance and to provide feedback to the resident on the accuracy of the resident’s self-assessment of his or her performance. Results: Five “best practice” checklists were developed: central catheter placement, consultation, family discussions, resuscitation of hemorrhagic shock, and resuscitation of septic shock. On average, residents completed 2.6 checklists per rotation. Use of the cards was fairly evenly distributed, with the exception of resuscitation of hemorrhagic shock, which occurs less frequently than the other encounters in the medical ICU. Those who used more debriefing cards had higher fellow and faculty evaluations. Residents felt that debriefing cards were a useful learning tool in the ICU. Conclusions: Debriefing sessions using checklists can be successfully implemented in ICU rotations. Checklists can be used to assess both resident performance and consistency of practice with respect to published standards of care in critical care medicine.

Respiratory failure in myxedema is a complex medical emergency and may require prolonged ventilatory assistance. Appropriate management of this medical problem requires an understanding of its effects on the central nervous system and peripheral neuromusculoskeletal system. Weaning of these patients can be very protracted and requires a diligent multidisciplinary approach. Because of its infrequency, ventilatory management of severe hypothyroidism has not been studied in a controlled fashion. The first part of this review discusses the mechanisms of respiratory failure in myxedema. The second part explores strategies in mechanical ventilation and weaning of myxedematous patients.