Cognitive learning theory for clinical teaching

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/148367/1/tct12781_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/148367/2/tct12781.pd

Developing internal medicine subspecialty fellows’ teaching skills: a needs assessment

Abstract Background For academic physicians, teaching represents an essential skill. The proliferation of educator training programs aimed at residents and medical students signals the increasing commitment of training programs to develop teaching skills in their trainees as early as possible. However, clinical fellowships represent an important opportunity to advance training as educators. In addition to enriching the pipeline of future teachers, developing fellows as teachers augments the training experience for more junior trainees and may impact patient care. Fellows’ needs for programs to improve teaching skills have been largely unexplored. Methods We conducted a multi-institutional needs assessment of internal medicine (IM) subspecialty fellows to gauge interest in teaching and improvement of teaching skills. We surveyed IM subspecialty fellows at three academic medical centers about their access to fellow-as-teacher programs and other mechanisms to improve their teaching skills during fellowship. We also elicited their attitudes towards teaching and interest in training related to teaching skills. Results One hundred eighty-three fellows representing 20 programs and nine different subspecialties responded to the survey (48% response rate). The majority of participants (67%) reported having no specific training focused on teaching skills and only 12% reported receiving regular feedback about their teaching during their fellowship. Seventy-nine percent of fellows anticipated teaching to be part of their careers, and 22% planned to participate in medical education scholarship. Fellows reported a strong interest in teaching and programs aimed at improving their teaching skills. Conclusions The majority of fellows reported a lack of mechanisms to advance their teaching skills as fellows, despite anticipating teaching to be an important aspect of their future careers and having strong interest in such programs. Our findings at three academic medical centers confirm a lost opportunity among subspecialty fellowships to accelerate teaching skills development for future educators.https://deepblue.lib.umich.edu/bitstream/2027.42/145709/1/12909_2018_Article_1283.pd

Implementation of a Professional Society Core Curriculum and Integrated Maintenance of Certification Program

Medical professional societies exist to foster collaboration, guide career development, and provide continuing medical education opportunities. Maintenance of certification is a process by which physicians complete formal educational activities approved by certifying organizations. The American Thoracic Society (ATS) established an innovative maintenance of certification program in 2012 as a means to formalize and expand continuing medical education offerings. This program is unique as it includes explicit opportunities for collaboration and career development in addition to providing continuing medical education and maintenance of certification credit to society members. In describing the development of this program referred to as the “Core Curriculum,” the authors highlight the ATS process for content design, stages of curriculum development, and outcomes data with an eye toward assisting other societies that seek to program similar content. The curriculum development process described is generalizable and positively influences individual practitioners and professional societies in general, and as a result, provides a useful model for other professional societies to follow

The impact of a clinical pharmacist in an interprofessional intensive care unit recovery clinic providing care to intensive care unit survivors

IntroductionIntensive care unit (ICU) survivors are vulnerable to further health deterioration and medication-related problems (MRPs) with a high rate of potentially preventable hospital readmissions and late death. Therefore, it is critical to identify MRPs of ICU survivors post-hospitalization. ICU-recovery clinics (ICU-RCs) have been proposed as a potential mechanism to address the unmet needs of ICU survivors, and pharmacists should be key members of ICU-RCs.ObjectivesThe objective of this study was to evaluate the impact of a pharmacist in an interprofessional ICU-RC on MRPs.MethodsA retrospective cohort study was conducted in adult ICU survivors with sepsis/septic shock and/or respiratory failure. This study compared MRPs within 6 months of post-hospital discharge between intervention and control groups. The intervention group included patients who were seen by a pharmacist in an ICU-RC. MRPs and interventions between initial and 6-month follow-up visits in the intervention group were also evaluated.ResultsData were collected for 52 control and 52 intervention patients. There were no significant differences in baseline demographics and hospital characteristics between groups. Eighty-four MRPs were identified in the control vs 110 in the intervention group (P = .37). Half of patients in control and intervention groups had at least one MRP identified (P = .69). There was a significant decrease in mean number of MRPs at the 6-month follow-up visit (3.5 ± 1.7 with initial vs 2.4 ± 1.3 with follow-up visit; P = .025) in the intervention group. Almost all patients in initial and follow-up visits had at least one MRP.ConclusionsDedicated ICU-RC pharmacists in an interprofessional ICU-RC can assist with addressing and intervening on MRPs which could further impact clinical outcomes in ICU survivors.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/175097/1/jac51671_am.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/175097/2/jac51671.pd

Transthoracic echocardiography and mortality in sepsis: analysis of the MIMIC-III database

Abstract Purpose While the use of transthoracic echocardiography (TTE) in the ICU is rapidly expanding, the contribution of TTE to altering patient outcomes among ICU patients with sepsis has not been examined. This study was designed to examine the association of TTE with 28-day mortality specifically in that population. Methods and results The MIMIC-III database was employed to identify patients with sepsis who had and had not received TTE. The statistical approaches utilized included multivariate regression, propensity score analysis, doubly robust estimation, the gradient boosted model, and an inverse probability-weighting model to ensure the robustness of our findings. Significant benefit in terms of 28-day mortality was observed among the TTE patients compared to the control (no TTE) group (odds ratio = 0.78, 95% CI 0.68–0.90, p < 0.001). The amount of fluid administered (2.5 vs. 2.1 L on day 1, p < 0.001), use of dobutamine (2% vs. 1%, p = 0.007), and the maximum dose of norepinephrine (1.4 vs. 1 mg/min, p = 0.001) were significantly higher for the TTE patients. Importantly, the TTE patients were weaned off vasopressors more quickly than those in the no TTE group (vasopressor-free days on day 28 of 21 vs. 19, p = 0.004). Conclusion In a general population of critically ill patients with sepsis, use of TTE is associated with an improvement in 28-day mortality

Causes and characteristics of death in patients with acute hypoxemic respiratory failure and acute respiratory distress syndrome: a retrospective cohort study

Abstract Background Acute hypoxemic respiratory failure (AHRF) and acute respiratory distress syndrome (ARDS) are associated with high in-hospital mortality. However, in cohorts of ARDS patients from the 1990s, patients more commonly died from sepsis or multi-organ failure rather than refractory hypoxemia. Given increased attention to lung-protective ventilation and sepsis treatment in the past 25 years, we hypothesized that causes of death may be different among contemporary cohorts. These differences may provide clinicians with insight into targets for future therapeutic interventions. Methods We identified adult patients hospitalized at a single tertiary care center (2016–2017) with AHRF, defined as PaO2/FiO2 ≤ 300 while receiving invasive mechanical ventilation for > 12 h, who died during hospitalization. ARDS was adjudicated by multiple physicians using the Berlin definition. Separate abstractors blinded to ARDS status collected data on organ dysfunction and withdrawal of life support using a standardized tool. The primary cause of death was defined as the organ system that most directly contributed to death or withdrawal of life support. Results We identified 385 decedents with AHRF, of whom 127 (33%) had ARDS. The most common primary causes of death were sepsis (26%), pulmonary dysfunction (22%), and neurologic dysfunction (19%). Multi-organ failure was present in 70% at time of death, most commonly due to sepsis (50% of all patients), and 70% were on significant respiratory support at the time of death. Only 2% of patients had insupportable oxygenation or ventilation. Eighty-five percent died following withdrawal of life support. Patients with ARDS more often had pulmonary dysfunction as the primary cause of death (28% vs 19%; p = 0.04) and were also more likely to die while requiring significant respiratory support (82% vs 64%; p <  0.01). Conclusions In this contemporary cohort of patients with AHRF, the most common primary causes of death were sepsis and pulmonary dysfunction, but few patients had insupportable oxygenation or ventilation. The vast majority of deaths occurred after withdrawal of life support. ARDS patients were more likely to have pulmonary dysfunction as the primary cause of death and die while requiring significant respiratory support compared to patients without ARDS.http://deepblue.lib.umich.edu/bitstream/2027.42/173918/1/13054_2020_Article_3108.pd