Santhosh, Lekshmi

Abstract Background Procedural training is a required competency in internal medicine (IM) residency, yet limited data exist on residents’ experience of procedural training. Objectives We sought to understand how gender impacts access to procedural training among IM residents. Methods A mixed-methods, explanatory sequential study was performed. Procedure volume for IM residents between 2016 and 2020 was assessed at two large academic residencies (Program A and Program B: 399 residents and 4,020 procedures). Procedural rates and actual versus expected procedure volume by gender were compared, with separate analyses by clinical environment (intensive care unit [ICU] or structured procedural service). Semistructured gender-congruent focus groups were conducted. Topics included identity formation as a proceduralist and the resident procedural learning experience, including perceived gender bias in procedure allocation. Results Compared with men, women residents performed disproportionately fewer ICU procedures per month at Program A (1.4 vs. 2.7; P < 0.05) but not at Program B (0.36 vs. 0.54; P = 0.23). At Program A, women performed only 47% of ICU procedures, significantly fewer than the 54% they were expected to perform on the basis of their time on ICU rotations (P < 0.001). For equal gender distribution of procedural volume at Program A, 11% of the procedures performed by men would have needed to have been performed by women instead. Gender was not associated with differences in the Program A structured procedural service (53% observed vs. 52% expected; P = 0.935), Program B structured procedural service (40% observed vs. 43% expected; P = 0.174), or in Program B ICUs (33% observed vs. 34% expected; P = 0.656). Focus group analysis identified that women from both residencies perceived that assertiveness was required for procedural training in unstructured learning environments. Residents felt that gender influenced access to procedural opportunities, ability to self-advocate for procedural experience, identity formation as a proceduralist, and confidence in acquiring procedural skills. Conclusion Gender disparities in access to procedural training during ICU rotations were seen at one institution but not another. There were ubiquitous perceptions that assertiveness was important to access procedural opportunities. We hypothesize that structured allocation of procedures would mitigate disparities by allowing all residents to access procedural training regardless of self-advocacy. Residency programs should adopt structured procedural training programs to counteract inequities.

OBJECTIVES: The multifaceted long-term impairments resulting from critical illness and COVID-19 require interdisciplinary management approaches in the recovery phase of illness. Operational insights into the structure and process of recovery clinics (RCs) from heterogeneous health systems are needed. This study describes the structure and process characteristics of existing and newly implemented ICU-RCs and COVID-RCs in a subset of large health systems in the United States. DESIGN: Cross-sectional survey. SETTING: Thirty-nine RCs, representing a combined 156 hospitals within 29 health systems participated. PATIENTS: None. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: RC demographics, referral criteria, and operating characteristics were collected, including measures used to assess physical, psychologic, and cognitive recoveries. Thirty-nine RC surveys were completed (94% response rate). ICU-RC teams included physicians, pharmacists, social workers, physical therapists, and advanced practice providers. Funding sources for ICU-RCs included clinical billing (n = 20, 77%), volunteer staff support (n = 15, 58%), institutional staff/space support (n = 13, 46%), and grant or foundation funding (n = 3, 12%). Forty-six percent of RCs report patient visit durations of 1 hour or longer. ICU-RC teams reported use of validated scales to assess psychologic recovery (93%), physical recovery (89%), and cognitive recovery (86%) more often in standard visits compared with COVID-RC teams (psychologic, 54%; physical, 69%; and cognitive, 46%). CONCLUSIONS: Operating structures of RCs vary, though almost all describe modest capacity and reliance on volunteerism and discretionary institutional support. ICU- and COVID-RCs in the United States employ varied funding sources and endorse different assessment measures during visits to guide care coordination. Common features include integration of ICU clinicians, interdisciplinary approach, and focus on severe critical illness. The heterogeneity in RC structures and processes contributes to future research on the optimal structure and process to achieve the best postintensive care syndrome and postacute sequelae of COVID outcomes.

Abstract The Accreditation Council for Graduate Medical Education (ACGME) Milestones are a systematic assessment framework for medical trainees within the six core competencies of practice. Their use by internal medicine subspecialties, including semiannual reports to the ACGME, was mandated beginning in 2014. The Milestones, which were based on specific, observable behaviors, improved upon the prior subjective, global comparisons of each fellow with an “average” fellow in his or her field and served the goals of competency-based medical education. However, the original set of Milestones has proven challenging to apply and interpret. Part of the challenge stems from the use of identical Milestones across all medicine subspecialties, which led to unclear relevance of the patient care and medical knowledge domains to the practice of pulmonary and critical care. This also precluded their use for individualized feedback or development of a learning plan for fellows. In addition, verbose behavioral descriptors, which were designed to provide specificity, ultimately led to rater fatigue among assessors and clinical competency committees. Therefore, the ACGME convened committees for each of the medical subspecialties to revise the original Milestones in an effort to improve subspecialty relevance, minimize educational jargon, and simplify the current iteration. New patient care and medical knowledge Milestones were created to be subspecialty specific and improve utility. The remaining four Milestones were developed as a common set of shorter Milestones, harmonized across specialties. For pulmonary, critical care, and combined fellowship programs, the resulting Milestones 2.0 aims to simplify the use, implementation, and interpretation of this framework for program directors, trainees, and society.