Pro: Integrated Five-Year Anesthesiology Residency Should Be Implemented Widely

Fellowship Training in Adult Cardiothoracic Anesthesiology: Navigating the New Educational Landscape as a Result of the Coronavirus Crisis

The growth and promulgation of Advanced Practice Providers (APPs) across the entire spectrum of healthcare delivery has been profound, and APPs are increasingly common members of emergency department (ED) care teams. Emergency APP workforce growth is outpacing that of emergency physicians with little to suggest that this trend will subside. The evolution of the deployment of APPs in emergency care has been dramatic; initially, emergency APPs were deployed to lower acuity patients or environments-minor injury and illness and in conjunction with an emergency physician-hence the now antiquated description of APPs as "physician extenders."

Introduction: Advanced Practice Providers (APPs) are a well-established part of the multidisciplinary critical care team, but the scope and utilization of APPs vary dramatically between hospitals. This survey captures current demographic, workflow, and utilization trends in the Society of Critical Care (SCCM) APP community. Methods: This was a cross sectional REDCap survey emailed to 2775 SCCM physician assistant or nurse practitioner members in April 2021. There were 578 responses (20.8%) with 60 non-APP respondents excluded for a sample size of 518. Statistical analysis was performed via SPSS. Results: Of the 518 respondents, there were 149 (28.8%) physician assistants and 327 (63.1%) nurse practitioners. Most respondents (n=371, 72%) were female. 248 APPs (48.1%) worked for large hospitals (>500 beds) and most (n=343, 66.2%) worked in an academic setting. Of the surveyed, 447 (86.3%) reported greater than 2 years of ICU experience. Formal onboarding was common (n=354, 68.6%) and was most likely to occur in academic medical centers (n=233 of 354, p< 0.001). Onboarding was usually completed in under 6 months (n=310, 87.8%). Most APPs (n=409, 79.3%) did not pursue post-graduate fellowships. Most units had full time APP coverage (n=361, 70.1%) including weekends and holidays (n=427, 82.8%). Daytime APP to patient ratios were less than 1:10 (n=377, 75.7%); nighttime ratios were 1:11 or greater (n=328, 72.9%). The majority of APPs performed arterial lines (n=425, 82%), central venous catheters (n=410, 79.2%), temporary dialysis catheters (n=318, 62.4%), and point-of-care ultrasound (n=295, 56.9%). APPs most frequently billed critical care time (n=314, 60.6%) and procedures (n 333, 64.3%). A quarter of respondents (n=137, 26.4%) reported that they did not bill. APPs did not routinely have their billing measured (n=212, 41.5%) and many (n=106, 20.7%) did not know if productivity measures were utilized in their group. Conclusions: APPs are experienced members of the critical care team heavily utilized in large academic hospitals. Current APP roles are mostly clinical and unit-based, with emphasis on procedures and episodic care. Additional research will better quantify APP productivity and value since metrics are inconsistent and many APPs do not currently participate in billing.

Successful Integration of Advanced Practice Providers Into a Pediatric Academic Community Intensive Care Unit

IMPORTANCE:This study provides nationally representative data on critical care advanced practice provider (APP) workforce structure and practice, addressing gaps in onboarding, productivity assessment, and administrative roles that influence workforce sustainability.OBJECTIVES:To analyze the composition of the clinical practice and workforce demographics of critical care medicine APPs.DESIGN, SETTING, AND PARTICIPANTS:We utilized a cross-sectional survey, which was distributed via email through the Society of Critical Care Medicine email list, targeting critical care APPs.MAIN OUTCOMES AND MEASURES:A total of 518 critical care APPs participated in the survey, comprising 63.2% advanced practice registered nurses, 28.8% physician assistants, and 8% clinical nurse specialists. The majority of the sample APPs worked 12-hour shifts covering days, nights, and weekends, with over 50% managing 6–10 patients per day shift. Common billing practices included critical care time (60.6%) and bedside invasive procedures (64.3%). Formal onboarding was reported by 68.6% of respondents, with academic hospitals more likely to offer such programs than community hospitals (72.3% vs. 27.7%; p < 0.001). Administrative APP roles were more prevalent in academic centers (p < 0.001) and were associated with greater access to professional development opportunities (p < 0.001). A significant proportion of respondents (41.5%) reported that their productivity was not formally measured. Notably, 22% of respondents reported an intent to leave the profession, particularly those lacking leadership or professional growth opportunities (p < 0.01).CONCLUSIONS AND RELEVANCE:This study captures practice trends and demographics of the critical care APP workforce. Day-to-day tasks among all respondents were globally clinically focused, but there were disparities in workload distribution, onboarding, productivity measurement, and administrative roles across types of centers. Additionally, there was significant association between limited professional growth opportunities and intent to leave critical care. These findings underscore the need for healthcare systems to invest in structured support, leadership development, and professional growth to enhance APP retention, engagement, and productivity. Further research is needed to identify efficient workload and staffing models.

After completing their critical care rotations, pediatric residents are expected to have acquired skills in the resuscitation of critically ill newborns and children. Recent Accreditation Council on Graduate Medical Education (ACGME) guidelines have limited the time devoted to critical care training during pediatric residency. We sought to determine how individual programs have structured their critical care training experience in light of these changes. A questionnaire was mailed to each pediatric residency program listed in the 1996-1997 Graduate Medical Education Directory. Information was obtained regarding the structure of critical care training. Data were analyzed using descriptive techniques, one-way analysis of variance with Scheffé post hoc test, and Fisher exact test as appropriate. Data were received from 149 programs (71% response rate). Most programs were in compliance with ACGME standards regarding the number of months devoted to neonatal intensive care, pediatric intensive care, and emergency medicine. There were no significant differences in the total number of rotations in either the neonatal intensive care unit (NICU) or the pediatric intensive care unit (PICU) when the programs were stratified by size. There were no significant differences in the percentage of programs requiring night call in either the NICU or the PICU during off-service months. However, small programs (< 25 residents) required significantly fewer rotations in emergency medicine (P < 0.001). Most programs complemented the critical care experience by offering additional rotations and advanced life support training. Pediatric residency programs have structured their critical care rotations in a similar fashion in accordance with ACGME guidelines. The success in meeting the stated objectives, as measured by the ability of graduating residents to stabilize critically ill children, is not known and will require further study.

COUNTERPOINT: Should Interventional Pulmonology Be Given American Board of Internal Medicine Subspecialty Status? No

Introduction: Burnout results from physical and mental exhaustion and affects the intentionality to leave the profession. Unfortunately, burnout scenarios have been quite common among Critical Care Advance Practice Providers (APPs). The calls to action to sustain the critical care workforce were in full force before COVID-19 attacked the world and rapidly turned into a pandemic. Already overburdened and depleted critical care workforce was further exacerbated by overwhelming work demands. Our research was aimed at understanding the influence of COVID-19 on the critical care APPs. Methods: We utilized a cross-sectional REDCap survey to understand the self-perceived extent to which the burnout among critical APPs had changed. A single link to survey was emailed to 2775 SCCM physician assistant and nursing section members. There were 578 responses (response rate 20.8%). After excluding 60 non-APPs responses, our sample size was 518. Survey questions asked about the symptoms of emotional exhaustion, depersonalization, perception of reduced personal accomplishments and intention to leave. Results: We found an increase in burnout and related dimensions. Emotional exhaustion increased from 28.8%-69.9%, depersonalization increased from 17.2%-37.6%%, and perception of reduced personal accomplishments increased from 18.1%-38% among our study population. We also asked about the intentions to leave critical care and a total of 513 participants engaged with this question. Twenty-two percent (n=114) of our sample expressed an intention to leave critical care. We also asked about the intention to leave the profession altogether and only 21.8% (n=113) participants responded. A total of 43.3% (n=49) respondents reported the intention to leave the profession altogether within the following 2-5 years. Of those who responded, 22.1% (n=25) intended to leave within 1 year and 25.7% (n=29) intended to leave between 5-10 years while 8.9% (n=10) stated that they intended to stay beyond 10 years. Conclusions: COVID-19 pandemic exacerbated the burnout and its dimensions among critical care APPs. It is crucial to attend to the trends in burnout and intention to leave and mitigation strategies must be employed to sustain the critical care workforce which is key to planning the future of critical care in the US and globally.

The Gastroenterology Core Curriculum, Third Edition

Challenges in critical care obstetrics in West Africa

Back to table of contents Previous article Next article Education & TrainingFull AccessNew York City Training Programs, Residents Take On COVID-19Mark MoranMark MoranPublished Online:27 Apr 2020https://doi.org/10.1176/appi.pn.2020.5a27AbstractEven in parts of the country where psychiatry's educational mission has not been severely affected by COVID-19, the pandemic raises questions about the future.iStock/Halfpoint"Nobody predicted this," said Parma Zahid, M.D., a second-year psychiatry resident at Montefiore Medical Center in the Bronx, N.Y., now deployed to medical floors caring for patients with COVID-19."A few of my other psychiatry colleagues and I were supposed to be in Madrid giving presentations at the European Psychiatric Association. Instead of Madrid, I'm on a medical floor. People are really sick, some of them are dying, and families are really worried."But I'm glad I can help in this unprecedented crisis. All of us going through medical school fell in love with a specialty. But at the core, we are doctors, and right now we all are going back to that original foundation."Zahid's experience—of a personal world turned upside down and an educational plan thrown off track while being catapulted professionally into a setting for which one is only minimally prepared—mirrors that of many psychiatry residents in New York City, the nation's epicenter of the COVID-19 global pandemic. The willingness, without hesitation, to walk onto medical floors and treat patients with a highly infectious virus (going home later to spouses and children) is common in a city where locals are cheering and banging on pots and pans at night to applaud America's newly discovered health care heroes."At the core we are doctors, and right now we are all going back to that original foundation."—Parma Zahid, M.D.For residency training directors and their institutions everywhere, COVID-19 has scattered the cards. Even in parts of the country not severely affected by COVID in ways that have impacted the educational mission, the pandemic raises questions about the future."The period from March through June is typically a very busy ramp-up time for residency programs," said APA Secretary Sandra DeJong, M.D., senior consultant to the child and adolescent psychiatry training program at Cambridge Health Alliance and a past president of the American Association of Directors of Psychiatry Residency Training (AADPRT). "The degree of uncertainty about the duration of current restrictions on travel both to offices and across borders means that some of that work may not be able to happen, and incoming residents may not be able to move, get set up, and have orientation. And with all hands needed on deck where COVID-19 is peaking, all trainees will be under pressure to serve wherever their help is needed."'I Want to Do My Part'"Maintaining any kind of a normal routine in New York City has been almost impossible," said Melissa Arbuckle, M.D., Ph.D., director of residency training at Columbia University Irving Medical Center and president of AADPRT (see facing page). She told Psychiatric News that Columbia filed for Pandemic Emergency Status with the Accreditation Council for Graduate Medical Education (ACGME) on March 25. As described by the ACGME, most requirements are suspended so that programs can deploy trainees however necessary to meet the surge of patients for whom they must care, she said."I'm really good responding to intense emotional situations, talking with people who are really, really worried about their family members."—Paloma Reinoso, M.D."In the beginning of this crisis, we focused on developing remote didactics and getting our resident outpatient clinic up and running with telepsychiatry," she said. "Since then we have had to suspend most didactics. We have managed to continue a couple of classes a week. However, most of the educational activities have switched over to focus on critical care and palliative care in addition to getting residents up to speed with the documentation needs associated with these roles."In the second week of April, nine psychiatry residents from Columbia were deployed daily to help staff these settings. In addition, she said five residents and fellows are staffing the emergency department each day doing palliative care consultations on-site and remotely. "The remaining residents are doing additional work cross-covering critical psychiatric services, including an inpatient psychiatry unit with several COVID-19 patients," she said.Like Zahid at Montefiore, Paloma Reinoso, M.D., a first-year psychiatry resident at the Zucker Hillside Hospital at Hofstra-Northwell in Queens was hardly expecting to be where she found herself in the second week of April. Exhausted and just coming down from the adrenaline rush of an 11-hour shift on the medical floor (13 hours by the time she actually got away), she said, "We were asked if anyone would volunteer to work on the medical floor. I said, 'If I'm going to be in the hospital anyway and exposing myself to COVID, I want to do my part.' ""I had been told that people can underwstimate the value of psychiatry in a general medical setting, but there is very definitely a role for us."—Eric Nelson, M.D.Reinoso manages eight patients—all infected with COVID-19—with two interns and one attending. At the time of this interview, her husband, who is a surgical resident at Northwell Health, was working the night float shift in the ICU at Long Island Jewish Medical Center.She said that the hardest part of the challenge is talking with patients' family members who can't visit their loved ones at their bedside. The psychiatry skills she had already learned—and the empathic nature she brought to her training—have proven useful. "I'm really good responding to intense emotional situations, talking with people who are really, really worried about their family members," she said.All of the residents who spoke with Psychiatric News said they are, for now, adequately equipped with personal protective equipment (PPE). Navigating the need to be a compassionate doctor and not treat the infected patient as an alien "other" despite all the protective gear is what Eric Nelson, M.D., said he will remember about the extraordinary circumstance now confronting frontline physicians."You want to be there for patients—to reassure them and not treat them as if they are untouchable," he said. "You speak aloud to be heard, make eye contact, and give them an honest assessment and a chance to ask questions."At night he goes home to a wife and a 3-year-old, careful to shower and change before greeting his family. Like his colleagues, he testified to the camaraderie that exists in a situation where it is "all hands on deck.""My internal medicine colleagues have been very patient as I get up to speed, and I have had a very positive experience with them," Nelson said. "There have been a few of the patients I manage for whom psychiatry skills were useful."He recounted one whose anxiety was escalating dangerously. "A colleague and I just sat down and talked to her," he said. Even with all the PPE, their presence and attentiveness were enough. "After a while she told us, 'Thank you. I think I just needed someone to talk to.'"I had been told that people can underestimate the value of psychiatry in a general medical setting, but there is very definitely a role for us," he said.Arbuckle said that these stories, like those of her residents at Columbia, "have been my anchor." She said, "Residents have faced these challenges with grace and humor. They have talked about developing new friendships as they work alongside medicine colleagues and redeployed residents from pediatrics, neurosurgery, anesthesia, and physical medicine and rehabilitation. They have come together as a community to support one another in remarkable ways. Throughout all of this, I have also developed a new perspective on what it means to be 'courageous.' Our residents are not fearless—many are very afraid, and they continue to work in spite of that." ■ ISSUES NewArchived

Lessons Learned in Maximizing Open Surgical Experience for Vascular Integrated Residents During the Nonvascular Months of Training

Solid organ transplantation is a life-saving procedure, often performed in critically ill patients, and advanced practice providers (APPs) have increasingly been incorporated into the multidisciplinary transplant team. A literature review was performed and reinforces the value of transplant APPs, details their evolving roles and responsibilities, and highlights innovative solutions created to address complex problems. The literature review revealed a deficit of quality quantitative data supporting the utilization of APPs in transplantation. Thus, data regarding the value of APPs in critical care was also analyzed. The limited data despite decades long integration of transplant APPs into the multidisciplinary team, suggests there are likely positive outcomes and innovations that go undocumented. Thus, there are missed opportunities for learning and improvement. Transplant programs investing time and mentorship to support APP research will identify strengths and weaknesses within our existing care models, discover cost saving innovations, and continue to optimize the role of APPs in delivering high quality care that is efficient and evidence based.

New Duty-Hour Rules Present Challenges

Pleural Procedure Education in Fellowship: A National Survey of Program Directors