Hi, this is Dr. Passoris again, your moderator. We'll start off this Q&A session. I want to thank the speakers again for their wonderful talks. To start us off, maybe I can direct a question to Dr. White as it relates to, you know, some of the issues that come up with goals of care planning, sometimes border on issue of cultural or maybe even ethical issues related to how aggressive care should be done. What are some of your thoughts regarding maybe some urgent needs to how do we resolve ethical issues surrounding goals of care planning? Steve, hi, it's Doug. I take it that was directed at me. Yes. Yes. Okay, sorry. Yeah. Okay, Okay, fantastic. Well, first of all, it was great to be part of the session. I really enjoyed the conversation, enjoyed the other speakers. And so, you know, in terms of this idea of, in terms of ethical issues around prognostication and goals of care, I mean, there are several. One is, the way I think about it is around how we formulate our prognostications and then the other is around how we communicate them to families. You know, the communication to families about prognosis is from an ethical standpoint, it's straightforward that we should be sharing with them our best, you know, our best sense of what's likely to happen to the patient, not only in terms of survival, the hospital discharge, but also in terms of what their likely functional outcomes are to be. And in terms of talking with them about that, this is something that has to happen in the context of a, you know, a trusting and supportive relationship because we, you know, a lot of the work that I've done that I didn't present today is really focuses in on quite often families do not necessarily take at face value the accuracy of physician's prognostications. And so without other strategies to explore what we call families explanatory models or how they're thinking about what's going to determine their loved one's outcome, and then help them actually see medically what's going on with the patient, this is a recipe for, you know, for conflict with the family. The other part about it, the formulating of the prognostications, you know, the field has a long way to go here. How do we formulate a prognostic judgment? Well, a lot of physicians, at least for things like whether the patient's going to survive, the data suggests that our predictions are at least as accurate as mortality prediction models, though there are some specific biases depending on the profession. What we don't really have are good validated prediction models for long-term functional outcomes. And that's just a huge hole in the field because when you talk to patients about what's important to them, it's not just about am I going to make it out of the ICU? It's really about what's my life going to be like? From my own perspective as the patient, will I have a quality of life that is acceptable to me? So that's, you know, I think when we think about priorities in the field, that's a big one from my perspective, is focusing in on developing accurate, easily accessible risk prediction models for functional outcomes in the future. I'll stop there for now. Great. Thank you, Doug. I just want to remind our attendees, if you have any questions for any of our expert panel, feel free to put them into the questions box on your control panel. Doug, just to piggyback again on the idea of a family navigator, how do you like operationalize this? Let's say whether it's in, let's say not so much in an academic setting, but more in a community setting where they may not be as blessed with staff and resources. Is this something that you foresee operationalizing with a dedicated nurse in the ICU, a social worker, an APP perhaps? How would you kind of think of operationalizing that concept in families? Yeah. So great question, Steve. You know, you can either have someone who is external to the interprofessional ICU team, which is a true family navigator role, or, what I think is a better approach is to train up the interprofessional team in a structured family support pathway that involves, you know, the physicians and APPs playing the role that they normally do. But complementing that with either the social worker or nurse leaders in the ICU, also engaging with the families in a, you know, really day-to-day checking in with them, emotionally supporting them, making sure there are no, what I call nascent conflicts, you know, the beginnings, the brewings of a conflict, and that those other members of the interprofessional team are working hand in glove with the physicians and APPs to provide sort of continuous support of the family. And that approach, why I like that approach, which is to say using the interprofessional ICU team rather than an external navigator, is that it doesn't require bringing in someone new to the ICU setting, which is already a complicated healthcare delivery model. And I think it also helps our full team, the nurses and the social workers, begin to practice more at the scope of their competence. You know, I feel like we underutilize nurses and social workers in supporting families. And if these resources are already here and we can simply tighten up our processes by how we all work together as a team, that is a very efficient way to better support families with the existing resources. Great. Thank you, Doug. A question on leadership for Dr. Kapoor. April, what are your thoughts about the need for greater gender parity in critical care medicine leadership? Why can't we have more women leaders in critical care? Yeah, I think that the way you said that question is actually very true. Why can't we have more? We need more diversity. Women have a unique background perspective. They can add significantly to the thought and the discussions on the critical care team. There's data that shows that having more women in leadership, you have overall collectively better patient outcomes and a healthier work environment. So there is a lot in terms of how can we increase the diversity on our teams. We're in an environment that's constantly evolving. We need innovative solutions. We need perspective so that we can constantly be innovating. And as you bring more women into leadership, that begets itself. You see more role models. I'm a nurse practitioner. I saw a nurse practitioner in action in an ICU, and I said, that's what I want to do. I don't know that if I hadn't seen that, that I would have thought that I could have done that. And most nurses, if you ask nurses, they will say at some point in their life, they talked to a nurse, maybe it was a family member, and then they could see themselves in that role. And so we need to be doing that with our next generation, not just with women, but diversity across the spectrum. And organizations need to be held accountable for their metrics in terms of diversity. So role modeling, perspective of thought, being innovative and effective, we absolutely need more diversity across the board. Yes, we certainly welcome Dr. Khalilzad's take on this as well. She is one of the very, very few women leaders of a critical care organization. So Rupa, feel free to chime in on this gender parity issue and why can't we have enough or have more critical care women leaders. Thanks, Stephen. Thanks, April. You've done a good job with this panel. It's three to two ratio right now with April, Sharla, and myself. But yes, definitely, I would start by saying that the Institute for Critical Care Medicine has 50% women leaders, and it has a lot to do with our eye on diversity, equity, and inclusion. And of course, our fellowship program, which is our training ground, and Dr. Oropallo has done a fantastic job of having trainees, also 50% women in the training program, and those are our pipeline. So if we train, recruit women in our training programs, as well as support them, because women work a tad differently than men, as you can imagine. It's not just the work job. They have the responsibilities at home that are equally time-consuming. So leaders need to be supportive. Organizations need to be supportive. And of course, gender equity, parity, and we can talk a lot about it, and that will be all day long. So, so true. Besides gender, we can also talk about, like, why don't we hear enough voices from other diverse racial or cultural backgrounds? You know, a lot of the times, you know, they don't tend to speak out as much, and when a new leader is chosen, the voices generally of the ones who really are loudest tend to be the ones heard, and the ones that are maybe more in the front line, who may come from backgrounds that may not always be, you know, front and center, are not getting enough of that recognition. So how do you work around some of getting those voices? And it could be April, or anyone in the panel can certainly feel free to answer that. I think for us, it's been very important that you be very intentional about hearing everyone and listening to everyone's voice. And you have to create an environment where there's some environment where there's safety to speak up. And I keep, I always share examples of myself. I've been in an environment where I was on rounds, and I did not feel safe to speak up. I felt that if I spoke up as a woman, as a nurse, that my thoughts, my contributions would not be, would be discounted. And so how do we change that dynamic where we have safety to speak up, but also we have to be intentional, and our processes and systems have to be in place to harvest that voice to make sure everyone's voice is heard. So both of those things, the environment and the system, the infrastructure has to be intentional. Thank you. We all felt the brunt of the COVID pandemic and its impact on all our healthcare systems, on a personal level, professional level, among colleagues and patients and their families. Resources were limited, they were tight, you know, almost to a point where we had to basically sometimes hoard our own resources just to make sure our own hospitals and affiliated hospitals with us. So maybe Rupa can speak to some of the challenges, pitfalls, limitations in how you would share, you know, Sinai resources from your healthcare system to others that may not be able to handle or not have resources. And maybe the others can speak to what they did as well. Thanks, Steve. So I'll start by saying that, as you said, you'll never have enough because you're taking from Peter to pay Paul. So Paul is happy, Peter is not happy, and you still have to distribute the resources across different campuses and perhaps even other health systems. So I'll start by saying, as you know, Sinai is a seven, it's an eight campus system with seven of them have ICUs. So during COVID, and we had a very recent labor disruption too, we were staffing different campuses with ICU physicians, APPs, as well as residents and nurses. Very challenging times because a handful of critical care staff were managing large number of patients in unfamiliar environments. And also the knowledge and skills of the staff varied. And April, you touched on this, all this can lead to, you know, a lot of burnout. We did lose a couple of faculty right after COVID to burnout and staff feeling overwhelmed and stressed. As far as resources, we are very much aware our PPEs, our masks were in, you know, we were distributing across all our 19 ICUs. So we were using one mask the entire day so that we could save on our PPE. We even split our ventilators, one ventilator into two circuits. You know, as you can imagine, yeah, it is innovation, but it can come up with a whole host of different issues if you really think about it. HAIs, you know, you're having two patients in one room and a split ventilator circuit. And something really sensitive, we were making ethical decisions on which patient to assign resources to. So a lot of stress as well as decision making at that time. But I would like to say that for us, a lot of good came out of that since then. MSH campus, which is our flagship with seven ICUs, has a lot of resources. The Institute was already there for four or five years before the pandemic. So we had resources. Our other campuses did not have resources. So when we were evening out resources, providing 24-7 coverage, we piggybacked on that. And now all our ICUs, 19 ICUs, have 24-7 intensivist coverage in-house with APPs as well as intensivists. So that's came out of it. On top of it, other than the resources, now each of the campuses has an infrastructure we can build on. If there is another crisis, we will be able to build on that infrastructure and scale it up. We also recruited, Doug, a system-wide palliative critical care director. So this person has individual, has a team, and we move palliative care upstream. So we are thinking of utilizing our resources on a daily basis. It is not just during crisis. So we are thinking how we are going to utilize resources, what we are going to do. And to make up for staff knowledge, we started having system-wide simulations across the health system. And these are regular programs we do for our faculty, for our staff, and anybody else who wants to join in. In the world of Zoom, things have become relatively easier. And the collaborations we made with other health systems, learning from them, that was an additional plus ultimately. Great. Thank you. In terms of leadership, we probably have several of our attendees who may be rising critical care leaders. And coming from your experience, April, what early career pitfalls or challenges that if you were to look back, you would now suggest to an early career rising star who wants to be a leader in critical care to try to avoid or know how to confront? What would be some pearls that you would impart on them that maybe from your experience early on, maybe something that they can use? Yeah, a couple of things. One is I would take advantage of every opportunity, both formally and informally, to grow my leadership skill. And there are formal programs. I know that's when I chose to pursue my doctorate in nursing practice. But there's a lot of informal trainings and education that you can take advantage of as a team and as an individual. And I would do that because you learn a lot that you did not learn as you were learning critical care. You really learned that broader spectrum of being a leader and really about people and relating with people and working on a multidisciplinary team of team members that might include a chief financial officer, a chief executive officer, people that really don't know what's happening within the ICU. The second thing that was really eye-opening, and I don't know if I could go back if I would just do the same thing again because I just didn't know what I didn't know, is there's an art to presenting and having conversation and understanding who you're speaking with. And oftentimes, as health care providers, we're so passionate, we're so focused on our patients that it's hard to have a conversation where we're really looking at, like Rupa said, robbing Peter to pay Paul, those big, hard financial decisions. But really, we have to really engage and learn how to speak and think broader than our critical care unit and think as part of the overall health system and how do we work within that bigger system. And then thinking beyond the walls of our health system broadly with health care today. So, that was something I think it was just stretching my brain and thinking further and not just being focused on what was happening in my world of the ICU. Yeah, if I could just add one thing. April, that's a fantastic response. One of the things that I think is especially important for junior people to do is to find a way to be at the table to at least begin to see how are these decisions being made? How are they playing out? And often that can take the form of an assistant director role or an associate director role of either the ICU or a particular set of the staff, or even as a fellowship type opportunity in an informal way to be shadowing the director. Because there's a big learning curve to figuring out how to function as part of a complex organization that has many different stakeholders with many different opinions and pressures on them. And seeing like actually being in the room and getting the exposure to that and playing out how you might respond. That's the beginning of being ready to be the person actually at the table responding. Great, thank you. A more general question for everybody. How can we make more trainees go and do critical care? What is attractive about our specialty that we need to draw more? And as a program director, this is something that I deal with on a constant basis in selecting fellows, but I just don't see a large enough pool of candidates that seem to be attractive. I thought COVID would bring in and we did see a bump in applications, but that seems to have began to slow down again. So how do we get trainees to go into our field and find joy and fulfillment doing it and not feel like they're burning out? Are there any specific challenges? And anyone on the panel can certainly share their views on this particular issue. Team, we've seen that time and time again. If you feel part included, if you have an inclusive environment where you feel part of the team, that I think for all of us in critical care that have really felt that team that has that good flow, everyone respecting one another, everybody contributing, it's fun. It's a wonderful dynamic and you enjoy going to work because you're learning you're growing, you're relying on one another. So how do you create that space? The second thing that I've seen quite often, especially with what we've just experienced with the pandemic, is offering those opportunities for change. And I mean, you can only do what you can do for so long that you need to break it up a little bit and have some sort of change. So whether you balance some days in the critical care unit with teaching, so you're giving back, or you're working in two different areas, but offering opportunities for change and then opportunities for professional growth. Do you have an opportunity to take on an assistant director role? Do you have an opportunity to do something a little bit different? It's keeping it exciting, it's keeping it fun, it's to do something a little bit different. It's keeping it exciting and feeling included. It's social in nature as well. I couldn't agree more. I think that that hit it right on the head. The other thing that I think is particularly important is the efforts of professional societies like SCCM to promulgate both an ethos of interprofessionalism in the ICUs, a strong national presence as an organization that's exciting and vibrant. And then even at the level of making sure that intensivists are not getting crushed with unrealistic numbers of patients. I think efforts that SCCM and others have put forward to say, here's the number of ICU beds per staff, per attending or per team unit should be out there. Personally, I know that our organization has looked at that as we have grown our number of ICUs and thought about staffing models. So those sorts of things, as long as the numbers are reasonable, which I think for SCCM they are quite reasonable, can be really helpful when you're thinking about the long view of how can we make it so that we're preventing burnout in our intensivists from just too big a patient load. Thank you both. In addition to what's said here, giving them a very robust training in a multidisciplinary training program. So they're not just learning medical ICU or a CTICU, they are going through community hospital, they're going to an academic center, they're learning in transplant ICU, giving them diverse skills. And I think I'm talking about diversity in very different ways, learning from diverse faculty who they identify with, faculty from different specialties, opening our programs to EM critical care, combined fellowship program with nephrology and cardiology, and even heart failure. So give them training that they can ordinarily not get. I think that would attract the newer crop to our programs. Also giving them seat at the table. It's been said earlier, having them being part of the medical board, where they're listening to how the hospital functions and how decisions are made, absorbing from other people's experience. I think all those factors could really help recruit and retain. And it's a word of mouth when they go to different society meetings, they talk about it and attract additional trainees. Yeah, it really is a challenge. And the number of critical care standalone programs has increased, but not to the extent that you could really put an intensivist, trained intensivist, certified intensive into any ICU in the country. So that remains a challenge. The number of pulmonary candidates applying into critical care, that number seems to be falling each year as the number of standalone pulmonary programs certainly have been decreasing as they combine to make a three-year program. So the attraction is coming now from the nephrology, cardiology, neurocritical care, as well as infectious disease. So I think that seems to be another rich pool. And as long as they practice in different settings, not just in academic medical centers, I think that would be great. I think our APP pool, as April has mentioned, has really grown. I think I don't think most of our ICUs will really be able to function with our model of having just residents and fellows. I think the APP is just like our own pharmacists and respiratory therapists bring a lot to the table. And I think SCCM, as you all know, is the only society that brings all these multi-professionals at their annual meeting and with all the programs, catering to every aspect of the team, as I think is a constant subject that we always emphasize a lot. I don't see any more questions in the chat box. So I think this will conclude our Q&A session.

critical care medicine

ethical issues

goals of care planning

communication

trust

prognostications