Hi, I'm Erin Hennessey, and I will be giving the first part of our year-in-review for the in-training section, focusing on medical education and critical care training innovations pre- and post-pandemic. The learning objectives for this presentation include discussing methodologies used in critical care medical education research, reviewing the trends in 2021 and meta-research relevant to critical care, exploring barriers to innovation, teaching, and research publications in med-ed relevant to our subspecialty in the pandemic, and propose future topics of interest for med-ed studies and critical care medicine. Financial disclosures. I'd like to begin by reviewing the Delphi method, which is often used in med-ed research. The Delphi method is a methodology to generate consensus opinion. The methodology is used when evidence is limited, but it implements collective knowledge of experts in a certain field, focusing on a specific question and problem. It's often used for curriculum framework or curriculum development, and we see quite a few studies that did this in critical care medicine in 2021. The Delphi method is a six-step process, which starts with problem identification, followed by an extensive literature search, as well as a survey development. The survey is implemented through multiple rounds to an expert panel, and there's feedback between these rounds provided to the expert panel in order to achieve consensus. The final step is summarizing the findings and offering the recommendations. When critiquing studies that use the Delphi method, one should look for their method of justification and any alterations that they use in the six-step process. One should also look at how they select their expert panel and whether or not it's a diverse group of experts. Should look at how many rounds were required and the response rate of the participants for each round. The determination of consensus should be determined a priori, and the discussion of consensus or lack thereof should be included in each paper for every item. I would like to briefly highlight three studies that use the Delphi process to advance medical education in critical care medicine. Prior to the start of the pandemic, this group in China was working on creating a framework for competency for critical care nurses. They used focus groups and literature review for their first two steps, developed a panel of 30 different experts, and had three rounds of iteration. They ultimately developed 92 competencies in six different domains. With the goal of using this framework for assessment and training of critical care nurses and performance evaluations. In a second study published in critical care medicine in January 2020, right before the pandemic in the United States, the authors looked at the development of an undergraduate medical education critical care content outline utilizing the Delphi method. The ultimate goal was to develop a national structured critical care education platform in which individual medical schools could develop their curriculum based on this outline. They developed an expert panel of critical care medical educators with undergraduate medical education experience, as well as residency program directors and residents from the core programs. They looked at the double AMC and trustable professional activities, the SCCM VCCR learning module and objectives from two different school medicine clerkships to develop their content items and their survey. They had 82% participation rate. They used three rounds of iteration, and they used a 75% cutoff for agreement for consensus. Overall they recommended 19 different elements that were proved to be highly recommended for an undergraduate medical education in critical care medicine. They also looked at the level of competency expected on the first day of residency. Overall they generated a high yield topic list for educators to develop critical care education for medical students. Additionally, along the lines of developing a framework in critical care education, this group published another modified Delphi consensus project specifically looking at priorities for critical care simulation. This group looked at a framework across different medical specialties. They had three rounds of iteration. They ultimately had 27 out of 52 experts participate into round three, and the experts were physicians, nurse practitioners, nurses, pharmacists, and respiratory therapists. They ultimately developed 106 items total, which were mapped to four different domains, and there was a call for developing common scenarios amongst different interprofessional societies, as well as sharing of resources to advance simulation training and medical education. On the previous slide, we looked at frameworks for how to advance training in nursing, students, physicians, and interprofessional teams in critical care medicine. But when the pandemic hit, we jumped into innovation mode. I used to always tell medical students that critical care was learned at the bedside. Well, then it wasn't. For some learners, they were removed from workplace clinical training, and they went virtual. For other trainees, we grappled with the service over education dilemma. The number of publications regarding how to continue medical education when in-person educational events were no longer allowed went up, but the rigor, quality, and impact of those published have not quite yet proven that we can do everything online. The best evidence medical education collaboration went into warp speed to produce scoping literature review and systematic reviews to provide us with evidence on what works, what doesn't work, and perhaps why. I'd like to highlight one of their reviews, which focused on pivoting to online learning for adapting or continuing workplace-based clinical learning and medical education following the COVID-19 pandemic. The articles that were included in this systematic review were not specific to critical care, but I felt that it was relevant to our overall pivoting in critical care medical education that has happened over the past two years. After identification and screening, they did a full text eligibility of 422 articles. Ultimately, 393 of those were excluded, mostly because they were not related to a change in education in response to COVID-19 or the participants did not include medical students, residents, fellows, or physicians, or there were no outcomes reported, or they weren't focusing on workplace-based learning. Ultimately, there were 55 studies included in this systematic review. And the authors note that the uniqueness of this pandemic is that all of those involved in medical education, regardless of how the learning was delivered previously, had to rapidly adjust their approaches to maintain educational progress and limit the collateral damage of the numerous and necessary public protection measures. But what that meant is that these publications often were not rigorous, have outcomes, or could potentially be duplicated by others because of the lack of rigorous methodology. When looking at the educational innovations of the studies included in this systematic review, the majority of the pivot was to online learning, with 61.8% of the studies reporting this as their main educational innovation. Online simulation was also fairly popular, as well as remote clinical interactions. Interestingly, only 3.6% reported remote adaptation of multidisciplinary team meetings, and only 10.9% reported remote adaptation of multidisciplinary ward rounds. And these could be potential innovations that would be highly relevant to critical care medicine, which focus on team-based care and multidisciplinary care. When looking at outcomes that were reported, most of the studies only looked at Kirkpatrick Level 1 outcomes, focusing on satisfaction or reaction of learners. 27% did document Level 2A, or changes in attitude of the learners, and 30% showed Level 2B, changes in knowledge or skill. These early studies did not represent change in behavior or results in outcomes related to patient care, and could be an area of focus for future studies. Prior to the pandemic, our focus on training in critical care education was on those that were going to practice in the subspecialty, or required foundational knowledge for graduation. But another pivot occurred, and we had to focus on up-training. We had to teach quick skill acquisition for health care providers that were not in the field of critical care, but were being redeployed to care for critically ill patients during the pandemic. In a study published in the Journal of Critical Care in 2021, they looked at a three-hour simulation curriculum for up-training of health care providers being redeployed. They looked at five different areas in their curriculum, shock, acute hypoxemia, lung ultrasound, ARDS, and care of the COVID-19 patients in the ICU. They trained 175 providers. They included faculty, fellows, chief residents, nurse practitioners, and physician assistants in this study. Out of those that trained and ultimately ended up working in the COVID-19 unit, they had a 62 response rate on the impact of the educational curriculum, and 96% of them said that they increased their knowledge and skills, mostly in shock and acute hypoxemia. Now, there are some weaknesses of the study in the fact that they did not do a pre- and post-test evaluation, and they only looked at the comfort level of training, and they didn't look at direct observation of skills. However, a unique thing about this study is that, unlike other simulation studies in which you teach a skill, and then there's a delay before the learners are able to use that skill, this study actually taught the skill, and then the learners were able to immediately practice the skills learned, and 96% of them felt like this increased their knowledge in this area, and ultimately, they were able to use those skills immediately after the educational intervention. I'm going to switch gears a little bit and focus on critical care ultrasound and echocardiography, because it's a hot topic in critical care medical education and had multiple publications in 2021. We will revisit the DELPHI process for framework building, and we will look at barriers to implementing critical care ultrasound training. There were two DELPHI studies looking at framework for training in critical care echocardiography. The first was published in 2021 by the European Society of Intensive Care Medicine and created the competencies, and this most recent one was published in CHEST and highlights a formalized process for developing a longitudinal basic critical care echocompetence training pathway. They had an expert panel of 21 experts, and they used four rounds of iteration to develop this framework. The fourth round was added specifically for the peer review process. They set the consensus cutoff of greater than 80% for item inclusion and less than 30% for item exclusion. They had a 95% participation in round two and a 76% participation in round three, and they ultimately developed 28 items for expert recommendation in critical care echocardiography. The 28 items were mapped to these core topics for the longitudinal competence training. To start with an introductory course, a formative training, the readiness for summative assessment, a cognitive assessment, competency achievement, and a maintenance of competency. What the authors did is they gave an outline or how-to manual for critical care educators to be able to develop this curriculum and train trainees in critical care echo. This is extremely important because if we look at an earlier article that was published in 2021 in CHEST by Burkett et al., it looks at that the majority of PCCM fellows felt that the barriers to obtaining skills in critical care ultrasound was a lack of faculty currently trained or the lack of a formalized curriculum. This paper here will hopefully help improve those barriers. Now, COVID-19 may have hindered this briefly, but critical care ultrasound training and a means to competency and certification remain a pressing issue in GME programs. Looking forward, programs can implement this training pathway, study the impact, outcomes, and any barriers to implementation in order to continue to advance the training in critical care echocardiography. I would like to finalize this talk with a discussion of where we should be going in medical education within the critical care arena. One of the things that we can look to is the top 10 list of downloads from MedEd Portal. If we take a look at some of the words in these top 10 downloads, you're going to see things like educator identity formation, early intervention for LGBTQ health, disability, ableism, microaggressions, anti-bias, critical consciousness as a framework for health equity, imposter syndrome, and a guide to basic statistics for educational research. But what you'll notice is that that list may give us a glimpse of where we should be heading in critical care medicine education, a focus on diversity, equity, and inclusion or social justice curriculum. One of the top 10 of the MedEd Portal list is directly related to critical care medicine. This was a case-based critical care curriculum for internal medicine residents addressing social determinants of health. They looked at 11 residents in this study, so not a very big N, but with the top downloads and if we all incorporated some aspect of their curriculum that is now readily available to all of us, we could have a very great impact on advancing this topic in critical care medicine. They took a previously published case-based series for a curriculum in critical care and added the key topics for social determinants of health. I've listed four of their learning objectives for this case-based critical care curriculum. And again, if all of us decide to implement this in our current case-based lecture series in the ICU, despite the fact that this study only looked at 11 residents, it could have a big impact. Thank you for listening to our session and giving me an opportunity to discuss a topic that's near and dear to my heart. I hope that this in-training section inspires us all to continue to teach, search for best practices, and share strategies on how to improve teaching, which will ultimately improve the quality of care that we provide to our patients. Thank you.

medical education

critical care training

Delphi method

online learning

diversity