Hi everyone, my name is Alex Lukic. I'm one of the position assistants with the PA and in training section committees. We are here today with Jolie Gallagher and Melissa Ricker. I'll give them an opportunity to introduce themselves. Hi everybody, I'm Jolie Gallagher. I'm a pharmacist at Emory University Hospital. I work in one of our ICUs. I work in the ARICU, which is an acute respiratory ICU. It really serves as a medical ICU for our institution and has been a COVID ICU and a kind of mixed medical and COVID in the downtimes. I did my pharmacy school at the University of Colorado, so I'm from Colorado, and then I came to Emory to do my post-graduate training. So I did a first year residency at Emory and then I did a second year specializing in critical care. I've been at Emory for eight years now and I've been in my current role in the ARICU as well as the residency program director for our critical care program for the past three and a half years now. Thank you, Jolie. My name is Melissa Ricker. I'm a physician assistant at Atrium Health in Charlotte, North Carolina. Following PA school graduation in 2013, I did an optional critical care fellowship at East Carolina and then shortly thereafter got into fellowship education due to my passion and sort of the impact that it had on my clinical integration. I've been at Atrium now almost five years, but I've been the PA fellowship director overseeing all of our fellowship tracks, several of which are in the specialty of critical care for a little over three years. So it's been an incredible joy. I still work several hours a week, even though I'm only PRN in the ICU, which we oversee several of which medical, neuro, et cetera. So I don't have one specific critical care specialty, but very excited to facilitate and participate in this discussion today. All right. Thanks, Melissa and Jolie. I didn't touch my background, but I'm here in San Diego at Scripps Health. I've been in critical care for about six and a half years now. I joined Scripps about a year and a half ago. Before that, I was in Cleveland, Ohio, where I did my kind of a training program in critical care and stayed there for about four and a half years before transitioning out to the West Coast. So after those introductions, we'll just go through what we're here to talk about in our SCCM crosstalk, which is titled PANP PharmD Transitioning into Practice After Critical Care Fellowship. So our objectives for this talk are to allow for professional discussion among directors on supporting trainees administratively, academically and socially through training and beyond. We want to discuss how these non-physician trainees are evaluated via competency based metrics and then also talk about some barriers, solutions for program expansion, evaluation, adding to faculty development. So we have a few questions prepared and either individual can answer and maybe both are relevant to both specialties or disciplines. So the first thing we want to touch on is what is the percentage of PAs, NPs, PharmDs working in critical care that have completed a residency or fellowship training program? Jolie, if you want to start and then we can go to Melissa. Yeah, so I actually try to do a little bit of digging into this. It's a little difficult to find the exact number, but I would say that the vast majority of pharmacists who are working specifically in critical care at least have probably a first year of residency training behind them. I'd say probably 80 to 90 percent of critical care pharmacists. And then if you look at probably more recent graduates, so 2010 and beyond, I would say upwards of 90 percent of those people who are working within critical care have some level of PGY1 and PGY2 training. On the PA and NP side, it is very different. Less than one percent of all nurse practitioner and physician assistant graduates actually complete a residency. And with that being said, some of the drivers that have recently started to increase those numbers, which we may see that number increase over the next several years, institutions are now increasing the requirements for employment, such as a minimum of two years experience or fellowship training. So a lot of new grads are kind of stuck. And where do I get this experience? Number two, as we see with RNs, some of our other medical disciplines also have chosen this path as kind of a second career and really want to get started in that specialty. So they're turning to fellowship education as really that gateway to get started immediately. Very interesting. Different for that, for this particular discipline. I was curious when I when I was looking at this question, it kind of led me to thinking about what percentage then of PA's and NP's completing their critical care fellowship stay in critical care for the long term, I wonder. And then the same for pharmacy. Are there are there people that complete their residency, postgraduate training and then decide that they don't want the inpatient critical care life anymore? That's a great question. Unfortunately, due to lack of centralized reporting, there is limitations in whether or not we have the accuracy of that number. Anecdotally, throughout the pandemic, I've actually seen more people from other specialties, such as hospital medicine and emergency medicine, come to critical care after their fellowship training in those respective specialty areas because of some of the increased acute needs, because of some of the, we'll say, glamour of saving lives and sort of the the adrenaline rush of critical care. But definitely something we should look into. Yeah. You know, as with all other professions within critical care, burnout is definitely at the forefront for pharmacists. And I think for most people, in my experience, they tend to stay on the inpatient side for a good amount of time before transitioning more into managerial roles or even working in industry, which is another avenue for pharmacy for pharmacists to kind of take kind of post inpatient care. The majority of my colleagues here at Emory University Hospital have been critical care pharmacists for decades or else they're just post their training. And so they're still kind of in the thick of getting their bearings and really staying within it. It's kind of interesting because a little bit different than Michelle mentioned is that pharmacy is usually a first career for most pharmacists. And, you know, inpatient pharmacy is not really typically a second career. And so I think people are come out of residency training, still pretty bright eyed and fresh, fresh face based. And so we stay in it maybe a little bit for a longer time, but maybe a little bit younger when we start the beginning of our career. Excellent. Thanks for those responses. I'm leading us to another another question. A similar path is what do PANP PharmD students or new graduates need to know when they're considering their options to decide to go to the path of fellowship or residency training versus just learning on the job? Excellent. And I'll say with what makes PA and NP education more unique compared to pharmacy education is typically these programs are a two to maybe three year master's program, period. A doctorate program is still optional for our training and any postgraduate training, again, is still optional. So for those seeking NP and PA fellowships, number one, this is not clinical rotations 2.0. Number two, this is not just your 40 hour a week job. If you are worried about that transition to practice or that on the job training, fellowship may be for you. But this is, again, not clinical rotations 2.0. It also encompasses both a clinical and a didactic component. So if you're a little didactically burnt out and you just kind of ready to focus on the clinical aspect of things, maybe look towards on the job. There are also several other academic quote unquote pillars such as leadership and professional development, research, education, community and sort of other social determinants of health focused initiatives that are infused into training. So consider your week looking like a 60 hour clinical week plus 10 to 20 hours of additional academic requirements. So for those who are seeking fellowship, 100 percent commitment to that process and and really facing each of those with the utmost attention and enthusiasm because it's a hard year. But because it's an optional year, we typically do find that the most enthusiastic do end up coming through the process, which is which is great. And I would similarly echo very similar sentiments in terms of being ready to work. I do think pharmacy school kind of prepares students really well for that understanding that residency training is a year to two years of very hard work, very long hours. And, you know, what I the best recommend or best piece of advice I try to give all residents or all students who are looking at residency training is to be very open minded and to, you know, learn as much as they can from each specialty rotation, because it's probably the last year or two that you're going to be able to really kind of delve into specialty services and really learn about those topics. And so I, you know, I recommend each rotation to really learn how to be a pharmacist of that specialty, whether or not you want to do that specialty for the rest of your life. And, you know, those skills that you learn and that knowledge you learn, you can always take forward into your career, but definitely going to be a very hard year or two of work. And probably with pharmacy residency as well, these positions are often for less pay and are often held to a little bit higher standard in terms of performance and attention to work requirements, i.e. for PTO, there may be a limitation on PTO. So if you want to take that six week vacation, residency year is probably not the year to take it. So financially, emotionally, mentally, spiritually, academically, clinically, it is kind of a full picture year that must be taken into consideration. And can I ask, how do you guys in your leadership roles, is it easy to separate the person from the student trainee versus now the credentialed graduate trainee that's now in this middle ground? Or do you view them as somebody hybrid? I would say at least from a pharmacy standpoint, they're very clearly delineated types of learners. With students, they have less capability in terms of being able to put in orders or provide order verification. And so my expectation of what you can do in the day and what your follow up should look like is significantly different. If I have a student who is gung ho, who really has expressed interest in residency training, I try to push them because I want them to understand what the next year of their life will feel like. But with residents, the buck stops with them. And so I have to learn a little bit of allowing release of control and allowing them to be in control of making sure all the orders get in, all the information is communicated. But it's definitely very clearly different in my mind. And we also get the fortune of having students and residents learning at the same time oftentimes. So we get a lot of layered learning, which is also helpful in making sure those those two roles are very clearly delineated. And from the PA and NP side, I would say the biggest difference is hiring an NP versus a PA, whether they have a lot of experience or none, because a lot of the NPs come to the table with years, maybe even double digit years experience as an RN. So they know basic drug names. They know how to titrate pumps. There's this bedside compassionate provider that that may not know the foundation of what it means to be an NP, but you don't have to teach some of that intro to X, Y or Z topic because they know that as a nurse. On the other hand, some of our PAs, the PA programs require a researcher scholarly project. So a lot of them can kind of hit the ground running and know how to navigate the IRB process where some of my nurses who may most don't have the opportunity to do that during NP school need a lot more support or at least direction initially. So I think embracing the differences is a way to celebrate how unique we are trained, both PA and NP, but also appreciating that when it comes to bedside abilities, we both in most states can can do the same thing in training. That's awesome. Leading us to our next question, which is evaluating trainees. How do you evaluate your trainees and how do you develop those competency based metrics? Is there national standards? Are they individualized to the to the programs or institutions that you're at? I was going to say, I'm happy to. This could be an entire session in and of itself. And what from the PA and NP side, what makes this so unique to the institution is that the accreditation process is optional. However, most programs have aligned their evaluation and curriculum based components of a program with ACGME, our physician residency partners, and that nomenclature, for example, the competency is kind of the overarching and an example of that would be patient care. Then the milestone under that would be, OK, here's how we take a history. And then the objectives under that are the specific kind of road map examples of how you can master the milestone, how you can master the competency. And an example of that would be demonstrates cultural competency with taking a sexual history. Now, the evaluator, as they're kind of observing these learners, we try to emphasize observational based evaluations, i.e. how much supervision or how much handholding does this person need to safely perform the objectives? Now, it could range from cannot perform without an immediate bedside, for example, when we start central line training, cannot perform without immediate assistance at the bedside to full mastery now they're teaching it. Now, to take it one step further, I think it's important to make sure that your curriculum is aligned to the competencies and to make sure that you have a robust array of opportunities for that learner to demonstrate mastery of the content. For example, if we are talking about patient care, we may use initial reading so that that learner is then reading articles on how to do X, Y or Z. The second thing they're engaging in discussion with their mentor. So whether it be their bedside mentor, whether it be in kind of a multidisciplinary rounds approach. And then lastly, they're physically demonstrating their competency of the topic. So you're accommodating the visual learner, you're accommodating the auditory learner, you're accommodating the kinetic learner and holding everyone to the same standard. Now, again, a super broad topic, but I think the takeaway here is to make sure that your competencies are clear and your competencies are basic. Ones that we often use are patient care, medical knowledge, communication, professionalism, systems based practice, etc. And to make sure that your curriculum aligns with whatever it is that you're trying to teach. I'd say it's probably a little bit different on the pharmacy side where most residency, I mean, the vast majority over probably 99 percent are accredited by our accrediting body, which is the American Society for Health Systems Pharmacists or ASHP. And that that body also helps us with the matching process and the interview process and recruitment. And so being accredited is important so that you have kind of that outreach and the ability to reach students and residents who want residency training or additional years of residency training. So we do evaluate our residents based off the ASHP goals and objectives, which they have various goals and objectives for critical care specialty as well as other specialties and then for PGY-1. And generally we evaluate our residents on the required objectives, which are things like patient care, research, dissemination of knowledge, kind of like teaching education, as well as advancing the practice. And so we will kind of sort those goals and objectives throughout the various rotations that they take. So each rotation residents are evaluated both in person with their preceptor as well as through our formal process called Pharmacademic, which again ASHP kind of controls and operates that platform that we're able to provide the feedback on. And then on an institution level, we also do a training plan with our residents and we check in with the initial training plan, kind of go over what are your strengths, what are your weaknesses, what do you really need to work on this year? Is it more knowledge? Is it time management skills? What are the skills that we need to grow? And then we evaluate those on a quarterly basis with our resident. And then our resident also has an advisor in addition to me, the RPD, so that there's kind of two people overseeing their progress. And then in addition to that, we also have a monthly pass off for our residents where each preceptor discusses, you know, this is what we discussed on this rotation. This is where they grew and here are the areas that they need to continue to work on for the next rotation so that preceptor can continue that growth going forward. But I would say it's probably more standardized, and that's because our accrediting body kind of requires that standardization. Interesting. Yeah, the difference is mostly, can you comment on the accrediting body for the fellowship, the PANP-APP fellowship? Absolutely. So there is one accrediting body for PA fellowships, and that is the ARC-PA. It's the same accrediting body that accredits PA programs, and it's the only solely PA accrediting body. The nurse practitioners, on the other hand, have three different accrediting bodies that all have their own set of standards, that all have their own application process and eligibility requirements. Some include a site visit and some don't. Now, the challenging part for program directors is programs like my own and several others across the country that bring in both PAs and NPs, whose standards are you going to align with and who are you going to ultimately pay your money to? These accrediting organizations are not necessarily cheap, and most institutions will only support the funds to apply for one program or to one accrediting body. The challenges with there not being a joint accreditation, most often tend to pay the least amount of money to get accredited, and that currently is a nurse practitioner organization. The process to apply is also a bit cumbersome with the ARC-PA. It had gone kind of a revamp period, and it relaunched in 2020, although it is still quite complex. So, we'll see what the future holds. My hope is that because we represent both professions, that there will be a joint accreditation body and that the standards will be more standardized to all programs and that they will be achievable and affordable. I actually have a question. So, I'm not as familiar with your matching process. So, how do you interview and then match or select residents? Absolutely. Each program has their own application requirements and process. They all don't start at the same time either. Because PA and NP programs are graduating at all times during the year, there are multiple start dates, and what we've seen for the most part, it's either a spring start date, a summer start date, or a fall start date. Most PA and NP programs graduate between the months of May and August. So, you'll see more programs starting around that October timeline. What also helps institutions with the onboarding is if you don't start at the same time as your medical residents, because often there's a huge influx of new learners and there's a huge competition for onboarding resources. The downside of only having one start date per year is not many graduates are willing to wait more than four or five months to start employment. So, you as a program director can then decide, and we can kind of get into some program structure questions later, but doing that research ahead of time can help you optimize your applicant pool as well. And, Melissa, Anjali, how many programs are there for critical care, APP fellowship residencies, and how many are there on the pharmacy side? I think that there's something like in the 120s number of PGY2 critical care programs. Most programs, similar to mine, just have one residency position, but there are institutions that have two-plus positions, and then there are other institutions who can kind of flux the total number of residents that they have. So, they might have 10 total residents, and that includes PGY1s and then all their specialty PGY2s. And if they don't match to a specialty PGY2, they might flux that to the critical care program. Here at Emory, we tend to stay pretty, you know, within our own lane. We always, you know, transplant always matches, critical care always matches, and we don't usually get to have more than one, although that is actually one of my limitations. I think we can more than support two residents at my program. And on the PA and NP side, we're running between 33 and 35 annually. The reasons for a program to shut, unfortunately, has been due to some of the economic contractions due to COVID and educator bandwidth to train. We all know that critical care has experienced, like you said, a lot of burnout, and unfortunately, that the first programs to often go are optional educational programs, which are PA and NP fellowships. However, most do employ between one and four fellows over an entire calendar year. There are a few exceptions. Emory can train up to eight per year in critical care. And with that, though, comes maybe a smaller number the following year. So, like you said, it can kind of flux depending on the acute needs and sort of what the bandwidth to train is. But I'm excited to hopefully create within SECM a centralized platform to mainly a resource page for these PAs and NPs to see what types of programs are out there. Because they're unlike the pharmacy side, there's no centralized process that people have to do a lot of research to find out what programs are out there and what their application process and timeline is. So hopefully get that up and running to make it a little bit more transparent to interested parties what programs are out there. I think that's actually a really excellent idea. We have, ASHB has a residency directory, and you can look it up by state specialty. Also, ACCP, which is another kind of inpatient clinical pharmacy organization, also has a directory so that people can find that information, see how many residents are matched, what the salaries are, what the benefits are. It's very transparent. And one of the things I just wanted to point out that's probably a little bit different, too. So, you know, we do have a number of residencies out there, but it's highly competitive and remains highly competitive for pharmacy with only about, I think, 30, 35 percent of new grads matching to inpatient PGY-1 residency programs for those who apply. So, for instance, we've had over 100 applicants for our six PGY-1 positions. And then last year I had, I think, 20 applicants for my one PGY-2 position. We generally try to early commit. So that means that we commit a first year resident who might be interested in a specialty, which is what I've done this year. So we had PGY-1, she's expressed interest in critical care, and we've done an interview process and we were able to early commit her. So I don't have to go through the match again. But when I do, I usually have a huge pool of applicants. Residency training is very, you know, a very big part of inpatient clinical pharmacy. I love that. Yeah. And I love that idea, Melissa. That's fantastic. I remember when I was back at Cleveland, we were in the process of discussing starting a fellowship program. And what do you do the first thing? You Google PAMP fellowship programs. And then you're, you know, it's confusing. There's different standards for everyone who actually has these programs. And it seems like a new one would pop up. Oh, I haven't heard about this one. So, yeah, a centralized location for that is a brilliant idea. I think that's fantastic. So we talked a little bit about the evaluation criteria before. Then we got a little sidetracked. Let's go back to that for a moment and talk about assessing and evaluating new hires and residents. Is there a quarterly process, a monthly process when they switch to preceptors? How often are they formally evaluated in the respective programs? And this is also really tough. Again, it's not outlined within the accreditation standards, the frequency. It just states that they must be evaluated. So many programs will utilize a combination of what we call formative and summative feedback. Formative is, it's more regularly, whether it be monthly, weekly. And it outlines maybe some suggestions for improvement and areas of success within each of those competencies that you've outlined. And then the summative is really when you take in that 360 view. How are you doing professionally? How are you doing personally? Here's where you stand across observational competence in each of the competency areas. Here are some additional areas of improvement, whether it be professionalism or leadership opportunities, etc. And those quarterly meetings typically encompass more opinions as well. So you're seeking out their mentors feedback. You're seeking out nurse and other interdisciplinary impressions of their both clinical and professional performance. And that way it gives them a more, quote unquote, 360 evaluation. That quarterly moment is also their opportunity to express any questions, concerns and feedback for the program as well. And I think it makes them feel this more to a street collaboration as opposed to more of an authoritative direct down. Here's how you're doing. And I think it improves engagement. I also think it improves accountability when they feel like you've got something to work on. They've got something to work on at that point. Yeah, and I kind of touched on this just a little bit earlier, but we kind of do the summative evaluation on a quarterly basis with our resident. But then we are required to have feedback with each rotation. So they do get a monthly feedback session. And then in addition to that, our preceptors are always encouraged to give feedback as soon as possible. Right. And so, you know, if they've given a presentation or they did an in-service, we always want that feedback to go right away instead of at the end of the monthly process. And then a lot of the preceptors here at Emory and probably at different institutions have adopted what we call feedback Fridays, which is our opportunity to kind of go over with the resident on rotation. You know, what are you doing well this week? What's what's the goal that you want to work on for next week? I do that with both students and residents, and I find it really helpful for them to self-identify what they're doing well, but then also have a goal and a focus for the following week of what they want to work on. And again, whether it's a clinical skill, an area of knowledge, it doesn't really matter as long as you're deciding something that you want to do to grow, because residency training is about growing and learning how to be a clinician. I think that summarizes it perfectly. So talking about that, transitioning from the evaluations to support from your institutions. So education is obviously a cornerstone of the of the training programs. What kind of support from the institutions is provided for quality education? That's an excellent question. And again, I think one of the major differences between other professional residency and fellowship trainings, PA and NP fellowships by and large receive no government funding. So these are each institutionally designed to take it one step further. Some fellowship programs will operate theirs out of a centralized center, i.e. a center for advanced practice or an APP leadership center. That kind of directs the flow of money, quote unquote, and make sure that the program is sustainable, that you're demonstrating return on investment, etc. Part of that return on investment is retention, is quality, is feedback, is publication, institutional notoriety, etc. Now, if you are a single fellowship track critical care program that is funded, maybe like the way Emory funds their critical care program, the critical care department is directly responsible for that. There tends to be a little bit more, we'll just say scrutiny in the weeds and how the program is doing. And again, with these optional tracks, if you are not demonstrating whatever it is that that service line intended for that fellowship, then you are at risk of potentially losing some of that funding. It may be in the form of FTEs. So instead of four fellows a year, maybe you're cut back to two. Maybe it's cutting back on the stipend that the program director receives or whatever the compensation is for the program director. But I think the benefits of having an alignment with an academic institution is that academics, quality education and interprofessional collaboration, i.e. if you have a license for a product, it's touching all service, all learner groups, as opposed to just APP fellows or as opposed to just residents. I think the other thing that really enhances the opportunities to have access to these quality education opportunities is leveraging interdisciplinary opportunities. Like Jolie said, this is becoming a really hot topic in education. So whether it be built into rotations, whether it be a specific rotation in and of itself, for example, our hemlock rotation, while not critical care, they do times with several other disciplines to really enhance their understanding of how to better provide patient care. And then I think lastly, too, it's getting buy in from our physician colleagues. We kind of look at them as our sort of seniors in terms of medical knowledge and applying that medical knowledge at the bedside. So making sure that there's physician presence and physician collaboration, I think, really is a great way to enhance the quality that our APP fellows are receiving. In terms of pharmacy funding for positions, there's kind of, I think, two traditional routes that most residency programs take. Either the department funds the FTE or a school of pharmacy. So especially if you're affiliated with the school of pharmacy, there can be some working out of them funding or paying for that position. But, you know, similar to what Melissa said, it comes along with, you know, there are strings attached, meaning that there is some commitment of that resident to the school of pharmacy. And so some sort of education or teaching that they might have to help with or partake in. Here at Emory, our department funds our FTEs for PGY-2 programs and PGY-1. There is some CMS funding that we can apply for for PGY-1 residency training. That does go back to the hospital itself that, again, we can apply for. And the more residents you have, the more money that you can make back to the system. I'm very lucky in that the Emory Critical Care Center very much supports training and education. And so, you know, we've developed an interdisciplinary committee where all of the fellowship and residency program directors, we meet quarterly. And we discuss how we can share our resources in terms of like learning and what things might be helpful for all disciplines and not just, you know, medicine or not just pharmacy. In addition to that, Emory Health Care is a health care system. And so we have multiple hospitals with multiple residents. And there are some training, professional development things that we share amongst the pharmacy departments at all sites. And it benefits all residents regardless of specialty or year in training. We have a Pharmacy Grand Rounds that all of our residents participate in. And again, you know, that kind of helps serve a purpose for the department as well as the residents in terms of like their learning and education. It sounds great. I love that. There's so much interdisciplinary involvement, which mimics SCUCM. They do such a great job with involving every specialty across the board. So good to see that with the programs as well. So let's let's talk a little bit about jumping around a little bit. I think that we can tie in some other things. But a curiosity I have is how do the programs assist with job placement afterwards? And also, how many residents do you tend to keep within your residents or fellows within your own institution? Great question. Again, a lot of variability. But where we've seen the most success is when programs have established a partnership with whether it be human resources or their recruitment team. Because like you said, not everyone that trains in critical care wants to stay. But is there still a return on investment if they stay with an alternative group within the system? Vice versa, they're often the first professional made aware of a position opening or of someone leaving or of a disciplinary action that results in a termination. And then they're kind of clued into, OK, hey, I've got this fellow in the hopper that I would love to retain. Now, we very much delineate when fellows can transition fully into those roles to make sure that we observe the integrity of the training. So this is not to say a month to a position opens up and that fellow immediately fills the hole. But having that collaboration allows for more parties at the table to influence the hire of that fellow. Now, another strategy is we have an alumni network within the atrium health system. So if someone's looking outside of our own institution, then we can say the Seattle area, search the database by Seattle and reach out to folks to say, hey, do you know if anyone is hiring within the area? Something else that, you know, I think institutions may employ is a mandatory retention. Emory is one of them, and that is one way to immediately eliminate that variable from the table. You know, for a year or two post fellowship, you are committed to this service line or you must financially pay back an X amount. Typically, folks are not willing to pay that and want to stay. But for those programs, kind of keep that in mind if you are interested in a fellowship program, because it very well may be Midtown Atlanta is not for you. Likewise, a lot of these professionals seeking fellowship are in the infancy of their quote unquote professional career and are looking to put some roots down in the city. So it does have the potential to to become a to become a home. And next thing you know, three years goes by like that. I think another thing, too, is establishing that conversation not early, but within maybe the first six months of the fellowship and making people aware that even if they don't stay, that they're learning is not going to be compromised. That there is some institutional benefit of someone leaving Atrium Health or leaving Emory or any other institution that has a very reputable program and going to a program or going to a hospital in Texas or in the Northeast or in the West, because they're establishing, you know, the Atrium name or the name at an alternative institution. So it's not all bad. I think it goes back to how do you set up your demonstration of return on investment? You want to maintain this partial retention rate, but I think it's also OK to leverage those outside networks to connect them to the best professional fit. Yeah, I think ideally in the pharmacy world, it's ideal to want to keep your resident if you have a position and it all comes down to timing and expansion of clinical services. We've been very fortunate in the past, I think, about six years. We've kept almost every single one of our residents on in some capacity. And most of that is through expanding our clinical services. And this is really where the world of pharmacy is seeing a lot of growth is into kind of those off hours. So most of our residents aren't getting these daytime specialists in an ICU positions and they're more of working evenings, overnights. Again, we would love to try to keep all of our residents because we've put the time and effort into training them. However, we do train them with the idea that they might leave the nest and go spread to a different institution. And hopeful, you know, I'm always hopeful that they spread the good name of Emory and their good training to other institutions. And I support my residents in whatever kind of position that they want. I've actually had the past few residents have had kind of a second love outside of critical care. So emergency medicine and cardiology. And I've really I really try to help them guide them through the process of what kind of jobs fit both of those loves and desires and needs that they want out of their positions. So we do have a lot of, you know, before me, there was most of our residents did not end up staying on at Emory and they went to go do specialist positions or off hours in other institutions. So it just kind of depends. And again, we have a lot of support through ASHP in terms of a centralized kind of job finding forum for our residents, which is where they find a lot of the positions that they're looking for. But we do also have networks of preceptors who've been at other places and they can kind of help find or put in the good word if there's another institution looking for a critical care pharmacist. I think I think those are both great answers. So just kind of summarize in my mind. Ideally, you'd always want to keep the resident if it can work out because it's financially, you know, ideal for the for the institution. You've trained this individual, so you know what their their capabilities are. And then also, to Melissa's point, having that perspective, if they don't want to stay with the institution and they're looking elsewhere, having that thought that, OK, at least they're going to spread the good name of the training program, hopefully, is the idea. So I really appreciate those responses. I'm just being mindful of time right about 45 minutes right now. So I think that time for a couple more discussion questions. One I wanted I thought was a really interesting question that we discussed is if you're hiring both new graduates or outside fellows residents and you also have a individuals in the new training program. What is the differences in handling the onboarding of those individuals? And whoever would like. Yeah, that's a great question. So in terms of transitioning into critical care, most institutions will not hire new grads, period. So you're typically not doing the ground up legwork, but you may have a new hire that's worked in critical care for several years. And they're put on kind of an abbreviated three ish month transition to practice or I should say transition to institution where you're teaching more systems based practice. You're teaching more EMR nuances and sort of who do you call when and for what reasons, as opposed to your fellow who was way more clinically deficient, which we expect. And the reason they're in the training program. So their emphasis on training is more in the clinical and academic space with those along the way and fusion of systems based practice, practice based learning and improvement metrics. So it is possible to have someone who is hired externally to the system from a from an onboarding perspective, train alongside a fellow because they have different needs. They have different usually mentors, preceptors, etc. Now, what does impact the team is when you're training both eight fellows and you hire six new PAs and NPs, the sheer volume of learner needs can can I from anecdotal, I can say has has brought the most angst to a team and not necessarily training a one by one. Yeah, and probably the hiring process, especially when you're thinking about the critical care specialty for pharmacy departments is you're hiring somebody who has had some residency training or has experience. I don't I it would be very rare to find a critical care pharmacist who came fresh out of being a new grad. So you are getting kind of that baseline, you know, somebody who already has a clinical knowledge and it's more how does this institution function and how does pharmacy function within this institution. And so they're onboarding here. At least we've actually had a couple of new hires within the recent, you know, one to two years. And most of what they're doing is they're following the specialists and their ICUs each day and kind of seeing what, you know, like the nuances of their unit. And then they're orienting with the department to understand what are the pharmacy department issues that I need to understand. And then they're finally able to be on their own. And so that's probably about a four to six week process of onboarding versus the clinical training that you're doing with the resident for a year, which they're learning all of these things about the institution, but you're also building in that clinical knowledge. Excellent. And I'm sorry, you may have said this, both of you in the introductions, but are you both products and examples of starting your residency at Atrium and Emory, respectively, and then staying on with it? I actually did my postgraduate training elsewhere because at the time I didn't even know of Atrium Health's program. And I knew I wanted to do critical care as a PA, but we aren't often afforded an elective in specialties. So when I inquired to my program director, she made the suggestion. And I typed literally, like you said, in the Google search. And I found this website that had sort of a reasonable list. And it was the only program I applied to. I had no idea that there was this depth and breadth of training opportunities and truly felt that after I completed a critical care fellowship that I could not have done it without the program. Everything from mentorship to procedural training to, you know, learning difficult lessons just clinically. And I remember just a quick story. I was called to the OR for DSATs and they did a PA because a patient was proned for an orthopedic surgery and they were having high peak pressures, chest x-ray, yada, yada. I needed to put a chest tube in. But the way the patient was positioned, it looked like the chest tube traversed the liver. Let me tell you, I was pacing back and forth outside of that operating room and just realizing, okay, I should have troubleshooted. Was there any difficulty with it? No. Was the chest tube, was the pleurovac operating fine? Yes. I should have just let it go today. I would have let it go. But then it taught me to trust your gut and to really kind of go back through the steps. I share that with you because what ultimately motivated me to get into this role was to help people make that transition, to give them that confidence and to increase the exposure in the single year that they have to get comfortable with critical care and to ask the questions why, to make mistakes, but in a very protected and fun kind of way. I think the difficult mistakes are the biggest learning lessons often. And through the education curriculum or continuum, we all have our fair share. And how up front we are about them is another story. I was going to say, Jolie, did you train at Atrium? I'm sorry, at Atrium. At Emory? Yes, I did. I did both my PGY1 and PGY2 here. Excellent. Perfect example of the question we were talking about. So I think we're coming to the end a little bit here. I wanted to hear from, you know, we've talked about the programs and evaluation processes afterwards and beyond. What are some things that are areas that you wish that you could support your trainees, your fellows, your residents a little bit better? So I think probably, and this is, I don't think Emory specific, but probably the biggest challenge to our trainees right now is preceptor burnout. I think supporting our preceptors to ensure that they're able to appropriately train our residents is really important. We ask our preceptors to do a lot more, right? They provide patient care. They provide training. They're, you know, most of our specialists here at Emory are on various committees, both institutional as well as national. They're working on protocols. They're working on research. We ask them to do a lot in addition to training our residents. And so finding a way to combat preceptor burnout and to fight preceptor, especially burnout with like layered learning. A lot of institutions have residents on, you know, eight of the 12 months of the year and they have students nine of the 12 months of the year and they don't really ever kind of get a break or they can just come in and be a pharmacist in practice and go home. Right. So I think supporting our preceptors and finding more time for them will help make our training process better. So, you know, especially with the pandemic and people not being able to socialize as well here, Emory, we're taking steps to get back into socializing, get back into life outside of work, you know, getting to know each other again and supporting each other kind of that way, which I think is a major has been a major contributor to burnout in the past couple of years. Absolutely. And some of the things Atrium has done, certain award systems that the institution will support, whether it be monetary gift cards, et cetera. Number two, taking the time to truly acknowledge their efforts and to make sure that they feel appreciated and that without them, this whole process would not be possible. And then lastly, getting the service line to support mental health days and other days off without the exhaustion of their PTO. I would say another thing that I would change from a trainee perspective is the diversity and the procedural opportunities that were present pre-COVID, i.e. we actually had a legit stroke unit. We actually had a bone marrow transplant ICU, and I feel like a lot of the volume of patients they've seen this year have been COVID patients. For better or for worse, the strokes and the heart attacks weren't coming to the hospital because they didn't want to get COVID. So the diversity of pathology has greatly diminished because of COVID. And subsequently, their procedural opportunities have as well. A lot of these early high-risk intubations we were calling anesthesia, and the physicians really wanted to own that responsibility, which really limited our numbers. So ways that we've kind of gone around that is optimizing some of these more regional facilities that have lower COVID comparison census, i.e. a lot of the high-risk COVIDs or diminishing conditions came to the academic center. Which kind of left some of our other pathologies at the regional facilities. Number two is utilizing the simulation center. While not perfect, it does create this atmosphere in conversation of additional pathologies. And then I think lastly is retention. A lot of our fellows really want to stay and or a lot of our fellows really want to go to city X, Y, and Z. But as with some of the economic contractions and or huge hiring flux maybe a year ago, there just isn't a lot of opening at the moment. And that may be institutional dependent, but I really wish I could support a position for every fellow that's really put in a lot of hard work this year, but just may not be possible. Those are great responses. Appreciate that, guys. So we're about at the limit for the discussion right now, but I think that we've had a really great discussion, brought up a lot of interesting points, and really had a valuable use of our time. So I want to just say again, thank you to Julie Gallagher from Emory and Melissa Ricker from Atrium Health for your expertise and your time discussing something that you're leading in the field right now. So this is excellent, and we really appreciated your expertise here. Thank you. Any closing thoughts before we end this that you guys wanted to hit home on? I think two parties. For the future learners that are interested in programs and or critical care, you can do it. It is going to be hard. Get creative. Apply to fellowships. Really commit to the learning, the asking the why. The mentorship, the clinical, the didactic education at the end will all be worth it. And then I think, too, to the co-educators, co-program directors, co-facilitators, you are not alone in this fight to educate the next generation of learners. So lean in on the community of your colleagues within your own walls, outside of your own walls, because we all are experiencing similar struggles. We all are experiencing similar emotions internally about what it's like to train during a global pandemic. So thank you for your time listening, and hopefully this sparks some conversation within your own communities as well. Right. Appreciate that, Melissa. Okay, everyone. Thank you so much.

critical care

training

supporting trainees

residency training programs

competency-based metrics

job placement

mentorship

diversity in pathology

interdisciplinary collaboration