Hello everyone. It is a pleasure to moderate the inaugural year review for the in-training section at this year's SCCM conference. The in-training section is one of the youngest sections of the Society of Critical Care Medicine, with an aim to develop and foster trainees and young faculty as they transition from students to professional practice. We welcome all medical professionals represented in the critical care field, including physicians, critical care nurses, nurse practitioners, pharmacists, physician assistants, respiratory therapists, and others. Our section is diverse, but a common theme does emerge. We are devoted to the advancement in the practice of medical education. It is this attention to medical education that is recognized by the Society of Critical Care Medicine with our very own year in review, a year filled with so many challenges. 2021 forced us to reconsider how we safely reach and educate trainees, finding innovative ways to educate and mentor. Our speakers today will highlight academic work that have furthered the way we use remote learning to achieve this mission, as well as work on the implementation and assessment of ultrasound training. Finally, we will hear on the importance of the joy we feel when we come to work. This last topic of wellness and burnout, and the very lasting consequence that it could have on career fulfillment, is too important not to be discussed early in the careers of our members. Our very first speaker is Dr. Erin Hennessey, a clinical associate professor in the Department of Anesthesia, Perioperative, and Pain Medicine at Stanford University. She's a director of the Critical Care Clerkship for Undergraduate Medical Education, and the program director of the Anesthesia Critical Care Medicine Fellowship. She currently serves as the chair for the program director's advisory committee for SOCA, the Society of Critical Care Anesthesiologists. She received her master's in education in health profession from Johns Hopkins University, and has an interest in competency-based assessments, curriculum development, and holistic review processes for recruitment. Our second speaker, Dr. Andrea Sicora, is a clinical associate professor and a critical care pharmacist at the University of Georgia College of Pharmacy in Augusta University Medical Center. Her interest includes burnout mentoring and wellness in the health professions. Please join me as I welcome our two dynamic speakers to the year in review for the in-training section. 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 in med-ed 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 in critical care medicine. No 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 AAMC and trustable professional activities, the SCCM VCCR learning modules, and objectives from two different school of medicine clerkships to develop their content items and their survey. They had 82 percent participation rate, they used three rounds of iteration, and they used a 75 percent 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. Similarly, 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. Until 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, 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 the 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. But these early studies did not represent change in behavior or results and outcomes related to patient care, and could be an area of focus for future studies. Prior to the pandemic, our focus on training and 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, summative assessment, a cognitive assessment, competency achievement, and a maintenance of competency. And what the authors did is they gave an outline or how-to manual for critical care And 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. Now 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 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. And 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. Moving 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. Hello, everyone. My name is Andrea Sikora, and today I am looking forward to presenting as part of the in-training sessions 2021 year in review. The specific topics we're gonna be focusing on are gonna be mentorship as well as burnout. Burnout is a syndrome that has three dimensions that results from chronic workplace stress that has not been successfully managed. These feelings include energy depletion or exhaustion, as well as increased mental distance or cynicism related to one's job. Now, it's interesting to realize that burnout has components that are related to healthcare, so we think of distance from patients and patient care, but also is noted in education, so distance from students and so forth. So any profession that has some degree of caring or teaching another, you might see this. And finally, it has reduced professional efficacy. The healthcare profession right now is really facing a pandemic burnout, and this burnout was present even before COVID-19 came on the scene, and COVID-19 has really just served to fan those flames. So some good numbers to see are that over 75% of U.S. healthcare workers claim self-reported burnout, with 90% experiencing stress, 80-plus percent experiencing anxiety, and 77% reporting increased frustration and feelings of being overwhelmed. The rates of burnout are greater than 50% that have been reported across professions, so physicians, nurses, pharmacists, and this is specifically true in critical care and emergency medicine, especially, again, in the COVID-19 pandemic, but has also seemed to be inherent to these disciplines. When we think about burnout, we generally think of organizational factors as well as personal characteristics that are coming together to create this syndrome. But when we think about the specific intersection of burnout and critical care, we also have to bring in the unique factors of an ICU environment, which is going to have elements of compassion fatigue from dealing with critically ill patients, moral distress from difficult decisions that are being made under very stressful situations, perceived delivery of inappropriate care, and so forth. So that already creates a unique setting for feelings of burnout. Then, on top of that, you bring in the fact that critical care is an academic discipline, and so many of the people that are taking care of those patients also have faculty and teaching-type roles, doing research, doing service, giving SCCM talks, and so forth. That's another independent factor that comes in and can relate to burnout syndrome. All of this comes into these issues that we're facing, including post-traumatic stress disorder and psychological symptoms faced by critical care healthcare workers, decreased patient satisfaction and quality of care that's being delivered at the bedside, and also increased rates of job turnover and even attrition from the field, which is not only unfortunate for the individuals that are leaving the field after years of training and so forth, but there's also increased cost to the institutions. This brings us to the first article that we want to highlight, called Igniting Change, Supporting the Well-Being of Academicians Who Practice and Teach Critical Care, and it was published in the Critical Care Nursing Clinics of North America journal. You can see here the key points that they're highlighting, which is that there are unique challenges and stressors that can threaten well-being when you have someone who is, who works at the healthcare bedside, in this case, nursing was the highlight, but also is a faculty member. So you have someone who's taking care of both patients, but then also serving students, and likely has a research and service component as well. This article is unique in that it discusses the environment specific to those that are teaching, learning, and practicing within the critical care domain, and what is gonna be useful for overall well-being. And then also discusses some of the strategies, and although this article was focused on critical care nurses, I think that many of the lessons can translate among all the fields and professions that we have within critical care. So the two key highlights of this article focus on wellness and the models that are gonna improve wellness. And so it discusses the synergy model to improve well-being of these academicians who are practicing and teaching critical care, and highlights the use of this structured wellness program that's designed for those teaching, practicing, and advising colleagues and students in the critical care environment. And this brings me to yet another aspect of caring for others, which is so a part of what critical care is, which is again, not only that we're taking care of a critically ill patient, but then you may be teaching, you're gonna have learners and trainees, you're also gonna be potentially mentoring colleagues and people that are in various phases of their career, and this is on top of if you hold a leadership position or a supervisory position, where you're going to be in those roles as well. And so overall, this asks a lot of each individual when it comes to empathy and caring and feeling like you're making a difference. It has been really wonderful to see that there is much more awareness of burnout and burnout's effect on the individuals as well as on patient care. It's also been great to see this increasing promotion of wellness and just awareness of burnout. But you will also hear at times critiques of different programs in discussions where essentially a frayed ICU worker comes out of their 12 plus hour shift where they felt like they didn't have the resources that they needed, they didn't have the staff that they needed, and their point is the pizza party didn't really do anything for my wellness or my feelings of burnout. And I think that's a very fair complaint or critique of some of these programs. And one of the things that I like the best about this article is that it has institutional components for improving this environment as well as individual components. And so individual components are very important, and this is kind of on the individual to take responsibility in that way in terms of sleeping, exercising, nutrition. I mean, there's a lot of good things to be said for taking that time for yourself and promoting wellness on that level. However, those things can be very difficult if you don't have institutional support or feel that you have institutional support to do that. And so one of the things I liked about this was that you can see that they're equally balanced concepts here where they're discussing having a wellness committee, developing curriculum, having events, and investing in professional development. And the reason why these things are important is when you start talking about feelings of personal inefficacy and so forth, professional development can be very useful for this. I also think these type of committees, when done well, can identify problems that can be fixed on a structural or institutional level. And I think that's one of the most important parts of this article and why it's worth reading and thinking about how it can be applied to your setting. The next article that I want to discuss is called Killing the Fire, the Power of Mentorship, and it was published in the American Journal of Health System Pharmacy. This article discusses mentorship within the profession of pharmacy, but I think the concepts go well into any profession within critical care. I also think that this article goes well with our discussion of burnout. You can notice in the previous, it was discussing seek high-quality feedback and connection. I think one of the best things about mentorship when it's done well is that not only does it provide you practical, hands-on advice of, hey, you have too much on your plate, don't take that on, which can eventually lead to burnout, but I also think it provides you these really high-quality connections. And one of the most important things for preventing burnout and for feeling, I guess, efficacy in the field and so forth is these feelings of connection and loyalty over time. This article defines mentorship as a deliberate, effortful, and evolving relationship characterized by mutual growth and shared altruism with a primary goal of the personal and professional development of the mentee. I want to break down this definition for you all because I think it's a very meaningful definition. The first is that it's deliberate. This is not a happenstance experience of you happen to see someone in the hallway and you provide them a little bit of advice. This is something where you're seeking an individual out, you're following up with someone, you're making time to meet, both people are reaching out, both the mentor and the mentee are reaching out to each other, investing in the relationship. This gets to the effortful side of things. This is something that you're going to expend effort into. If a mentor says, I think you should go look into this fellowship program, you're going to go spend the time and look into that program or if a mentee asks you a question and you don't have a good answer for it, you're going to spend time looking up the answer or finding people that can help them answer that question. You're willing to put in that time and that effort. Finally, it's evolving. This means that you may have a mentor-mentee relationship with a third-year pharmacy student that has a certain dynamic and then five and 10 years later, as they graduate from pharmacy school or residency, take on their first or second job, it can evolve into a much more collegial-type relationship. Second, this characterization of mutual growth. So the mutual growth means that both individuals are there in a give-and-take type dynamic. You're both giving to each other and providing something, but you're also taking something from the other in that you're becoming hopefully kind of your best self through the process of mentoring or being mentored. It's also shared altruism. At the end of the day, what you guys are doing in this dynamic is trying to do what's best for the other. It's important to realize that the primary goal is the personal and professional development of the mentee, but again, it's important to realize that mentors are taking just as much from this relationship at times as the mentee is. You will sometimes hear mentorship, advising, coaching, and precepting used kind of in similar ways, but they are very distinct concepts. So a coach is someone who's helping you with a specific skillset. They're saying, I'm gonna coach you on how to become better at doing a literature search in this way. An advisor is a formal program. They may also be a mentor, and this relationship may extend beyond the formalities, but this could be you start your first year as a faculty and you have an advisor for the first year that you're required to meet with every month to discuss your progress. That's wonderful, and that person may grow into being a mentor, but the idea of mentorship is that it transcends some of these more structural aspects. Thinking of the evolution of mentorship, I think it's really important to realize how much was grounded in healthcare and even how healthcare mentorship has evolved over time. One of the things to kind of think about is that the odyssey, that's where the word mentor comes from is when Athena, the goddess Athena, takes on the role of mentor to help a young Telemachus through his difficult journey. It's interesting to note that the Hippocratic Oath begins with saying mentorship and saying that he's part of a long line of individuals who's passing down tradition. It doesn't even start with medicine, and it certainly doesn't start with do no harm, which I think is very interesting. You move into the guild and apprenticeships of the Renaissance times. This is a very hierarchical standpoint. You have the senior person advising the more junior person with kind of one, the flow of information and benefit kind of going in one direction. And finally, I think as we've evolved in healthcare, we're seeing again these mutual growth, shared altruism-based relationships that have the power to provide advocacy, enhance connection, but again, is characterized by this give and take of both individuals. Another really important article that came out this year focused on gender equity in pharmacy. It wasn't necessarily within critical care. And again, it was focused within one profession. But what I loved about this article was how action oriented it was. And I think that many of the concepts that are discussed here would translate well into critical care as well as other professions. And one aspect in particular I wanna highlight within this kind of donated mentorship is that one of the specific actions that was recommended was that diverse mentorship can promote diversity, equity, and inclusion in leadership, in recognition, and so forth. And I think this is a really beautiful thing that this construct that we're gonna use in so many other areas can also promote DEI concepts. It's really interesting to realize that mentorship, although it can have these kind of touchy feely words like mutual growth and shared altruism and so forth, has extremely practical benefits. The numbers are very supportive of the fact that having a mentor makes you more likely to get a promotion that you want, to be given awards and titles that you're interested in. It results in higher salary and pay overall. But it also decreases turnover, increases feelings of satisfaction and personal wellbeing. There's a lot of benefit that kind of shows that what you put into a mentoring relationship is likely what you're gonna get back out. And I think that's really powerful to realize. This article proposes an ethical construct for mentorship that is based on healthcare ethics of autonomy, beneficence, non-maleficence, honesty, as well as justice. Autonomy can be thought of as the independent and successful functioning of the mentee. So good practices are identifying challenging and attainable activities, engaging the mentee in meaningful dialogue, having the mentee seek alternative viewpoints and provide follow-up on guidance that's taken. And so again, what we're looking for here is that the mentee can have these really thoughtful experiences and reflection and self-development, but that they are gonna be ultimately independent of the mentor. Beneficence here is the act of doing good with personal and professional success of the mentee as the goal. So we're looking to identify new connections and individuals for the mentee based on their interests, generating new ideas and topic discussions, providing meaningful feedback and so forth. So the goal here is for the mentee to have the most benefit. And so it's good to think about, okay, what are the best uses of their time, not just what's most useful for the mentor and so forth. Justice is generally concerned with the fair and equitable treatment of others. Within a mentor-mentee relationship, to me this means providing appropriate authorship and credit on scholarly work products, prioritizing time together, so not canceling meetings last second, putting the calendar invite on there, respecting each other's time and efforts, as well as making sure that everyone is gaining things from this relationship in the best ways possible. Non-maleficence has to do with not harming others. Obviously you will hear stories of egregious infractions of sexual harassment or coercion of other kinds, and this should never be tolerated. But also I think that there are moments where there are difficult ethical discussions between a mentor-mentee that are maybe in more of the gray areas. And so again, to me this has to do with making sure you're having the best use of your mentee's time. Just because they can maybe help you with something doesn't mean that it's beneficial for them to do so. Again, providing appropriate level of credit and sponsorship for different published works and deliverable products, putting your mentee forward in the best possible way as opposed to basically using their work for your benefit only. Also, I think globally being aware that both of you are professional reflections of the other is very important. The final construct is honesty, which is the truthful and authentic reflection and feedback which is gonna be core to mutual growth. So this is gonna include scheduling time for open dialogue, asking difficult questions, providing detailed feedback at regular intervals that includes both positive and negative feedback, although I think all feedback can be delivered supportively. Reflecting on questions for discussion in future time and basically just being honest regarding current struggles, feelings and so forth because if you're not honest, you're not gonna get the most out of the relationship that you're looking for. I want to thank all of you for coming to this discussion today. I hope you will read these articles and take something from them. I found them both to be incredibly idea-generating in terms of how to apply to your own practice and your own institution. I wish you the best of luck.

critical care field

COVID-19 pandemic

medical education

mentorship

burnout

diversity

patient care