Annals of the American Thoracic Society
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Compared with their Full Code counterparts, patients with do not resuscitate/do not intubate (DNR/DNI) status receive fewer interventions and have higher mortality than predicted by clinical characteristics. ⋯ Residents appear to assume that patients who would refuse cardiopulmonary resuscitation would prefer not to receive other interventions. Without explicit clarification of the patient's goals of care, potentially beneficial care may be withheld against the patient's wishes.
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Twenty years ago, the term "hospitalist" was coined at the University of California-San Francisco (San Francisco, CA), heralding a new specialty focused on the care of inpatients. There are now more than 50,000 hospitalists practicing in the United States. At many academic medical centers, hospitalists are largely replacing subspecialists as attendings on the inpatient medicine wards. ⋯ Residency programs have instituted creative solutions to encourage more internal medicine residents to pursue careers in subspecialty medicine. Some solutions include creating rotations that promote more contact with subspecialists and physician-scientists, creating clinician-educator tracks within fellowship programs, and appointing subspecialists to internal medicine residency leadership positions. We need more rigorous research to track the trends and implications of the generalist-specialist balance of inpatient ward teams on resident career choices, and learn what interventions affect those choices.
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The implementation of team-based care models in residency programs is one method to improve patient and provider outpatient satisfaction. However, to our knowledge, this has not yet been studied in fellowship programs. ⋯ The Fellow of the Day role was successfully implemented at our institution with multiple benefits, not only to fellows but also to patients, medical students, and supervising faculty. Our education committee has recommended continuation of the role in our fellowship program.
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Critical thinking, the capacity to be deliberate about thinking, is increasingly the focus of undergraduate medical education, but is not commonly addressed in graduate medical education. Without critical thinking, physicians, and particularly residents, are prone to cognitive errors, which can lead to diagnostic errors, especially in a high-stakes environment such as the intensive care unit. ⋯ The five strategies are: make the thinking process explicit by helping learners understand that the brain uses two cognitive processes: type 1, an intuitive pattern-recognizing process, and type 2, an analytic process; discuss cognitive biases, such as premature closure, and teach residents to minimize biases by expressing uncertainty and keeping differentials broad; model and teach inductive reasoning by utilizing concept and mechanism maps and explicitly teach how this reasoning differs from the more commonly used hypothetico-deductive reasoning; use questions to stimulate critical thinking: "how" or "why" questions can be used to coach trainees and to uncover their thought processes; and assess and provide feedback on learner's critical thinking. We believe these five strategies provide practical approaches for teaching critical thinking in the intensive care unit.
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Point-of-care lung ultrasound imaging has substantial diagnostic value and is widely used in respiratory, emergency, and critical care medicine. Like other ultrasound examinations, lung ultrasound is operator dependent. The current recommendations for competence in lung ultrasound set a fixed number of ultrasound procedures to be performed without considering different learning rates. Recommendations do not consider different uses of lung ultrasound across specialties. ⋯ This assessment tool provides a relevant, valid, and feasible method for evaluation of operator competence in point-of-care lung ultrasound across multiple specialties. This allows for a more individualized assessment of competence than current recommendations.