Program evaluation data collected from learners are widely used in medical education for quality improvement, accountability, and accreditation. Generally, success entails high response rates and mean item scores above predetermined thresholds. Although pragmatic, these practices assume when data from multiple learners are aggregated, they converge on a more accurate representation of a single educational object, such as a training program, and reduce the influence of misrepresentative, outlying data. Drawing on Communities of Practice and the professional identity formation literature, this Perspective argues learner-completed program evaluations are better understood as traces of learner-program interactions, shaped by each learner's experience of socializing into a community of practice. Because trainees enter programs with pre-existing personal and professional identities, participation in training is never fully identical from one learner to the next. Rather than capturing multiple data points about a "single" program, evaluation responses describe multiple fellowships, each of which emerged through the interaction between a particular learner and the program's design. This reconceptualization has important implications for the interpretation of isolated ("N of 1") findings. Outliers, especially when they suggest a negative experience, should not be dismissed merely as a minority view, as they capture meaningful experiences obscured by aggregate reporting. This requires reconsideration of how educational data are interpreted, how evaluation systems preserve variation, and how curricula are designed and delivered.
Program signaling was introduced to address application inflation in graduate medical education (GME) by providing applicants with a structured mechanism to express genuine program interest. While signaling has been widely adopted across specialties, evidence-based guidance specific to fellowship recruitment in Pulmonary and Critical Care Medicine (PCCM), Critical Care Medicine (CCM), and Pulmonary Medicine is lacking. The Association of Pulmonary and Critical Care Medicine Program Directors (APCCMPD) Recruitment Committee developed specialty-specific signaling recommendations, drawing on a comprehensive literature review, a national benchmarking survey of program directors (n=108), and through consultation with ERAS representatives. Our literature review confirmed that signaling increases interview yield across specialties, with the strongest gains observed among MD graduates compared with DO and international medical graduate (IMG) applicants. The benchmarking survey revealed that 92.8% of programs participated in signaling, over half reported reduced application review time, and most programs used gold and silver signals identically. Key deliberative considerations included the unique cross-applicant dynamics among PCCM, CCM, and Pulmonary pathways, the structural inability of ERAS to distinguish CCM tracks within PCCM programs, equity implications for IMG applicants, and the relationship between signal number and signal value. Based on these findings, we recommend transitioning to a non-tiered signaling system, allocating 15 signals for PCCM, 10 for CCM, and 2 for Pulmonary, and maintaining separate signal pools with continued monitoring. We also provide specific guidance for both applicants and programs to promote transparency, equity, and holistic review. These recommendations will be reviewed iteratively as applicant behaviors and match outcome data evolve.
The Internal Medicine (IM) Match into subspecialty fellowship has grown in complexity and competitiveness with record numbers of applicants and applications submitted, evolving specialty-specific expectations, and introduction of preference signaling among contributing factors. Insufficient available positions relative to interest already leave many qualified candidates unmatched and Graduate Medical Education reform needed to confront the looming physician deficit in the face of an aging, medically complex general population may further destabilize the fellowship Match process. Advising has historically occurred through informal networks exacerbating uncertainty and inequities, and potentially contributing to reactive application strategies rather than deliberate pursuit of program alignment. These factors threaten the future availability of subspecialists to partner with generalist colleagues in care delivery; and may jeopardize patients' access care. We advocate for formalization of an Associate (or Assistant) Program Director for Subspecialty Medicine to provide structured, longitudinal subspecialty-specific guidance for fellowship-bound residents. This role provides support through three critical phases: 1: Early conversations about goals, diverse career options, and mentorship connections for equitable access to opportunities; 2: Elective and scholarly experiences planning to deepen engagement in the preferred field and build cohesive portfolios; 3: Application preparation emphasizing program alignment and delineation of support networks irrespective of outcome. The role can be adapted depending on programmatic characteristics, and regional collaborations can broaden the reach of mentorship resources. Embedding subspecialty-informed advising within residency infrastructure facilitates proactive, equitable and intentional mentorship for residents as their professional identities are evolving and formalizes faculty effort toward the development of a well-rounded subspecialty workforce.
INTRODUCTION:Coal Mine Dust Lung Disease (CMDLD, often referred to as Black Lung) is associated with social, economic and emotional impacts for miners, their families and Appalachian communities. Effective care for coal miners requires a multidisciplinary approach centered on collaboration between physicians, behavioral health specialists, epidemiologists, federal regulators, attorneys, journalists, community advocates, and policy experts. These partnerships are essential for clinical management, disease prevention, benefits navigation, and worker protections. Despite this complexity, most health professionals receive little formal training in occupational surveillance programs, benefits navigation, or policy advocacy relevant to coal miners. To address these needs, on September 17, 2025 we convened the Central Appalachian Coal Miner Summit, a multidisciplinary continuing education conference. METHODS:Speakers were selected for subject matter expertise across clinical care, public health, law, journalism, social sciences and policy. The plenary session, delivered by a New York Times journalist was entitled, "Why journalism matters to coal miners and Appalachia." Additional sessions addressed CMDLD epidemiology, mental health of coal miners, CDC prevention programs, mine safety regulations, and black lung benefits. Conference effectiveness was evaluated by pre- and post- conference surveys assessing self-reported confidence across five competency domains. RESULTS:Forty in-person participants completed both a pre- and post-conference survey and were included in the paired analysis. Participants demonstrated statistically significant improvements in confidence across four of the five assessed domains, particularly in areas underrepresented in traditional medical education, including benefits navigation and occupational health policy. DISCUSSION:Conference participation was associated with significant improvements in confidence across multiple domains central to coal miner health, particularly in areas underrepresented in traditional medical education, including benefits navigation and occupational health policy. In the immediate aftermath of the conference, participants also joined collaborative advocacy efforts and formed new research partnerships to work towards improved coal miner health. Future work will assess whether these gains translate into sustained changes in clinical practice, surveillance participation, and benefits utilization.
Intensive care unit (ICU) triage is a cognitively complex and emotionally charged task that challenges clinicians across training levels. Although trainees may recognise prognostic factors and ethical principles, many lack a coherent structure to integrate these elements into a defensible real-time assessment. We describe a three-domain triage framework - Premorbid, Morbid, and Postmorbid - designed to support structured reasoning during ICU triage, particularly for on-call senior residents and clinicians who do not practice critical care routinely. The framework is taught through case-based discussions embedded in routine clinical care within a high-volume medical ICU at a large tertiary hospital. The Premorbid domain considers baseline physiologic reserve, including functional status, prolonged hospitalization, nutritional state, and irreversible comorbidities. The Morbid domain focuses on the present illness, emphasizing etiologic diagnosis and recoverability, and the burden of ICU syndromes such as shock, respiratory failure, and acute kidney injury. The Postmorbid domain guides learners to translate these assessments into a set of realistic outcome trajectories, supporting clearer prognostication and communication. By providing a shared language for discussions among senior residents, intensivists, and referring teams, the framework offers a practical cognitive scaffold for organizing complex information under pressure. Rather than eliminating uncertainty, the Premorbid-Morbid-Postmorbid framework provides trainees with a reproducible method to reason through uncertainty, communicate transparently and approach ICU triage with greater clarity and confidence.
BACKGROUND:Air pollution plays a significant role in human health, impacting respiratory outcomes. Despite decades of evidence detailing these health consequences as a result of both short and long-term air pollution exposure, the harms of air pollution exposure are infrequently taught at the graduate medical education level, particularly at the level of pulmonary fellowship. As the climate changes and air pollution increases, patients are becoming increasingly aware of how these changes affect their health, but do not routinely receive guidance from their pulmonologist, in part due to limited healthcare provider knowledge. OBJECTIVE:We developed an air pollution curriculum to increase fellow knowledge about air pollution and its health impacts by focusing on the question "what do pulmonologists need to know about air pollution?" METHODS:Using Kern's six steps for curriculum development, we developed an air pollution and health impact curriculum. Following identification of the five domains of focus (composition, health effects, monitoring, risk mitigation, and environmental justice) by a panel of content experts, a 20-item knowledge scale was developed via a modified Delphi process to deliver as both a pre- and post-curriculum assessment. By delivering it over the course of the year and infusing it with interactive components, the curriculum allowed for implementation of spaced repetition, active recall, and reinforcement of key air pollution topics to facilitate learning a novel topic within the constraints of an existing educational program's structure. RESULTS:Fellows demonstrated an increase in knowledge in all five domains of the air pollution curriculum when comparing pre- and post-course assessments (p < 0.001). The curriculum was well-received with requests for both repetition of the curriculum and expansion to other climate-related topics. CONCLUSION:This study demonstrates the feasibility and effective implementation of an air pollution curriculum for pulmonary and critical care trainees that increases knowledge of this critical environmental exposure.
BACKGROUND:Thoracentesis is a common bedside procedure. Complication rates are, among other factors, associated with the clinicians' skills. Simulation-based training (SBT) for teaching procedural skills is widely recommended in medical education. However, the current evidence on the effectiveness of SBT for thoracentesis and the impact of different instructional features has not yet been comprehensively reviewed. OBJECTIVE:To summarize and critically appraise the current evidence on the effectiveness of SBT for thoracentesis in improving educational and patient outcomes, and to examine the instructional characteristics of effective training programs. METHODS:A systematic review of the published literature on effectiveness of SBT for thoracentesis was performed and is reported according to PRISMA guidelines. Methodological quality was assessed using the MERSQI and the risk of bias of the included studies was evaluated. Extracted data were analyzed descriptively and random-effects meta-analyses were used to calculate the pooled correlation for self-confidence and performance scores. RESULTS:Of the 17 studies included in the review, 14 used a pretest-posttest design and 15 investigated the effectiveness of high-fidelity simulation. Instructional features and outcome measures varied considerably across studies and no association was recognized. The majority of the reported outcomes were positive. The pooled correlation for self-confidence was 1.59 (95% confidence interval [CI] 0.94-2.24; n = 5 studies), and for performance scores 23.94 (95% CI 8.83-39.05, n = 5). CONCLUSION:SBT for thoracentesis using high-fidelity simulators is effective in improving procedural skills and self-confidence. More evidence is needed to demonstrate a potential positive impact on behavioral and patient-related outcomes. PROTOCOL REGISTRATION:PROSPERO; No.: CRD420251064566; URL: https://www.crd.york.ac.uk/PROSPERO/view/CRD420251064566.
Physician-scientists bring a critical perspective to scientific discovery and contribute to a significant proportion of medical breakthroughs that improve patient care; however, recent reductions in the proportion of pulmonary and critical care medicine fellows pursuing careers as physician-scientists, mirroring trends in other medical specialties, raise concern about the long-term viability of the current training paradigm. Numerous factors potentially contribute to the drop in trainees pursuing research careers, including reduced availability of research training opportunities during residency and fellowship, increasing clinical and research training complexity, a longer timeline to career independence, and funding uncertainties. Increasing educational debt, an often rigid training structure, and declining resources also contribute. This 2025 American Thoracic Society International Conference symposium provided an overview of these challenges, as well as potential solutions to preserve this vital career path, including the need for critical evaluation of the current training model, reexamination of success metrics, and focused efforts to create more supportive, fair, and collaborative training environments. In response to growing concerns about the sustainability of the physicians-scientist training pathway, education leaders and physician-scientists from around the country presented a special symposium at the 2025 American Thoracic Society International Conference. Content selection was developed through iterative discussion among the presenting authors. The session highlighted important recent trends reflecting decreased engagement with this pathway, challenges faced by trainees, and the potential roles that administrative and education leaders might play in reimagining the physician-scientist training paradigm. This paper summarizes key elements and messages of the session and highlights the opportunity for stakeholders to collaboratively develop a clearer vision of the future for this critical career path. This session highlighted new opportunities, including maximizing competency-based training, enhancing organizational supports, a sharper focus on professional identity formation, and reframing our understanding of what constitutes high-value research contributions by physicians (Table).
BACKGROUND:Pulmonary Hypertension (PH) is a heterogeneous disease with high morbidity and mortality. Despite advances in therapeutics, delays in diagnosis and misclassification of patients remain prevalent, leading to harm. Pulmonary and Critical Care Medicine (PCCM) physicians play an essential role in treatment of PH. However, the adequacy of PH education in PCCM fellowship has not been rigorously investigated. OBJECTIVE:To evaluate contemporary training of PCCM fellows including training environment, attitudes, and self-reported proficiency in core and advanced PH competencies. METHODS:We conducted a national, cross-sectional survey of PCCM fellows and Program Directors (PDs) between October 2024 and December 2025. The survey assessed demographics, training environment, clinical exposure, preparedness across core and advanced PH competencies, and attitudes toward PH education. Preparedness was measured using a 5-point Likert scale and dichotomized as proficient versus not proficient. An exploratory descriptive analysis was performed with results from a 2007 survey. RESULTS:70 fellows and 42 PDs completed our 2024-2025 survey. Among core competencies, fellows reported high proficiency in PH classification (85.7%) and diagnosis (81.0%), with moderate proficiency in risk stratification (62.9%) and initial therapeutic strategy (55.7%). Proficiency was lower for right heart catheterization (RHC) interpretation (42.9%) and management of medication side effects (37.1%). There were low levels of proficiency in performing RHC (20.0%) and managing infusion therapies (<30%). Increasing fellowship training year was associated with improved self-reported proficiency in most competencies; however, only half of senior fellows reported competency in right heart catheterization (RHC) and initiation of PAH therapy. In descriptive analysis, fellows in both eras reported low levels of competency in RHC and management of infusion therapy. CONCLUSION:Despite broad access to PH expertise, contemporary PCCM fellows reported limited preparedness to provide comprehensive PH care. There was low proficiency in advanced competencies including performing RHC and titration of infusion therapy, and modest proficiency in core competencies such as risk stratification and management of PAH medication side effects. Our study highlights a need to improve PCCM training through standardized curriculum to improve the care of PH patients.
Since the COVID-19 pandemic, the need to develop innovative strategies for virtual engagement and interaction has emerged. There has been a growing emphasis on online recruitment strategies for most medical specialties. For the last several interview seasons, many national organizations have recommended that fellowship interviews be conducted virtually for all applicants. Social media represents a powerful tool for both the program and the applicants. However, there remains a paucity of data published on social media use for virtual recruitment in pulmonary and critical care medicine (PCCM). Here, we review the available data for virtual recruitment and propose best practices for PCCM programs. Our social media strategy outlines specific and practical steps that form the framework for a social media charter including defining the goal and audience, following institutional guidelines, choosing appropriate platform(s), identifying and defining an account management plan, devising a strategy for content generation and posting, and continuing to reassess and optimize the process. Our best practices provide a practice framework for PCCM programs, both novice and advanced for social media use. They also emphasize a need for more research on social media’s impact on future recruitment cycles while providing a better understanding of current practices for applicant program selection and virtual recruitment.
BACKGROUND:The environmental impact of medical conferences has prompted calls for carbon minimization strategies to be more widely adopted. The COVID crisis has occasioned greater acceptance of digital conference formats, which can enhance access and broaden participants inclusion. However, studies on the impact of carbon minimization models on participant satisfaction and engagement are limited. OBJECTIVE(S):To assess participant satisfaction, and estimate travel-related carbon emissions, from an Australian national lung conference that utilized a carbon-minimizing "hybrid spoke-and-hub" format offering either in-person or virtual attendance, which can also facilitate participation for those unable to travel due to personal or professional constraints. METHODS:Participant satisfaction was assessed using a pre-specified survey tool. Actual travel-related carbon emissions for air and car travel were calculated for the hybrid meeting and compared to the inferred impact if the same meeting had been held in a single major city (Sydney) as in-person attendance only. RESULTS:174 delegates attended (88 in-person, 86 virtual). The participant survey was completed by 45% of eligible attendees. The hybrid model reduced air passenger carbon emissions by 95%, and car passenger emissions by 48%, resulting in a reduction of 26.19 metric tonnes of carbon emissions compared to the inferred single-hub format. Participant satisfaction was high across all parameters, though 'ability to interact with colleagues' and 'ask questions', were negatively impacted by the hybrid model. CONCLUSIONS:This hybrid approach led to a major reduction in inferred environmental impact with unexpectedly high user acceptability and preference. Key limitations were interaction with colleagues and ability to ask questions. These findings support the adoption of hybrid model meeting formats that minimize environmental impact.
BACKGROUND:The Accreditation Council of Graduate Medical Education (ACGME) requires proficiency in procedures such as endotracheal intubation, central line insertion, and bronchoscopy for certification in critical care medicine (CCM). These are common in the intensive care unit and gaining sufficient exposure to attain competence during fellowship training is generally not challenging. However, intensivists are also expected to perform several high-risk procedures that are less frequent. Such high-acuity, low-occurrence (HALO) procedures lack a clear designation, possibly due to a lack of consensus on training standards, and exposure to them during fellowships can be inconsistent. OBJECTIVES:We aimed to identify HALO procedures specific to CCM fellowship training. METHODS:A modified Delphi methodology was employed to gather iterative data from and reach consensus among a diverse panel of CCM-trained fellowship faculty with expertise in fellowship curricula. Three rounds of quantitative data were completed, with a final round of qualitative data collected to better define why experts chose certain procedures over others. Experts were blinded to the responses of each other, and investigators were blinded to the responses of individual experts. RESULTS:Six procedures (namely, awake bronchoscopic intubation, bronchoscopic intubation under sedation, cricothyrotomy, esophageal balloon tamponade, pericardiocentesis, and surgical chest tube placement requiring blunt dissection) qualified as HALO procedures relevant to CCM fellowship training. According to feedback from experts, procedures were selected based on their relevance to high-risk situations in the ICU, their frequency of occurrence, and the typical scope of practice of ICU providers. CONCLUSIONS:This study provides a consensus-based list of qualifying HALO procedures in CCM training. This list can inform curriculum development and support the integration of targeted training strategies to better prepare CCM fellows for rare, high-risk procedures. CLINICAL TRIAL REGISTRATION:N/A. PRIMARY SOURCE OF FUNDING:N/A.
