In this article, the authors provide guidance for applicants to any subspecialty in the medical specialties matching program, with a particular focus on those seeking a match into a pulmonary or critical care medicine training program, or both. The preparation, application, interview, ranking, and match steps are used to discuss available literature that informs this process. Preparing a fellowship application is discussed in terms of personal career goals, and specific strategies are suggested that can help a candidate to assess a program's fit with those goals. In addition to review of recent data on virtual interviewing and interview questioning, the authors provide practical recommendations for candidates seeking to maximize their success in the current interview environment. Finally, key points about generating a rank order list are summarized. This resource will prove useful to any candidate pursuing medical subspecialty training in the current era.

BACKGROUND: The prevalence of burnout and depressive symptoms is high among physician trainees. RESEARCH QUESTION: What is the burden of burnout and depressive symptoms among fellows training in pulmonary and critical care medicine (PCCM) and what are associated individual fellow, program, and institutional characteristics? STUDY DESIGN AND METHODS: We conducted a cross-sectional electronic survey of fellows enrolled in pulmonary, PCCM, and critical care medicine training programs in the United States to assess burnout and depressive symptoms. Burnout symptoms were measured using the Maslach Burnout Index two-item measure. The two- item Primary Care Evaluation of Mental Disorders Procedure was used to screen for depressive symptoms. For each of the two outcomes (burnout and depressive symptoms), we constructed three multivariate logistic regression models to assess individual fellow characteristics, program structure, and institutional polices associated with either burnout or depressive symptoms. RESULTS: Five hundred two of the 976 fellows who received the survey completed it-including both outcome measures-giving a response rate of 51%. Fifty percent of fellows showed positive results for either burnout or depressive symptoms, with 41% showing positive results for depressive symptoms, 32% showing positive results for burnout, and 23% showing positive results for both. Reporting a coverage system in the case of personal illness or emergency ( adjusted OR [aOR], 0.44; 95% CI, 0.26-0.73) and access to mental health services (aOR, 0.14; 95% CI, 0.04-0.47) were associated with lower odds of burnout. Financial concern was associated with higher odds of depressive symptoms (aOR, 1.13; 95% CI, 1.05-1.22). Working more than 70 hours in an average clinical week and the burdens of electronic health record (EHR) documentation were associated with a higher odds of both burnout and depressive symptoms. INTERPRETATION: Given the high prevalence of burnout and depressive symptoms among fellows training in PCCM, an urgent need exists to identify solutions that address this public health crisis. Strategies such as providing an easily accessible coverage system, access to mental health resources, reducing EHR burden, addressing work hours, and addressing financial concerns among trainees may help to reduce burnout or depressive symptoms and should be studied further by the graduate medical education community.

The intensive care unit (ICU) provides unique educational opportunities for both undergraduate and postgraduate learners, including procedural training, ventilator management guidance, complex communication scenarios, and didactic lectures on dynamic topics like multi-system organ failure. However, certain challenges are inherent in this setting that can make teaching difficult. Different trainee educational backgrounds, variability in disease states, time limitations and urgent patient care considerations highlight some challenges that limit teaching opportunities. The following twelve tips address these unique aspects of the ICU environment and provide strategies to optimize teaching. These tips focus on three main goals: creating an optimal learning environment, increasing learner engagement, and critically challenging learners.

BACKGROUND: The prevalence of burnout and depressive symptoms is high among physician trainees. RESEARCH QUESTION: What is the burden of burnout and depressive symptoms among fellows training in pulmonary and critical care medicine (PCCM) and what are associated individual fellow, program, and institutional characteristics? STUDY DESIGN AND METHODS: We conducted a cross-sectional electronic survey of fellows enrolled in pulmonary, PCCM, and critical care medicine training programs in the United States to assess burnout and depressive symptoms. Burnout symptoms were measured using the Maslach Burnout Index two-item measure. The two-item Primary Care Evaluation of Mental Disorders Procedure was used to screen for depressive symptoms. For each of the two outcomes (burnout and depressive symptoms), we constructed three multivariate logistic regression models to assess individual fellow characteristics, program structure, and institutional polices associated with either burnout or depressive symptoms. RESULTS: Five hundred two of the 976 fellows who received the survey completed it — including both outcome measures — giving a response rate of 51%. Fifty percent of fellows showed positive results for either burnout or depressive symptoms, with 41% showing positive results for depressive symptoms, 32% showing positive results for burnout, and 23% showing positive results for both. Reporting a coverage system in the case of personal illness or emergency (adjusted OR [aOR], INTERPRETATION: Given the high prevalence of burnout and depressive symptoms among fellows training in PCCM, an urgent need exists to identify solutions that address this public health crisis. Strategies such as providing an easily accessible coverage system, access to mental health resources, reducing EHR burden, addressing work hours, and addressing fi nancial concerns among trainees may help to reduce burnout or depressive symptoms and should be studied further by the graduate medical education community.

Background: Burnout is common among physicians who care for critically ill patients and is known to contribute to worse patient outcomes. Fellows training in pulmonary and critical care medicine (PCCM) have risk factors that make them susceptible to burnout; for example, clinical environments that require increased intellectual and emotional demands with long hours. The Accreditation Council for Graduate Medical Education has recognized the increasing importance of trainee burnout and encourages training programs to address burnout. Objective: To assess factors related to training and practice that posed a threat to the well-being among fellows training in PCCM and to obtain suggestions regarding how programs can improve fellow well-being. Methods: We conducted a qualitative content analysis of data collected from a prior cross-sectional electronic survey with free-response questions of fellows enrolled in pulmonary, PCCM, and critical care medicine training programs in the United States. Fellows were asked what factors posed a threat to their well-being and what changes their training program could implement. Responses were qualitatively coded and categorized into themes using thematic analysis. Results: A total of 427 fellows (44% of survey respondents) completed at least one free-response question. The majority of respondents (60%) identified as male and white/non-Hispanic (59%). The threats to well-being and burnout were grouped into five themes: clinical burden, individual factors, team culture, limited autonomy, and program resources. Clinical burden was the most common threat discussed by fellows. Fellows highlighted factors contributing to burnout that specifically pertained to trainees including challenging interpersonal relationships with attending physicians and limited protected educational time. Fellows proposed solutions addressing clinical care, changes at the program or institution level, and organizational culture changes to improve well-being. Conclusion: This study provides insight into factors fellows report as contributors to burnout and decreased well-being in addition to investigating fellow-driven solutions toward improving well-being. These solutions may help pulmonary, PCCM, and critical care medicine program directors better address fellow well-being in the future.

As we face the coronavirus disease (COVID-19) pandemic for yet another month, it rings true that our training programs, medical teams, and trainees need a sound plan and script. The pandemic has changed the way we deliver care, teach, and conference in medicine (1–3). COVID-19 has even forced us to change the way we interview applicants for our specialties (4, 5). Two articles recently published in ATS Scholar inform us of how COVID-19 altered medical education globally in the intensive care unit and in U.S. pulmonary critical care medicine (PCCM) training programs as a whole. Matta and colleagues surveyed program directors from the United States to evaluate the impact of COVID-19 on American PCCM fellowship training (6), whereas Wahlster and colleagues performed a global survey of trainees and attending physicians from around the globe on COVID-19’s effect on critical care training (7). From their surveys, these authors illuminate strategies to overcome COVID-19 obstacles and further add to the educational script to date. These articles deliver practical strategies in a timely fashion that programs can use to augment education as the pandemic continues. Matta and colleagues distributed an efficient program director–only survey that yielded rich quantitative and qualitative data. Directly accessing program leadership ensured that educational efforts across the entire country were well represented. Significant gaps in particular curricular areas related to COVID-19 were identified, including reduced opportunities for fellow pulmonary function test interpretations, procedures such as elective bronchoscopies, and outpatient encounters. The inclusion of qualitative data offered insight on how programs adapted their curricula to account for these changes and delivered “how to train in a pandemic” recommendations for PCCM fellowships: have frequent check-ins with fellows, adjust work schedules to ensure contiguous days off during busy rotations, continue to educate with didactics using virtual platforms, and add simulation opportunities to bolster procedure experiences. Although the authors are applauded for obtaining robust information during a pandemic peak, the efficiency-based approach applied certainly came with limitations, including a relatively low response rate at 28.5%, and most of the information derived came from university-based programs, leaving some uncertainty regarding curricular changes at community-based programs. To maintain efficiency, no trainee

The coronavirus pandemic forced the Association of Pulmonary and Critical Care Medicine Program Directors to change the 2020 annual conference to a virtual format with relatively short notice. Using the experience of the planning committee and survey feedback from attendees, we describe the steps taken to implement a virtual conference and lessons learned in the process. The lessons described include frequent and concise communication, establishment of roles within a discrete production team, preparing speakers with a protocolized training session, active moderation of the chat box, using interactive polling and online documents to improve interactivity, a shorter agenda with more frequent breaks, encouraging "virtual happy hours" to connect with colleagues, and establishing facilitators for breakout rooms.

Applying for the first job during fellowship training is significantly different from all other application processes encountered in medical school, residency, and fellowship. There is much less formalized guidance, no universal application service, and no strict timeline to follow. The process may differ depending on the type of practice one is seeking: academic or nonacademic, research, or clinical. Although a small number may choose a career in industry, this career choice is not the focus of the current paper. The lack of standardization of this process often leads to a significant amount of uncertainty and stress amidst one of the most important decisions for the soon-to-be graduating fellow. The process of preparing for a competitive application begins as early as the first year of fellowship where the focus should be on obtaining solid clinical training with emphasis in the latter half of the year toward developing a long-term career plan. The second year is spent pursuing a more tailored niche that fits within the applicant’s track. Although the interview process varies for each person, interviews may start as early as the second year to apportion adequate time for onboarding and credentialing during the third year. The recommendations offered here were compiled from a diverse group of pulmonary and critical care physicians from across the United States who have had experience in clinical, research, academic, and private practice medicine. Authors were selected to provide diversity with respect to geographic location, and consensus was obtained via a modified Delphi process. Time is of the essence. Choosing a career path earlier rather than later in fellowship can help future job procurement in multiple ways. Early career path identification can lead to more meaningful scheduling during fellowship and help with early mentor identification, and it may provide more experiential opportunities to fill one’s portfolio. Schedule optimization can allow elective and scholarly time to be chosen in a fashion that supports the career trajectory. For example, a fellow planning to enter a large clinical practice with a focused expertise may select subspecialty clinical experiences during elective time that vastly differ from the teaching experiences a rising clinician educator seeks or a trainee who is focused on research may desire. Mentors can help identify and focus experiences so the portfolio develops evidence that the fellow is becoming an expert in his or her field or niche area. It is certainly not mandatory to know the exact details of one’s career trajectory on day one of fellowship, but portfolio building can be enhanced by identifying a career track earlier in fellowship. A major branch point in the career decision-making tree is choosing a private practice vs academic career because the preparatory experiences for these pathways can be different. For those who are considering private practice, efforts should be made to broaden clinical experience. For example, it may be necessary to seek additional training in interventional bronchoscopy, allergy, pulmonary hypertension, or sleep medicine. Although physician in-state retention data are not available for subspecialty training, the Association of American Medical Colleges found that overall, 55% of individuals who completed residency between 2007 and 2016 are practicing in the state of residency training. As such, getting to know private practice physicians in the local community can be helpful. This process may include arranging a rotation within one or more practices. Networking at national and local meetings can also help facilitate connections and mentorship. Optimizing fellowship time can help trainees focus career aims in a goal-directed manner. Fellows are encouraged to begin discussions early in fellowship, even during the first semi-annual review with the program director. Individual and personal development plans are resources that can help fellows establish goals and set timelines for success. Additional resources such as these are provided in the Suggested Readings list. From an employer’s perspective, it is critical that program leadership is able to quickly and accurately identify the applicant’s track into clinical or research for multiple reasons. From an academic perspective, clinical space may be limited and often dictated by subspecialty areas of need, inpatient rounding demands, outpatient clinical space, referral demands, and overall patient access matters. Unless a hospital system is expanding, inpatient and outpatient clinical positions could be highly competitive and limited owing to the need to meet the clinical requirements for the currently appointed faculty. Obtaining a fully protected research position out of fellowship will usually be reserved only for those applicants who have secured grant funding in the final year of fellowship, or will be supported for 1 to 2 years during the application for a career development grant if he or she is believed to show research potential. Alternatively, private practice positions are likely to be dictated by the practice’s patient volume and clinical demands. Ultimately, the future employer will want a clear and direct understanding of the applicant’s career trajectory. Being pluripotent at this stage is no longer considered advantageous. An applicant seeking a primarily clinical academic position will need to communicate directly about his or her areas of subspecialty interest/expertise. Those interested in a research-focused career should have a mentor or mentor team that can provide scientific as well as career development support to show success during fellowship through abstracts, publications, presentations at national meetings, and application for fellowship grants such as the Ruth L. Kirschstein National Research Service Award, F32, or participation on a T32 training grant. The organization of the curriculum vitae (CV) will differ depending upon one’s track. It is generally customary to lead with the training/education background followed by board certifications/board eligibility. The next section should highlight the topics that most closely communicate the type of position one is seeking. Topics include research experience, current grant funding, research or clinical awards, leadership positions, education/teaching experience and awards, expert clinical training inside or outside of the parent institution, manuscripts/publications, abstracts, book chapters, and invited lectures. There may be a format for the CV recommended by the promotions and tenure committee of one’s institution for promotional purposes, which can be used as well. More information can be found in the Suggested Readings list. A cover letter is sent to a division chief or recruiter to accompany the CV. It is an opportunity to provide detail that was not otherwise appropriate in the CV. Providing a cover letter with the CV can help differentiate the applicant from others by providing more specific and personal details, career goals, geographic connections, and major accomplishments, or explain gaps within a CV. The cover letter should be thought of as an opportunity to focus on future-oriented goals, as opposed to the CV, which depicts past accomplishments. The format should generally follow a three-paragraph, one-page maximum. The first paragraph should introduce why the applicant is writing to the stated individual (eg, seeking a specific position or expressing general interest). The second paragraph should provide additional details of why one is interested in the position, what particular connections exist geographically if applicable and specific skill sets or interests that are unique to the position. In the final paragraph, the recipient should be thanked for the opportunity to apply and for reviewing the application. The letter should conclude by expressing a positive interest in continued communication and visiting the program or practice for a formal interview. More information about how to structure a cover letter can be found in the Suggested Readings list. Having the CV and cover letter finalized first will help dramatically when sorting through the number of programs to which to apply. Several factors are important when considering places of employment and are likely to include a combination of personal and professional influences, career goals, job opportunities for partners or spouses, school systems for children, and proximity to family. When seeking employment in a subspecialty niche or academic center, it can be of great value to seek advice from mentors and faculty within the parent institution who may also have additional insights into programs or practices due to personal connections. Program directors and division chiefs are also great resources to help narrow the program search. Additional information can be obtained from reviewing a division’s program online. It can also provide the applicant with a general overview of program strengths both clinically and scientifically. For those seeking private practice positions, one should become familiar with the practice type, local reputation, accessibility of consultants, physician turnover, specialty and procedural services, city and hospital size, as well as the surrounding referral area. Table 1 provides a more detailed description of different private practice options.Table 1Private Practice OptionsTypeSolo•Practicing without partners or other employment affiliations•Greatest autonomy of all practice settings•Burden of running entire practice•High risk of financial setbacks: lack of referrals, small patient base, loss of income due to illness, vacation•Higher overhead: office space, staff, electronic records•Quality of life may be affected by call duties/coverage requirementsSingle specialty group practice•Two or more physicians of the same specialty•Generally with track to partnership in 1 to 3 y•Affords trial period before commitment (ie, partnership)•Less risk up front as salary is often guaranteed for 1 to 3 y•Minimal administrative and management up front to allow focus on clinical practice•Partnership is not guaranteed•Differing practice philosophies of members may affect comanagement of shared patients•Senior partners may have fewer call responsibilities compared with junior partners•Less autonomy in practice-related decisions before becoming partner•Number of group practices in the region may limit referral baseMultispecialty group practice•Offer various types of medical specialty care in 1 organization•Generally with track to partnership in 1 to 3 y•Large referral base, especially when primary care is included•Potential to negotiate favorable managed care contracts due to size and multiple specialties•Affords a trial period prior to commitment•Less financial risk up front as salary is guaranteed for 1 to 3 y•Minimal administrative and management responsibilities•Decreased autonomy and decision-making ability•The larger the practice, the higher the chance that it will become more bureaucratic and policy-driven•Clashes between physicians over referrals, the ability to deliver certain types of care, performance of procedures, and relative compensation•Chance of not being offered partnershipHospital employeeDirectly employed by the hospital with guaranteed salary and with or without productivity incentive•Least amount of financial risk, especially if the hospital is in good financial position•Large referral network•Physician autonomy is diminished•Policies and procedures are developed by groups often with little input from members•Can involve work on committees and teaching that may or may not be compensated separatelyLocum tenens•Provide physicians with short-term employment•The organization dictates work schedule but covers cost of travel, lodging, and malpractice insurance•Pay rate is higher than what the permanent position would offer•Allows physician to "try out" a practice type or location•Allows physicians to choose own hours and the number of days worked•Benefits such as health care and retirement usually not offered Open table in a new tab Selecting the appropriate number of programs for which to apply depends upon several factors, including program reputation, local market saturation, quality of applicant and program, career plans, and personal circumstances. At this stage, one is free to initiate contact and solicit interest; deciding on which programs to interview will likely be limited by time, prospective interest, and potentially finances. Making the initial contact with a division chief, chief medical officer, managing physician in a private practice, or recruiter is completely appropriate via e-mail. A division chief’s or chief medical officer’s e-mail is usually easily located on the division’s home page or faculty page. It is not common for job opportunities to be widely advertised but on some occasions, postings can be found through journals, e-mail listings, specialty society websites, or online advertisements. Additional opportunities may be available through the use of a recruiter. The timing of initiating the first contact can be variable but typically occurs in the last few months of the second year or within the first few months of the third year of training. Figure 1 provides a general timeline to help navigate the interview process. When reaching out to programs, consider writing a short, concise introduction about who you are, where you are currently completing training, when you plan to graduate, and why you are interested in that particular position. This introduction should be an abbreviated version of the cover letter. If a faculty member has encouraged you to apply, include this information. If there are special geographic ties, this information is also important to include. Next, briefly describe the position you are seeking (eg, specialty niche, research, educator, inpatient vs outpatient). The goal is to be offered an opportunity to visit for a formal interview. Consider ending the e-mail with an offer to send the CV and cover letter if desired or send as attachments in this initial contact. Figure 2 provides a sample e-mail introduction to a division chief. For applicants who have mentors with strong connections to individuals and/or leadership at the program of interest, it may be worthwhile to discuss with the mentor his or her feelings about reaching out to the university. Some faculty may prefer to wait to be contacted by the institution but others may take this opportunity to make contact on the applicant’s behalf. Similarly, mentors can be very helpful in identifying contacts in the private sector for those interested in a nonacademic practice. Prior to contacting programs, it is important to initiate discussions within the home institution’s division leadership (ie, program director and division chief). It may feel uncomfortable to bring up the topic of job hunting outside of the applicant’s home institution, especially if being recruited to stay on as faculty. However, this approach provides an opportunity to discuss interests and showcase expertise to the home institution. In addition, it is important to understand that at some point, division leadership will be contacted as a reference if there is serious interest in the applicant. We suggest initiating these discussions proactively for several reasons. First and foremost, the applicant should ensure that division leadership has a clear understanding of what type of position the applicant is seeking. This is the time to discuss those areas that are and are not negotiable regarding the potential job description. Second, it will be more advantageous if the home institution is well prepared regarding the job search as opposed to being caught off-guard. The applicant should expect to be asked why he or she is looking outside of the home institution and have a credible and well-considered answer. This question will very likely be asked of program leadership and references by the hiring institution as well. Allowing time for communication to come to a mutual understanding on these topics will greatly improve the chances of securing the job of top choice. In addition to meeting with leadership, a list of two to three additional references should be created to provide the potential employer if asked. Permission of an individual should always be requested prior to submitting his or her name to a potential employer. The future employer may not always ask for references if he or she knows faculty personally within the applicant’s program. However, a list of solid references should always be prepared that can attest to the applicant’s clinical skills, leadership capabilities, professional attributes, or research experiences in the event that the potential employer is highly interested after the interview occurs. The interview process may actually start prior to making any formal travel arrangements. Some employers will opt to hold one or more telephone interviews with the applicant prior to offering a formal interview. The applicant should be prepared to deliver a concise but detailed description of his or her ideal position. Consider rehearsing this to ensure enough detail is included but to avoid rambling and losing the telephone interviewer’s attention. In addition, holding a mock interview can be a great way to refine interview skills while receiving feedback from more experienced faculty. Knowing in advance which areas are negotiable can help both parties establish early if there is a potential fit. However, be cautious in providing too many specifics at this point to avoid being perceived as inflexible; view this stage as still trying to get one’s foot in the door. Telephone interviews are often used to prescreen applicants to ensure that the program’s needs at least partially match the applicant’s wants. Once a formal interview has been scheduled, the program should communicate additional details regarding travel and hotel accommodations. Details surrounding the visit should also be discussed early, including the number of days for the interview, whether a formal presentation is required, and preinterview dinner expectations. The full itinerary regarding the list of interviewers will likely not be available until closer to the interview date. The interview day can vary from program to program and can include anywhere from four to 10 interviews in 1 day. The applicant should expect to meet with division leadership and several key faculty, including those in the applicant’s field of interest. Additional interviews may be held with human resources and professional staff (respiratory therapists, nurse practitioners, and other support staff). For private practice positions, the applicant should expect to meet a mix of junior and senior partners in the practice. Although the specifics of an interview are impossible to predict, there are some general guidelines that we suggest keeping in mind. The first interview should be viewed as the program getting to know the applicant to assess if he or she is a good fit for the program. Second interviews are generally for the applicant to assess whether the program fits well within his or her needs. It is discouraged to bring up salary discussions during the initial interview unless directly addressed by an interviewer. Caution should be exercised regarding being too rigid with the potential job description as the program will want to know that the applicant is willing to at least potentially fill certain roles/positions that are vacant. It is a good idea, however, to share ideas and future goal-directed thinking. In addition, expressing a willingness to collaborate with those already well established in basic science or clinical research is often viewed as advantageous. Table 2 provides potential track-based questions to ask during the interview process.Table 2Sample Interview Questions Based Upon Career TrackPrivate practice1.How are the inpatient and outpatient duties currently divided (eg, what is the call schedule)?2.What are the current needs of the practice? Are there subspecialty focuses the practice needs (eg, sleep training or interventional pulmonology)?3.Are there expectations as to what I am to bring to the practice (eg, interventional bronchoscopy skills)?4.(If physician owned) Is there a path to partnership and what is the length of time required? Is there a “buy-in” to partnership?5.(For multispecialty or hospital owned) Are there any compensated directorships available?6.What is the policy for time off?7.What kind of clinical nursing support is available? Is there support from nurse practitioners or physician assistants?Academic clinician1.How can I expect my time to be divided between inpatient and outpatient responsibilities?2.Will I be allowed any subspecialty clinic time for my area of interest?3.Will I be given any administrative time and/or allowed any protected research time?4.What type of administrative support is available?Clinician educator1.How is protected time distributed for clinician educators? Is there a set rate or full-time equivalent percent allocation for program directors? Associate program directors?2.How is teaching reimbursed or supported? Is there a teaching practice plan or outline that describes how teaching is measured on a full-time-equivalence scale?3.What current teaching needs do you have?4.Is there a directorship for a medical student course, clerkship, or resident rotation you need?Clinical research1.What support is available via coursework/advanced degrees such as a Master’s Degree in Public Health or a Masters/PhD in clinical and translational science?2.Are there internal grants through a Clinical and Translational Science Award or other mechanisms to support young clinical researchers as they prepare for a K23 submission?3.What clinical research infrastructure (eg, coordinators, statisticians) would be available for a junior faculty clinical researcher?4.Is there an expectation that I arrive with a funded K23, or are there mechanisms to provide support for the next 1 to 2 years? How much support would be provided in the form of protected time and coordinator and statistical support?5.Is there any startup funding to support clinical research or would I join a group of researchers with similar interests?6.If the candidate has a K23 (for those applicants applying 1 to 2 years out of fellowship), what support do you offer for a junior faculty with a funded K23? (This question assumes that the area of expertise is present at the new institution or the National Institutes of Health will not transfer the grant)Basic science research1.What is the timeline expectation for K08 funding?2.Are startup funds available for new faculty who show research promise but do not yet have a K08?3.What support can I expect from my research mentor with regard to space, supplies, and technicians?4.What startup packages and salary do you offer for junior faculty with a funded K08? (This question is for those who have secured a K grant during or after fellowship but prior to relocating) Open table in a new tab It is very important to communicate with every program following the interview. Aside from being polite, this contact ensures the lines of communication stay open with all potential employers. One cannot be certain that his or her first choice will be final until all contracts, including negotiated changes, have been signed by all parties. Thus, communications should remain active with as many programs as possible provided there is interest from the applicant. Communication can be in the form of an e-mail, although a written letter to the division director or managing partner of the practice will make certain that the communication is not inadvertently deleted. A personal telephone call thanking this individual is almost always welcome and should convey appreciation for the opportunity to visit and a query as to what the next steps might be. It should not be a request for a contract as this step should be initiated by the prospective employer. Unfortunately, there is no “etiquette” as to when a response from the employer may be expected. This time line also depends on the number of applicants for the position. If the program is very interested in the applicant, follow-up may be expected within the next few weeks. However, it is not unreasonable to contact the potential employer within 2 weeks if nothing has been heard. This contact would also be an appropriate time to ask additional questions that may have come up following the interview. The employment contract is the most important document that the applicant will sign in his or her career. It is very important to have this document reviewed by a legal expert in physician contracts. Although part of the contract is drafted from divisional leadership/potential partners, several aspects of the contract are written by legal experts employed by these individuals. Thus, it is important for the applicant to fully understand the job title, description of duties, compensation, and benefits, and all the clauses or addendums that accompany the contract. Failure to do so may result in signing poor long-term arrangements. The contract should include specific information about compensation, duties, title and/or directorship duties, protected time, research support if applicable, nonsalary benefits, termination provisions, and noncompete covenants. In addition, contracts should include information in reference to the ability to work as a physician outside of the institution or practice (eg, volunteering in a free clinic, moonlighting or consulting). The applicant should have clarity on each component of the contract and also understand that most elements in the contract are negotiable. It is important to remember that compromise is the key to successful contract negotiation. All of the major specialty societies offer information to assist fellows in these early career transition phases and can be accessed in the Suggested Readings list. Seeking employment after fellowship training is the final milestone of all trainees. Understanding the processes involved in solidifying the ideal position starts with ample preparation during the early stages of fellowship training. Careful thought and planning allow the applicant to refine skills and experiences to tailor the application for a track or niche-specific job. Knowing the general timeline and expectations for interviews can help fellows ultimately secure the employment of choice.

Internal Medicine subspecialty fellows across the continuum of their training should be aware of key strategies to gain the most out of their fellowship training. More than during any other time in a physician's training, subspecialty fellows are expected to be proactive, self-motivated, and self-directed in their own education and career development. Training programs provide unique opportunities to individualize a fellow's experiences with the goal of preparing each fellow for a specific career path.

We read with great interest the study by Ashton et al1Ashton R.W. Burkart K.M. Lenz P.H. Kumar S. McCallister J.W. Strategies for success in fellowship.Chest. 2018; 153: 233-237Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar in a previous issue of CHEST (January 2018), and in particular the section entitled Take Responsibility for Learning, in which the authors include recommendations to incorporate self-reflection into the learning process and identify learning gaps to address with program leaders. We recently piloted an educational intervention at our institution to address a gap in training2Lopez-Campos J.L. Garcia Polo C. Leon Jimenez A. et al.Staff training influence on non-invasive ventilation outcome for acute hypercapneic respiratory failure.Monaldi Arch Chest Dis. 2006; 65: 145-151PubMed Google Scholar, 3Plumb J.O. Juszczyszyn M. Mabeza G. Non-invasive ventilation (NIV) a study of junior doctor competence.The Open Medical Education Journal. 2010; 2: 11-17Crossref Google Scholar using simulation, a technique focused on experiential learning and reflection. We studied the use of a respiratory simulator (RespiSim System; IngMar Medical) to train internal medicine residents on the use of noninvasive ventilation (NIV) for acute respiratory failure in COPD. We randomly allocated half of our internal medicine trainees (n = 37) to participate in a small group exercise, augmented by the mannequin-based simulator (group A), whereas the other half were educated on the same cases in a traditional small group (group B). Sessions were embedded within a curriculum about NIV that included a podcast for self-study and a didactic lecture. Outcomes were assessed immediately postintervention on a written test and at a 6-week interval on a formative Objective Structured Clinical Examination (OSCE). Baseline test scores between group A (53.3% ± 23.8%) and group B (61.8% ± 23.8%) were not significantly different (P = .06), and postintervention scores improved significantly with no difference between groups (mean: group A: 79.5% ± 13.7% vs group B: 87.2% ± 10.9%, P = .07). After 6 weeks, we found no difference between OSCE checklist scores (86% vs 78%, P = .53) or global rating scale scores (4.3 vs 3.9, P = .93) for group A vs group B, respectively (Fig 1). Residents who did not attend either session achieved significantly lower scores on the formative OSCE (64% vs 82%, P = .002). These findings are discordant with the literature that generally supports simulation for teaching medical knowledge and skills. This negative result might be explained in part by our methodology intended to minimize biases in favor of simulation. Specifically, we did not use a mannequin simulator for our primary outcome,4Spadaro S. Karbing D.S. Fogagnolo A. et al.Simulation training for residents focused on mechanical ventilation. A randomized trial using mannequin-based versus computer-based simulation.Simul Healthc. 2017; 12: 349-355PubMed Google Scholar and our protocol ensured equal exposure time and faculty quality in both groups. From this pilot study, we cannot exclude a small beneficial effect of simulator-based training for teaching NIV skills. However, we recommend that learners and program directors carefully weigh the evidence and, if necessary, conduct more research to assist the pulmonary community in choosing the best learning activities for fellowship and thereafter. Strategies for Success in FellowshipCHESTVol. 153Issue 1PreviewInternal Medicine subspecialty fellows across the continuum of their training should be aware of key strategies to gain the most out of their fellowship training. More than during any other time in a physician’s training, subspecialty fellows are expected to be proactive, self-motivated, and self-directed in their own education and career development. Training programs provide unique opportunities to individualize a fellow’s experiences with the goal of preparing each fellow for a specific career path. Full-Text PDF ResponseCHESTVol. 154Issue 4PreviewWe appreciate the comments of Gutman et al in response to our paper1 outlining strategies for success in fellowship. As educators of fellows, we applaud all those who are devoting their time and talents to improving our understanding of how best to teach the knowledge and skills of pulmonary and critical care medicine. These authors responded to our recommendation that fellows include self-reflection as part of an overall plan of self-directed learning. They describe a pilot study they conducted comparing two methods of teaching noninvasive ventilation: one group going through a simulation exercise (in which they point out that self-reflection is inherent) and the other spending an equal amount of time in a more traditional small group learning environment. Full-Text PDF

RATIONALE:Many pulmonary and critical care medicine (PCCM) fellows are interested in improving their teaching skills as well as learning about careers as clinician educators. Educational opportunities in PCCM fellowship programs designed to address these interests have not been well characterized in U.S. training programs.OBJECTIVES:We aimed to characterize educational content and structure for training fellows to teach in PCCM fellowship programs. We evaluated three major domains: (1) existing educational opportunities, (2) PCCM program directors' attitudes toward the importance of teaching fellows how to teach, and (3) potential components of an optimal teaching skills curriculum for PCCM fellows.METHODS:We surveyed program and associate program directors who were members of the Association of Pulmonary and Critical Care Medicine Program Directors in 2014. Survey domains included existing teaching skills content and structure, presence of a formal medical education curriculum or clinician educator track, perceived barriers to teaching fellows teaching skills, and open-ended qualitative inquiries about the ideal curricula. Data were analyzed both quantitatively and qualitatively.MEASUREMENTS AND MAIN RESULTS:Of 158 invited Association of Pulmonary and Critical Care Medicine Program Directors members, 85 program directors and associate directors responded (53.8% response rate). Annual curricular time dedicated to teaching skills varied widely (median, 3 h; mean, 5.4 h; interquartile range, 2.0-6.3 h), with 17 respondents (20%) allotting no time to teaching fellows to teach and 14 respondents (17%) dedicating more than 10 hours. Survey participants stated that the optimal duration for training fellows in teaching skills was significantly less than what they reported was actually occurring (median optimal duration, 1.5 h/yr; mean, 2.1 h/yr; interquartile range, 1.5-3.5 h/yr; P < 0.001). Only 28 (33.7%) had a formal curriculum for teaching medical education skills. Qualitative analyses identified several barriers to implementing formal teaching skills curricula, including "time," "financial resources," "competing priorities," and "lack of expert faculty."CONCLUSIONS:While prior work has demonstrated that fellows are interested in obtaining medical education skills, PCCM program directors and associate directors noted significant challenges to implementing formal educational opportunities to teach fellows these skills. Effective strategies are needed to design, implement, sustain, and assess teaching skills curricula for PCCM fellowships.

Lecturing is an essential teaching skill for scientists and health care professionals in pulmonary, critical care, and sleep medicine. However, fewmedical or scientific educators have received training in contemporary techniques or technology for large audience presentation. Interactive lecturing outperforms traditional, passive-style lecturing in educational outcomes, and is being increasingly incorporated into large group presentations. Evidence-based techniques range from the very simple, such as inserting pauses for audience discussion, to more technologically advanced approaches such as electronic audience response systems. Alternative software platforms such as Prezi can overcome some of the visual limits that the ubiquitous PowerPoint imposes on complex scientific narratives, and newer technology formats can help foster the interactive learning environment. Regardless of the technology, adherence to good principles of instructional design, multimedia learning, visualization of quantitative data, and informational public speaking can improve any lecture. The storyline must be clear, logical, and simplified compared with how it might be prepared for scientific publication. Succinct outline and summary slides can provide a roadmap for the audience. Changes of pace, and summaries or other cognitive breaks inserted every 15–20 minutes can renew attention. Graphics that emphasize clear, digestible data graphs or images over tables, and simple, focused tables over text slides, are more readily absorbed. Text slides should minimize words, using simple fonts in colors that contrast to a plain background. Adherence to these well-established principles and addition of some new approaches and technologies will yield an engaging lecture worth attending.

This paper outlines specific tips for those applying to pulmonary and/or critical care medicine fellowship training in the United States using the PAIR-Match steps: preparation, application, interview, ranking, and match. Preparation for fellowship begins long before the application process with an assessment of one's long-term goals (to the extent that these are known). The cornerstone of the application is the curriculum vitae, which should highlight applicants' pulmonary and critical care-related experiences and scholarly work. Applicants should obtain letters of recommendation from faculty members who know them well and can write a letter that speaks to their strengths in clinical, scholarly, or leadership areas. The personal statement is an opportunity to share experiences not otherwise shared in the application and is an opportunity to explain any breaks in training or performance lapses. When selecting programs to which they will apply, applicants should pay close attention to the areas of education and curriculum, clinical experience, scholarly opportunity, and personal factors. Preparing for interviews should include a review of the program at which one is interviewing and development of relevant questions regarding details of the program. The interview day is the applicant's opportunity to see the "personality" of the program by meeting with the program director, faculty, and current fellows and to assess whether the program is a good fit for their goals. Applicants should only rank those programs they are willing to attend, in order of preference; they should be aware that the match process is binding.

Background: Morbidity and mortality from asthma are high in older adults and quality of life (QOL) might be lower, although standardized measurements of QOL have not been validated in this population.Objective: To determine predictors of asthma-related QOL in older adults.Methods: Allergy and pulmonary outpatients (n = 164) at least 65 years old with an objective diagnosis of asthma completed the Mini-Asthma Quality of Life Questionnaire (mAQLQ). Demographics, medical history, and mean value for daily elemental carbon attributable to traffic, a surrogate for diesel exposure, were obtained. Regression analysis was used to determine predictors of mAQLQ scores.Results: Total mAQLQ (mean +/- SD 5.4 +/- 1.1) and symptom, emotional, and activity domain scores were similar to those of younger populations, whereas environmental domain scores (4.4 +/- 1.7) appeared lower. Poorer mAQLQ scores were significantly associated with emergency department visits (adjusted beta [a beta] = -1.3, where beta values indicate the strength and direction of association, P < .0001) and with poorer scores on the Asthma Control Questionnaire (a beta = -0.7, P < .0001). Greater ECAT exposure (a beta = -1.6, P < .02), female sex (a beta = -0.4, P < .006), body mass index of at least 30 kg/m(2) (a beta = -0.4, P < .01), gastroesophageal reflux (a beta = -0.4, P < .01), nonatopic status (a beta = -0.5, P < .002), and asthma onset before 40 years of age (a beta = -0.5, P < .004) were significantly associated with poorer mAQLQ scores.Conclusion: The mAQLQ scores in older adults with stable asthma were similar to those in younger populations and were predictive of other measurements of asthma control, verifying that the mAQLQ is an appropriate tool in older adults with asthma. Traffic pollution exposure was the strongest predictor of poorer asthma-related QOL in older adults with asthma. (C) 2015 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.

Lecturing is an essential teaching skill for scientists and health care professionals in pulmonary, critical care, and sleep medicine. However, few medical or scientific educators have received training in contemporary techniques or technology for large audience presentation. Interactive lecturing outperforms traditional, passive-style lecturing in educational outcomes, and is being increasingly incorporated into large group presentations. Evidence-based techniques range from the very simple, such as inserting pauses for audience discussion, to more technologically advanced approaches such as electronic audience response systems. Alternative software platforms such as Prezi can overcome some of the visual limits that the ubiquitous PowerPoint imposes on complex scientific narratives, and newer technology formats can help foster the interactive learning environment. Regardless of the technology, adherence to good principles of instructional design, multimedia learning, visualization of quantitative data, and informational public speaking can improve any lecture. The storyline must be clear, logical, and simplified compared with how it might be prepared for scientific publication. Succinct outline and summary slides can provide a roadmap for the audience. Changes of pace, and summaries or other cognitive breaks inserted every 15-20 minutes can renew attention. Graphics that emphasize clear, digestible data graphs or images over tables, and simple, focused tables over text slides, are more readily absorbed. Text slides should minimize words, using simple fonts in colors that contrast to a plain background. Adherence to these well-established principles and addition of some new approaches and technologies will yield an engaging lecture worth attending.

Historically, asthma and COPD (chronic obstructive pulmonary disease) have been considered separate and unique diseases with distinct characteristics. Classically, asthma has been characterized by reversible airways obstruction and COPD by fixed, less reversible, or irreversible airways obstruction. The definitions of asthma and COPD have undergone major revisions recently and COPD, like asthma, has now been recognized as an inflammatory disease of the airways [1, 2]. Even though asthma and COPD can be and are often appropriate‐ ly separated as clinical entities, there are times when they are clinically and physiologically indistinguishable. As the American Thoracic Society guidelines for the diagnosis of COPD [3] state, “the obstruction in many patients with COPD may include a significant reversible component and that some patients with asthma may go on to develop irreversible airflow obstruction indistinguishable from COPD.” This intersection of physiologic findings in asthma and COPD has led to the development of the concept of what is now known as the overlap syndrome of asthma and COPD [4]. As subcategories or phenotypes of asthma and COPD are identified, the distinction between these two disorders is less well defined. Some of the phenotypes exhibit very similar clinical, physiologic, and inflammatory profiles. The concept of asthma and COPD viewed as separate disease states has evolved as definitions and categorization of asthma and COPD change, and, as such, we are now encountering more overlap among these two disorders than was previously recognized. So we now pose the question: should asthma and COPD always be recognized and viewed as completely distinct diseases or is there enough similarity to view them equivalently at times? In essence, does an asthma-COPD overlap syndrome occur in some patients?

Nonadherence to asthma medications may contribute significantly to higher morbidity and mortality from asthma in adults age 65 years and older. Standardized measures to evaluate nonadherence in this population are lacking. Adults age 65 years and older with an objective diagnosis of asthma (n=175) were recruited from Allergy and Pulmonary clinics. They were administered a standardized survey with Likert scale responses, consisting of questions regarding asthma medication use and reasons for nonadherence in the previous month. Demographic data, medical history, including emergency department (ED) visits in the past year, and the validated asthma control questionnaire (ACQ) and asthma control test (ACT) were completed. Composite medication use scores (CMUS) were determined by summing responses. Logistic regression was used to compare asthma outcomes (ACT, ACQ, ED visits) to composite scores and individual questions, and to evaluate predictors of adherence. The mean CMUS was 7.1±2.9 (range 5-25; 5=perfect adherence); ACQ≥1.5 8.5, ACQ <1.5 6.7. Subjects with ACQ ≥1.5 and/or ACT<20 (poor asthma control) and/or any ED visits were less likely to be adherent (OR 0.37, [95% CI 0.19-0.72], p < 0.05; 0.44 [0.24-0.79], p < 0.05; 0.19 [0.07-0.50], p < 0.001, respectively). Individuals with ACQ≥1.5 were less likely to report continued asthma medication use despite symptom improvement (OR 0.29, [0.13-0.65], p < 0.005), and less able to afford medications (OR 0.23 [0.08-0.71], p < 0.05). Findings were similar for ED visits. Discontinuation of medications and the inability to afford medications were significant predictors of poor asthma control in older adults.

RationaleMorbidity and mortality from asthma is highest in older adults and quality of life (QOL) may be lower, although standardized measures of QOL have not been validated in this population. Predictors of asthma-related QOL in this population also have not been determined.MethodsAllergy and Pulmonary outpatients (n=164) age 65 years and older with an objective diagnosis of asthma completed the mini-Asthma Quality of Life Questionnaire (AQLQ). Demographics, medical history, and Elemental Carbon Attributable to Traffic (ECAT), a surrogate for diesel exposure, were determined. Regression was used to determine predictors of AQLQ scores.ResultsTotal AQLQ (mean ± SD= 5.4 ± 1.1), and symptom, emotional, and activity domain scores were similar to younger populations, while environmental domain scores (4.4 ± 1.7) appeared poorer. Poorer AQLQ scores were significantly associated with ED visits (adjusted [a] β=-1.3;p<0.0001) and with poorer scores on the Asthma Control Questionnaire (aβ=-0.7; p<0.0001). Higher ECAT exposure (aβ=-1.6; p<0.02), female gender (aβ =-0.4; p<0.006), BMI ≥ 30 kg/m2(aβ= -0.4; p<0.01), GERD (aβ=-0.4; p<0.01), non-atopic status (aβ=-0.5; p<0.002), and asthma onset before age 40 years (aβ=-0.5; p<0.004) were significantly associated with poorer AQLQ scores.ConclusionsAQLQ scores in stable, older asthmatics were similar to those in younger populations and were predictive of other measures of asthma control, verifying that the AQLQ is an appropriate tool in older asthmatics. Traffic pollution exposure was the strongest predictor of poorer asthma-related QOL in older asthmatics. RationaleMorbidity and mortality from asthma is highest in older adults and quality of life (QOL) may be lower, although standardized measures of QOL have not been validated in this population. Predictors of asthma-related QOL in this population also have not been determined. Morbidity and mortality from asthma is highest in older adults and quality of life (QOL) may be lower, although standardized measures of QOL have not been validated in this population. Predictors of asthma-related QOL in this population also have not been determined. MethodsAllergy and Pulmonary outpatients (n=164) age 65 years and older with an objective diagnosis of asthma completed the mini-Asthma Quality of Life Questionnaire (AQLQ). Demographics, medical history, and Elemental Carbon Attributable to Traffic (ECAT), a surrogate for diesel exposure, were determined. Regression was used to determine predictors of AQLQ scores. Allergy and Pulmonary outpatients (n=164) age 65 years and older with an objective diagnosis of asthma completed the mini-Asthma Quality of Life Questionnaire (AQLQ). Demographics, medical history, and Elemental Carbon Attributable to Traffic (ECAT), a surrogate for diesel exposure, were determined. Regression was used to determine predictors of AQLQ scores. ResultsTotal AQLQ (mean ± SD= 5.4 ± 1.1), and symptom, emotional, and activity domain scores were similar to younger populations, while environmental domain scores (4.4 ± 1.7) appeared poorer. Poorer AQLQ scores were significantly associated with ED visits (adjusted [a] β=-1.3;p<0.0001) and with poorer scores on the Asthma Control Questionnaire (aβ=-0.7; p<0.0001). Higher ECAT exposure (aβ=-1.6; p<0.02), female gender (aβ =-0.4; p<0.006), BMI ≥ 30 kg/m2(aβ= -0.4; p<0.01), GERD (aβ=-0.4; p<0.01), non-atopic status (aβ=-0.5; p<0.002), and asthma onset before age 40 years (aβ=-0.5; p<0.004) were significantly associated with poorer AQLQ scores. Total AQLQ (mean ± SD= 5.4 ± 1.1), and symptom, emotional, and activity domain scores were similar to younger populations, while environmental domain scores (4.4 ± 1.7) appeared poorer. Poorer AQLQ scores were significantly associated with ED visits (adjusted [a] β=-1.3;p<0.0001) and with poorer scores on the Asthma Control Questionnaire (aβ=-0.7; p<0.0001). Higher ECAT exposure (aβ=-1.6; p<0.02), female gender (aβ =-0.4; p<0.006), BMI ≥ 30 kg/m2(aβ= -0.4; p<0.01), GERD (aβ=-0.4; p<0.01), non-atopic status (aβ=-0.5; p<0.002), and asthma onset before age 40 years (aβ=-0.5; p<0.004) were significantly associated with poorer AQLQ scores. ConclusionsAQLQ scores in stable, older asthmatics were similar to those in younger populations and were predictive of other measures of asthma control, verifying that the AQLQ is an appropriate tool in older asthmatics. Traffic pollution exposure was the strongest predictor of poorer asthma-related QOL in older asthmatics. AQLQ scores in stable, older asthmatics were similar to those in younger populations and were predictive of other measures of asthma control, verifying that the AQLQ is an appropriate tool in older asthmatics. Traffic pollution exposure was the strongest predictor of poorer asthma-related QOL in older asthmatics.