University of California
San Francisco, CA

Program Director: Stephen Lazarus

Program Type: Pulmonary/Critical Care

Abstract Authors: Brian Block, MD Lekshmi Santhosh, MD Lorriana Leard, MD

Description of Fellowship Program: The UCSF Pulmonary and Critical Care fellowship enrolls seven fellows annually. Fellows spend eighteen months on clinical rotations, and eighteen months doing focused research, with the option to extend training and apply for independent research funding. Teaching conferences include 1) division-wide clinical case conferences, 2) weekly physiology lectures for first-year fellows, 3) a weekly critical care curriculum for second-year fellows, and 4) outpatient didactics and journal club, which run throughout all three years.

Abstract

Introduction

Pulmonary & Critical Care Medicine fellows are expected to achieve milestones and competencies enumerated by the American Board of Internal Medicine (ABIM) and Association of Pulmonary and Critical Care Medicine Program Directors (APCCMPD). Learning occurs in a variety of settings, including direct patient care, didactic sessions, case conferences, and self-directed study. We utilized curriculum mapping to evaluate how the clinical content of a teaching conference aligns with ABIM and APCCMPD priority areas.  

Methods

First-year Pulmonary and Critical Care fellows present clinical cases to the division five-times annually. Fellows select cases independently and invite a faculty member to discuss the case as an unknown. Approximately 35 cases are presented each year.  As a component of a multi-pronged effort to revamp this teaching conference, we reviewed presentations from the past three academic years to evaluate how the content compared to the ABIM Blueprint for the Pulmonary In-Training Exam (ABIM blueprint) and APCCMPD Milestones. Two authors (BB and LS) independently reviewed slides from prior presentations and assigned them to both ABIM blueprint domains and APCCMPD Milestones. When slides were unavailable for review, authors asked presenting fellows for ‘one-liner’ descriptions of their teaching topic to make assignments. In cases of disagreement, the authors reviewed differences and arrived at consensus.    Some cases addressed multiple ABIM domains (e.g. hypoxemic respiratory failure (domain “Critical Care Medicine”) due to pneumocystis pneumonia (domain “Infections”) in a lung transplant recipient (domain “Transplantation”).  We chose to assign a single domain based on the teaching points emphasized.  

Results

Eighty-two cases were presented during the study period (36 each in 2015-16 and 2016-17, and 10 so far in 2017-2018). Slides were available for review and scoring for 50 of 82 talks (61%). Fellows described an additional nine talks in sufficient detail for them to be assigned domains, for a total of 59 of 82 talks scored (72%).   The domains covered in the conference differed most strikingly from the ABIM blueprint for cases of vascular disease (15% of conferences versus 6% in ABIM blueprint) obstructive lung disease (10% versus 18%) and infections (19% versus 12%). The APCCMPD Milestones covered most frequently were Patient Care #8: Diffuse parenchymal lung diseases, Patient Care #6: Respiratory infections of the upper and lower airway, and Patient Care #3: Primary and metastatic malignancy of the lung and thorax.   Discussion: Without guidance, fellows chose to present cases representing domains that largely approximated the priorities espoused by the ABIM blueprint. They deviated by over-representing some domains (vascular diseases, infections) at the expense of others (obstructive lung disease), and when they did present cases related to obstruction, favored unusual diagnoses (e.g. Diffuse Idiopathic Neuroendocrine Cell Hyperplasia) over common ones.   Limitations of this mapping exercise include 1) capturing only 72% of presentations, 2) scoring some presentations without reviewing the slides, and 3) the single-centered nature of this study. We also acknowledge that an alternative approach would be to score presentations as representing multiple domains.  

Conclusions

The ABIM Blueprint and APCCMPD Milestones can be employed to create a curricular map of clinical content. Cases presented at our division conference emphasized rare diseases over routine entities. This begs the question of what type of teaching can best be accomplished in case conferences, and whether adjustments in case selection are needed to ensure coverage of core content. Future directions include evaluating other curricular activities to more comprehensively map our curriculum, assessing conferences at other institutions, and potentially guiding fellows to select cases that emphasize content areas that are currently underrepresented.

Figure 1: Comparison of ABIM Blueprint to domains covered at UCSF conference:

Figure 2: Examples of alignment of ABIM Blueprint with APCCMPD Milestones. Note that not all ABIM blueprint domains have corresponding APCCMPD Milestones