"It's Not Just Time Off": A Framework for Understanding Factors Promoting Recovery From Burnout Among Internal Medicine Residents.

Background: Burnout rates for internal medicine residents are among the highest of all specialties, yet little is known about how residents recover from burnout.

Objective: We identified factors promoting recovery from burnout and factors that assist with the subsequent avoidance of burnout among internal medicine residents.

Methods: A purposive sample of postgraduate year 2 (PGY-2), PGY-3, and recent graduates who experienced and recovered from burnout during residency participated in semistructured, 60-minute interviews from June to August 2016.

Improving Ambulatory Training in Internal Medicine: X + Y (or Why Not?).

The Accreditation Council for Graduate Medical Education (ACGME) requirement that internal medicine residents spend one-third of their training in an ambulatory setting has resulted in programmatic innovation across the country. The traditional weekly half-day clinic model has lost ground to the block or "X + Y" clinic model, which has gained in popularity for many reasons. Several disadvantages of the block model have been reported, however, and residency programs are caught between the threat of old and new challenges.

Shortening the Miles to the Milestones: Connecting EPA-Based Evaluations to ACGME Milestone Reports for Internal Medicine Residency Programs.

The Next Accreditation System requires internal medicine training programs to provide the Accreditation Council for Graduate Medical Education (ACGME) with semiannual information about each resident's progress in 22 subcompetency domains. Evaluation of resident "trustworthiness" in performing entrustable professional activities (EPAs) may offer a more tangible assessment construct than evaluations based on expectations of usual progression toward competence. However, translating results from EPA-based evaluations into ACGME milestone progress reports has proven to be challenging because the constructs that underlay these two systems differ.

Intensive care unit-acquired neuromyopathy and corticosteroids in survivors of persistent ARDS.

Objectives: To determine the incidence and outcomes of intensive care unit-acquired neuromyopathy and to investigate the role of methylprednisolone in survivors of persistent acute lung injury.

Design: Secondary analysis of completed randomized placebo-controlled trial.

Setting: Twenty-five hospitals in the NHLBI ARDS Network.

Integrating palliative and critical care: evaluation of a quality-improvement intervention.

Rationale: Palliative care in the intensive care unit (ICU) is an important focus for quality improvement.

Objectives: To evaluate the effectiveness of a multi-faceted quality improvement intervention to improve palliative care in the ICU.

Methods: We performed a single-hospital, before-after study of a quality-improvement intervention to improve palliative care in the ICU.

Intensivist physician staffing and the process of care in academic medical centres.

Background: Although intensivist physician staffing is associated with improved outcomes in critical care, little is known about the mechanism leading to this observation.

Objective: To determine the relationship between intensivist staffing and select process-based quality indicators in the intensive care unit.

Research Design: Retrospective cohort study in 29 academic hospitals participating in the University HealthSystem Consortium Mechanically Ventilated Patient Bundle Benchmarking Project.

Respiratory controversies in the critical care setting. Should tidal volume be 6 mL/kg predicted body weight in virtually all patients with acute respiratory failure?

Over the last 2 decades, it has become clear that mechanical ventilation itself can cause lung injury and affect outcome. The development of ventilator-induced lung injury is strongly associated with overdistension of lung parenchyma, and limiting lung stretch saves lives in patients with acute lung injury. The debate in this paper is whether all patients on mechanical ventilation should be managed with a tidal volume (V(T)) of 6 mL/kg predicted body weight.

Respiratory controversies in the critical care setting. When caring for critically ill patients, do clinicians have a responsibility to be innovative and try unproven approaches when accepted approaches are failing?

As the first paper in this Journal Conference on intensive care unit controversies, the editors wished us to set the tone for the debate by discussing the ethics of medical "adventurism" in the intensive care unit. More life-or-death decisions are made in the intensive care unit than elsewhere in the hospital, and the critical care specialist often sees himself or herself as a warrior in a battle with death. This adrenaline-charged calling attracts highly intelligent, hard-working, and compassionate caregivers, as well as fiercely independent clinicians.

The association between body mass index and clinical outcomes in acute lung injury.

Background: The association between body mass index (BMI) and outcomes in critically ill patients is unclear. Our objective was to determine the association between BMI and outcomes in a population-based cohort of patients with acute lung injury (ALI).

Methods: In a prospective cohort study of all ICU patients in King County, Washington, with ALI in 1 year (1999 to 2000), 825 patients had a BMI recorded.

Integrating palliative and critical care: description of an intervention.

A large proportion of deaths in the United States occur in the intensive care unit (ICU) or after a stay in the ICU, and there is evidence of problems in the quality of care these patients and their families receive. In an effort to respond to this problem, we developed a multifaceted, nurse-focused, quality improvement intervention that is based on self-efficacy theory applied to changing clinician behavior. We have called the intervention "Integrating Palliative and Critical Care.

Efficacy and safety of corticosteroids for persistent acute respiratory distress syndrome.

Background: Persistent acute respiratory distress syndrome (ARDS) is characterized by excessive fibroproliferation, ongoing inflammation, prolonged mechanical ventilation, and a substantial risk of death. Because previous reports suggested that corticosteroids may improve survival, we performed a multicenter, randomized controlled trial of corticosteroids in patients with persistent ARDS.

Methods: We randomly assigned 180 patients with ARDS of at least seven days' duration to receive either methylprednisolone or placebo in a double-blind fashion.

Causes and timing of death in patients with ARDS.

Background: Since the early 1980s, case fatality of patients with ARDS has decreased, and explanations are unclear.

Design And Methods: Using identical definitions of ARDS and organ failure, we analyzed consecutive cohorts of patients meeting syndrome criteria at our institution in 1982 (n = 46), 1990 (n = 112), 1994 (n = 99), and 1998 (n = 205) to determine causes and timing of death.

Results: Overall case fatality has decreased from 68% in 1981-1982 to a low of 29% in 1996, plateauing since the mid-1990s (p = 0.

Factors associated with nurse assessment of the quality of dying and death in the intensive care unit.

Objective: To determine the feasibility of using nurse ratings of quality of dying and death to assess quality of end-of-life care in the intensive care unit and to determine factors associated with nurse assessment of the quality of dying and death for patients dying in the intensive care unit.

Design: Prospective cohort study.

Setting: Hospital intensive care unit.

Narcotic and benzodiazepine use after withdrawal of life support: association with time to death?

Objective: To determine whether the dose of narcotics and benzodiazepines is associated with length of time from mechanical ventilation withdrawal to death in the setting of withdrawal of life-sustaining treatment in the ICU.

Design: Retrospective chart review.

Setting: University-affiliated, level I trauma center.

Evaluation of a standardized order form for the withdrawal of life support in the intensive care unit.

Objective: The intensive care unit remains a setting where death is common, and a large proportion of these deaths are preceded by withdrawal of life support. We describe a quality improvement project implementing and evaluating a "withdrawal of life support order form" to improve quality of end-of-life care in the intensive care unit.

Design: Before-after evaluation.

Chronic alcohol abuse is associated with an increased incidence of acute respiratory distress syndrome and severity of multiple organ dysfunction in patients with septic shock.

Objective: Alcohol is one of the most commonly used drugs in the world and causes dysfunction in many vital organs. However, the effects of chronic alcohol abuse on acute lung injury and nonpulmonary organ dysfunction are relatively unexplored. The goal of this study was to determine the effects of chronic alcohol abuse on the incidence and severity of the acute respiratory distress syndrome and multiple organ dysfunction syndrome in patients with septic shock.

Increased angiostatin levels in bronchoalveolar lavage fluids from ARDS patients and from human volunteers after lung instillation of endotoxin.

Acute respiratory distress syndrome (ARDS) is characterized by a disruption of the alveolar-capillary barrier, due to both an epithelial and an endothelial dysfunction. Whereas epithelial apoptosis seems to be mainly mediated by Fas ligand, the mediators of endothelial damage remain to be identified. Angiostatin, a powerful inhibitor of angiogenesis in vivo, also specifically induces apoptosis in endothelial cells.

Stress-related mucosal disease in the critically ill patient: risk factors and strategies to prevent stress-related bleeding in the intensive care unit.

Stress-related mucosal disease develops in patients in the intensive care unit and can result in clinically important bleeding, which is associated with increased mortality. Patients in the intensive care unit without either mechanical ventilation or coagulopathy, which are the primary risk factors for such bleeding, do not seem to need or to benefit from prophylactic acid suppression for stress-related mucosal disease. Although histamine-2-receptor antagonists significantly reduce clinically important bleeding in patients in the intensive care unit and are widely used for prophylaxis, their benefits are limited by the rapid development of tolerance.

Recovery rate and prognosis in older persons who develop acute lung injury and the acute respiratory distress syndrome.

Background: The incidence of acute respiratory failure requiring mechanical ventilation increases 10-fold from the ages of 55 to 85 years, yet the rate of recovery and outcomes in older persons who develop acute lung injury are poorly defined.

Objective: To examine age as an independent risk factor in recovery and intensive care unit discharge after acute lung injury.

Design: Prospective cohort study.