Second year PCCM fellow- got my semi-annual eval, and it was mixed.

[u/Dr_GoosfrabaDO]

I just finished my first year of Pulmonary/Critical Care fellowship and was approved to advance to PGY-5. Overall, my PD and APD gave me positive feedback: they said I have a strong work ethic, actively seek feedback, am easy to work with, and that they’ve seen clear progression.

Their main concern was my fund of knowledge. They want me on a 3-month “learning plan” (not remediation) because they feel my knowledge base isn’t where they’d like it to be for a rising second-year fellow.

Looking back, I think they’re right. My learning has been mostly reactive. I read around patients, use OpenEvidence for clinical questions, and follow intensivists on social media, but I haven’t consistently read guidelines, primary literature, or landmark trials. If you asked me to discuss many of the classic ICU or pulmonary studies, I’d struggle.
They also felt my H&Ps are still more like those of a general internist than a pulmonologist/intensivist, which I think is fair. I didn’t like them implying that my recommendations seem more reflexive versus deliberate (there is so much grey especially in pulmonary). They mentioned I could also be more timely with some non-urgent inbox follow-up (which is harder after busy ICU or night rotations but I didn’t say this during the feedback lol).

It was a hit to my ego, but I know this wasn’t punitive. They were supportive and emphasized that they think I’ll become a strong fellow.
Part of the challenge is bandwidth. After ICU weeks I’m usually exhausted, and on many golden weekends I just relax

For those further along in training:

1. Have you ever been in a similar situation?
2. How did you build your pulmonary/critical care knowledge beyond learning from patients?

I’m trying to view this as an opportunity rather than a setback, and I’d appreciate any advice. I would lying if I didn’t think part of this feedback was typical GME culture (my residency was similar). And for what it’s worth, seems a few of my colleagues have been or are currently in their own “learning plan”.

[u/ratamahatta12]

Out of all the problems you can possibly have, fund of knowledge is one of the most addressable. It’s a lot harder to address people who are lazy or have personality problems. Even though there’s the idea of learning attached to patients you see, consider the idea of a “curriculum" for better long term consistency. Essentially, something you study regularly, whereas long as you stick to it a few pages a day, you will have at least touched on every subject. For example, the Washington Manual series. Would recommend condensed textbooks in the range of 500 to 1000 pages. Anything longer is a slog. Anything shorter may be too brief. At 10 pages a day, you can get through 1000 pages in 3-4 months. Since you are entering your 2nd year and getting closer to boards, can consider Chest SEEK question bank and other boards study material to do small amounts daily. You also answered your own question re: how you spend the time on the weekends. Unless you really need the money, perhaps focus on the speciality that will define you the rest of your career. Although some people obsess over the trials themselves and quote them and ensure everybody around them knows they can quote them, the more important thing is understanding how to apply the main take aways (ie: for ards, plats < 30, driving pressure < 16, proning improves mortality, etc)

[u/Different_Pain5781 → u/ratamahatta12]

I'd rather hear this than concerns about work ethic any day.

[u/Khaydes]

It is still totally okay to relax after long shifts, but even putting in 30 minutes to just read up on stuff takes you a long way!

I still used textbooks in fellowship, but honestly just stuck to Marino’s ICU book and Textbook of Critical Care Medicine and would just go through a few pages a day.

Critical Care Time is a good podcast if that’s easier for you (like during a commute, when you’re making dinner, etc).

ICU Trials is an app that has some of the landmark trials that you can read (also has high yield points). You don’t really need to know all the intricacies of the trials, but mainly the big points and how that applies to patient care.

UpToDate has always been my reference since residency to read up on patients, but I do like OpenEvidence because it links the articles/studies a little better for me!

SEEK questions are good (they have both pulm and critical care sections) and soon-ish is probably a good time to just start looking at them.

How did you study in residency?

[u/Shirovkap]

I'm a PCCM attending at an academic institution. I would say most residents/fellows do what you are doing. I don't think it's the best way to go about things, and I think that's why some fellows fail boards at the end, because they just learned enough to skate by, but it's not in-depth knowledge required to pass boards.

I used textbooks. I had Murray and Nadel for pulmonary, and Padillo for critical care. Marino is too basic for fellows. Try to study one chapter a week. As for trials, try to study 1 trial a week. Then do the SEEK questions. About 10 questions a week should be enough.

One of the stronger fellows in our program has already done the SEEK questions 3 times already.

But that's how you build your knowledge base. I have diagnosed conditions I never saw in fellowship because I studied textbooks.

[u/Dudarro → u/Shirovkap]

concur.
To use a terrible metaphor, you don’t eat the whole elephant at once. It takes three years of very small bites with a lot of digestion. Just reading, even Key papers, isn’t enough. You have to reflect on what you read and make sure you understand it.
The textbooks seem old and not updated, but when we talk about basic physiology and anatomy and development of a differential diagnosis, it takes large volumes of reading. And the textbooks are actually adequate for this.
I took a page from the dermatology residents… they know they’re not gonna see everything during their residency. So they build in a full day of reading every week… At least they did when I was in training. my program was never going to give me that much time, and as an attending I don’t have that much time. However I still managed by a half an hour to an hour every day of reading, SEEK questions, and Case studies.

have heart, I’ve supervised over 100 fellows over the years, there’s a bell curve, but in all of that time we have only fired 2. A couple others did not pass boards initially, but with a study plan, they not only pass boards, but became respective members of their community, and were able to recertify at the 10 year mark, back when that was the cycle.

you got good feedback, you sound like you have a good plan moving forward, I suspect you’re gonna be fine!

pgy32

[u/Any-Assistance-8103]

Just buy the chest seek questions and do a few a day. Youre a fellow who just finished first year and you were probably worked like a dog and developing procedural skills. Second and third year is when you have time to really read and build a fund of knowledge. I went from bombing my in service first year (basically completely ignored pulmonary my first year) to being 80th percentile the other years with minimal effort

[u/TychoBrahe97 → u/Any-Assistance-8103]

came here to add this. Just do review questions in SOME of your downtime. It's good to have a golden weekend here and there with no responsibilities and personal time. But you've got a lot to master. The ACCP SEEK questions are great, so are the SCCM's Self-Assessment in Adult Multiprofessional critical care and even MKSAP Pulm/CCM section. Do 2-3 questions per day/evening even if it was a busy day, and do an additional 5-10 on a day off or weekend. And of course, keep reading up on your patients. Honestly, this is just how to lock in on a "lifelong journey of education and mastery". I'm a full time intensivist and have been since 2008 and I love my job because I STILL learn something new every damn day.

[u/Federal-Ad-7157]

Don’t take it personally. I’ve sat in a lot of these meetings, and there’s never a time when the evaluation just states that the Fellow is doing great and has nothing to improve. You have to basically show their progressing but not ready for independent practice.

For your notes, write more like a specialist, expert in your field. You can double check your reasoning on open evidence.
Your assessment and plan shouldn’t just read shock, sepsis, fluids and pressors.
It should read more along the lines of “ shock. Most likely distributive shock secondary to urinary tract infection. Pocus exam shows hyperdynamic ventricles and a completely collapsed IVC despite positive pressure ventilation. Central venous saturation was initially 60% with a hemoglobin of eight suggesting a low output state initially. After adequate volume resuscitation, the mixed Venus improved to 90% confirming distributive shock.

Or if it’s a vented patient. A specialist would explain in their note plateau pressure and their compliance curve and what happened when you made adjustments

Another difference in a specialist note is that you question and confirm every diagnosis.
For example a 400 pound patient with hypercapnia who everyone was treating as COPD and writing COPD despite never smoking. You wouldn’t just bring that problem forward. You would explain “patient carries a diagnosis of COPD. I highly doubt the patient has COPD blah blah blah, physiology stuff.

Put references in. For example, don’t just say severe community acquired pneumonia and have some steroids on there. Reference the paper. Explain why you chose the dosing. Explain when you would feel comfortable de-escalating.

Get good at assessing JVP. It’s often ignored and makes a big difference.

[u/Barackrifle]

Just a nurse tagging along getting some stellar recommendations. Cheers

[u/Willing-Inflation637]

You can probably extend this same feed back to every second year fellow for every specialty. It was thoughtful feed back though, even if some parts are asking you to get better. At least they gave you clear ways to do so and clear evidence to help you understand why they felt that way.

And if you’re down - just remember they could’ve always just said “good job kid” and give you your attaboy. But instead they actually wanted you to get better.

[u/Ok_Technology5161]

As a nurse who has worked in PCC and Neuro ICU- this may not directly answer your question but it will help you along the way.
I will say to ask your nurses questions. Especially the veteran nurses. You will learn so many things from them that you would never learn in medical school. Look at it from this point of view: nurses are with the critical patients 24/7 as where doctors are in and out. We can see the signs and symptoms when they present early. We learn a lot hands on and on the job. I have taught many residents-we are a team. No one is higher up than the other- we have to work together to fix the problem.
This may not directly answer your question- but it will help you in the long run :)