The robots are coming – at least according to a report,¹ which states that Google created an artificial intelligence model that was able to detect lung cancer and cut back on false-positives at a rate that beat experienced radiologists.

As a fan of Star Wars, sci-fi, and innovation, in general – I say, bring it on! It’s an exciting trend in medicine to see technology that has already changed the way we work and live enter into the world of health care. And, this is not about replacing humans either (like what occurs in a lot of sci-fi ); this technology will potentially provide clinicians with the tools they can use to improve outcomes for their patients.

The researchers for this study used a system called convolutional neural networks to study patterns in 3D CT scans. One advantage computers has over humans is that a computer can process the entire scan all at once while trained radiologists need to review individual slices of each scan to make their diagnosis.

While this technology will need more testing and large-scale trials before being used to diagnose patients’ disorders, the early results are encouraging. The researchers also picked a cancer that impacts so many of CHEST’s members and their patients. Lung cancer kills more Americans than any type of cancer while accounting for more than 25% of all cancer deaths annually.² In a statistic that many people find shocking, lung cancer actually kills more women than breast, ovarian, and uterine cancers combined.³ Given the devastation of this disease, we can use all of the help we can get. Another positive from this study that might be overlooked is the rate of improvement for false-positive results. This could be a major benefit of both saving the time and preventing invasive treatments or attempts to confirm a diagnosis.

This news is exciting for everyone trying to (as we say at CHEST) crush lung disease, but seeing AI in medicine is not surprising, because we are already using it at CHEST. The AI projects at CHEST include analyzing the types of activities that are most beneficial to members and building predictive analytics models for a project. These were only initial forays into using this new technology. One of the even more mind-blowing developments has been rolling out natural language processing⁴ for our internal data reporting.

This is a new development, and much like the Google lung cancer study, we cannot tell you what the end result will be. What we can say is that it’s likely to change the way we work and provide new opportunities to create analytics solutions for our partners.

CHEST is not “just” a medical association: we are also an innovative group using the latest tools to create a better future for members, partners, and ,ultimately, patients and their families.
 

Mr. Jackson is CHEST Chief Innovation Officer & Vice President of Market Growth and Innovation.

References

1. https://www.statnews.com/2019/05/20/googles-ai-improves-accuracy-of-lung-cancer-diagnosis-study-shows/. Accessed July 17, 2019.

2. https://foundation.chestnet.org/patient-education-resources/lung-cancer/. Accessed July 17, 2019.

3. https://foundation.chestnet.org/wp-content/uploads/2017/01/15110313_10154723685773104_3710772562030977299_o-1.png. Accessed July 17, 2019.

4. https://www.tableau.com/products/new-features/ask-data. Accessed July 17, 2019.

*This article originally appeared as a blog July 1, 2019, on https://insights.chestnet.org/.
 

The robots are coming – at least according to a report,¹ which states that Google created an artificial intelligence model that was able to detect lung cancer and cut back on false-positives at a rate that beat experienced radiologists.

As a fan of Star Wars, sci-fi, and innovation, in general – I say, bring it on! It’s an exciting trend in medicine to see technology that has already changed the way we work and live enter into the world of health care. And, this is not about replacing humans either (like what occurs in a lot of sci-fi ); this technology will potentially provide clinicians with the tools they can use to improve outcomes for their patients.

The researchers for this study used a system called convolutional neural networks to study patterns in 3D CT scans. One advantage computers has over humans is that a computer can process the entire scan all at once while trained radiologists need to review individual slices of each scan to make their diagnosis.

While this technology will need more testing and large-scale trials before being used to diagnose patients’ disorders, the early results are encouraging. The researchers also picked a cancer that impacts so many of CHEST’s members and their patients. Lung cancer kills more Americans than any type of cancer while accounting for more than 25% of all cancer deaths annually.² In a statistic that many people find shocking, lung cancer actually kills more women than breast, ovarian, and uterine cancers combined.³ Given the devastation of this disease, we can use all of the help we can get. Another positive from this study that might be overlooked is the rate of improvement for false-positive results. This could be a major benefit of both saving the time and preventing invasive treatments or attempts to confirm a diagnosis.

This news is exciting for everyone trying to (as we say at CHEST) crush lung disease, but seeing AI in medicine is not surprising, because we are already using it at CHEST. The AI projects at CHEST include analyzing the types of activities that are most beneficial to members and building predictive analytics models for a project. These were only initial forays into using this new technology. One of the even more mind-blowing developments has been rolling out natural language processing⁴ for our internal data reporting.

This is a new development, and much like the Google lung cancer study, we cannot tell you what the end result will be. What we can say is that it’s likely to change the way we work and provide new opportunities to create analytics solutions for our partners.

CHEST is not “just” a medical association: we are also an innovative group using the latest tools to create a better future for members, partners, and ,ultimately, patients and their families.
 

Mr. Jackson is CHEST Chief Innovation Officer & Vice President of Market Growth and Innovation.

References

1. https://www.statnews.com/2019/05/20/googles-ai-improves-accuracy-of-lung-cancer-diagnosis-study-shows/. Accessed July 17, 2019.

2. https://foundation.chestnet.org/patient-education-resources/lung-cancer/. Accessed July 17, 2019.

3. https://foundation.chestnet.org/wp-content/uploads/2017/01/15110313_10154723685773104_3710772562030977299_o-1.png. Accessed July 17, 2019.

4. https://www.tableau.com/products/new-features/ask-data. Accessed July 17, 2019.

*This article originally appeared as a blog July 1, 2019, on https://insights.chestnet.org/.
 

The robots are coming – at least according to a report,¹ which states that Google created an artificial intelligence model that was able to detect lung cancer and cut back on false-positives at a rate that beat experienced radiologists.

As a fan of Star Wars, sci-fi, and innovation, in general – I say, bring it on! It’s an exciting trend in medicine to see technology that has already changed the way we work and live enter into the world of health care. And, this is not about replacing humans either (like what occurs in a lot of sci-fi ); this technology will potentially provide clinicians with the tools they can use to improve outcomes for their patients.

The researchers for this study used a system called convolutional neural networks to study patterns in 3D CT scans. One advantage computers has over humans is that a computer can process the entire scan all at once while trained radiologists need to review individual slices of each scan to make their diagnosis.

While this technology will need more testing and large-scale trials before being used to diagnose patients’ disorders, the early results are encouraging. The researchers also picked a cancer that impacts so many of CHEST’s members and their patients. Lung cancer kills more Americans than any type of cancer while accounting for more than 25% of all cancer deaths annually.² In a statistic that many people find shocking, lung cancer actually kills more women than breast, ovarian, and uterine cancers combined.³ Given the devastation of this disease, we can use all of the help we can get. Another positive from this study that might be overlooked is the rate of improvement for false-positive results. This could be a major benefit of both saving the time and preventing invasive treatments or attempts to confirm a diagnosis.

This news is exciting for everyone trying to (as we say at CHEST) crush lung disease, but seeing AI in medicine is not surprising, because we are already using it at CHEST. The AI projects at CHEST include analyzing the types of activities that are most beneficial to members and building predictive analytics models for a project. These were only initial forays into using this new technology. One of the even more mind-blowing developments has been rolling out natural language processing⁴ for our internal data reporting.

This is a new development, and much like the Google lung cancer study, we cannot tell you what the end result will be. What we can say is that it’s likely to change the way we work and provide new opportunities to create analytics solutions for our partners.

CHEST is not “just” a medical association: we are also an innovative group using the latest tools to create a better future for members, partners, and ,ultimately, patients and their families.
 

Mr. Jackson is CHEST Chief Innovation Officer & Vice President of Market Growth and Innovation.

References

1. https://www.statnews.com/2019/05/20/googles-ai-improves-accuracy-of-lung-cancer-diagnosis-study-shows/. Accessed July 17, 2019.

2. https://foundation.chestnet.org/patient-education-resources/lung-cancer/. Accessed July 17, 2019.

3. https://foundation.chestnet.org/wp-content/uploads/2017/01/15110313_10154723685773104_3710772562030977299_o-1.png. Accessed July 17, 2019.

4. https://www.tableau.com/products/new-features/ask-data. Accessed July 17, 2019.

*This article originally appeared as a blog July 1, 2019, on https://insights.chestnet.org/.
 

Airway management is a complex process that, if not performed in a proper and timely manner, may result in significant morbidity or mortality. The risk of intubation failure and associated adverse events is higher in critically ill patients due to differences in patient condition, environment, and practitioner experience. Even when controlling for provider experience, intubating conditions are worse and success rates are lower in the ICU compared with the controlled environment of the operating room (Taboada, et al. Anesthesiology. 2018;129[2]:321). Furthermore, the risk of injury and adverse events increases with the number of intubation attempts during an emergency (Sakles JC, et al. Acad Emerg Med. 2013;20[1]:71). Unfortunately, the paucity of high-grade evidence leads practitioners to rely on practice patterns developed during training and predicated on common sense airway management principles. The difficulty in evaluating airway management in the critically ill lies in the multi-step and complex nature of the process, including the pre-intubation, intubation, and post-intubation activities (Fig 1). Several recent publications have the potential to change airway management practice in the ICU. We will address the latest information on preoxygenation, use of neuromuscular blockade (NMB), and checklists in this setting.

Preoxygenation: Overrated?

Rapid-sequence intubation (RSI) is a technique intended to minimize the time from induction to intubation and reduce the risk of aspiration by primarily avoiding ventilation. The avoidance of bag-mask ventilation during this apneic period is common, due to concerns that positive pressure can produce gastric insufflation and regurgitation that may lead to aspiration. To attenuate the risk for critical desaturation, preoxygenation is classically provided prior to induction of anesthesia in the operative procedural areas. Although the benefit can be seen in patients undergoing elective intubation, critically ill patients often have difficulty in significantly raising the blood oxygen content despite preoxygenation with 100% oxygen delivered via face mask. As a result, the oxygen saturation can drop precipitously during the process of ICU intubation, especially if multiple or prolonged intubation attempts are required. These factors all contribute to the risk of hypoxemia and cardiac arrest during ICU intubations (De Jong A, et al. Crit Care Med. 2018;46[4]:532), which has led to the debate about the avoidance of ventilation during RSI in the critically ill. Recently, Casey and colleagues (Casey JD, et al. N Engl J Med. 2019;380[9]:811) evaluated the use of bag-mask ventilation (BMV) during RSI. In this ICU study, intubations were randomized to either include BMV or no ventilation after induction. The results suggested that the frequency of critical desaturation was lower in the patients receiving BMV after induction without a concomitant increase in frequency of aspiration. Although not powered to evaluate the difference in the incidence of aspiration, this study supports the use of BMV during the apneic phase of intubation, thereby decreasing the risk for critical desaturation.

Neuromuscular blockade: Yes or no?

Awake intubation, with or without sedation, is often employed for managing the airway in high-risk patients. This technique allows the patient to maintain spontaneous ventilation in the event of repeated intubation attempts and has a lower hypotension risk. However, many critically ill patients cannot be managed in this manner due to lack of patient cooperation, emergent airway management requirements, or practitioner inexperience with this technique. As a result, many of these patients will require an induction agent, and concomitant administration of a neuromuscular blocking agent (NMB) to optimize intubating conditions. However, the avoidance of NMBs in emergent airway scenarios was not uncommon among attending physicians and trainees (Schmidt UH, et al. Anesthesiology. 2008;109[6]:973). The American College of Chest Physicians (CHEST) Difficult Airway Course faculty also recommended to not use NMB because of the high risk of failure to ventilate/oxygenate. Without NMB, the patient might be allowed to recover to spontaneous ventilation. This approach is taken in the American Society of Anesthesiologists Practice Guidelines for the Management of the Difficult Airway but is not necessarily applicable to the critically ill patient (Apfelbaum JL, et al. Anesthesiology. 2013;118[2]:251-70). In the event of “can’t intubate, can’t oxygenate” (CICO), the critically ill patient in extremis may not tolerate an attempt to return to spontaneous ventilation because spontaneous ventilation may have been initially inadequate.

In 2010, Jaber and colleagues demonstrated a lower incidence of hypoxemia and severe hemodynamic collapse with the implementation of an intubation bundle that included the use of NMBs for all rapid-sequence inductions (Jaber S, et al. Int Care Med. 2010;36:248). The safety of using paralytics in critically ill patients was later investigated by Wilcox and colleagues in a prospective, observational study that suggested a decrease in the incidence of hypoxemia and complications when employing NMB (Wilcox SR, et al. Crit Care Med. 2012;40[6]:1808). Although Wilcox et al.’s study was hypothesis-generating by the nature of its design, it was consistent with both Jaber’s findings and a more recent observational study performed by Moser et al (Mosier JM, et al. Ann Am Thorac Soc. 2015;12[5]:734). Furthermore, there is no evidence that NMBs worsen bag mask ventilation in the critically ill patient. NMBs in addition to induction agents might be associated with optimal intubating conditions, reduced complications, and allow for placement of a supraglottic airway device or surgical airway in the event of a CICO (Higgs A, et al. Br J Anaesth. 2018;120[2]:323).
 

Checking the checklists

Checklists are another intervention with the potential to improve outcomes or reduce adverse events. Airway management is often a complex process with significant opportunities for failure. Therefore, having reminders or checklists available to the provider may encourage the use of best practices. Jaber demonstrated that a straightforward, 10-point intubation bundle reduced the incidence of severe complications associated with emergent intubation in the ICU. In the 4th National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society, the use of checklists was recommended as a method to reduce adverse events and increase successful airway management (Cook TM, et al. Br J Anaesth. 2011;106[5]:632). In fact, several mnemonics have been developed to aid the practitioner, including the ‘7 Ps’ in the Manual of Emergency Airway Management (Walls RM, et al. Manual of Emergency Airway Management. 2012) and APPROACH from the CHEST Airway Management Training Team. More recently, Janz and colleagues developed and employed a checklist in a multicenter study and compared it with usual practice (Janz DR, et al. Chest. 2018;153[4]:816). Although the checklist was associated with improved provider compliance with airway assessment, preparation, and verbalization of a plan, it did not go far enough to include the known interventions for optimizing preoxygenation and hemodynamic stability. Two elements that might be included in a checklist include fluids and vasopressors administration during the pre-intubation and post-intubation period, and preoxygenation with noninvasive ventilation. The former is associated with a lower incidence of hypotension, while the latter may reduce the incidence of severe hypoxemia in ICU intubations (Baillard C, et al. Am J Respir Crit Care Med. 2006;174[2]:171).

Keeping apprised of evidence and adjusting practice are crucial to the competent clinician engaging in airway management, as they minimize the risk of harm while maximizing the benefit to the patient. However, the methods to achieve these goals are not always intuitive. Definitive high-level evidence is sparse. The use of neuromuscular blockade and BMV after induction has historically been controversial, but more recent evidence is favoring these approaches for RSI. The use of checklists or guidelines may ensure that the necessary safety steps are followed, especially at institutions that may not have experts in airway management. Over time, the hope is that many of our traditional practices are either supported by quality evidence or better techniques evolve.
 

Dr. Tokarczyk is with the Department of Anesthesia, NorthShore University HealthSystem; and Clinical Assistant Professor, University of Chicago, Pritzker School of Medicine. Dr. Greenberg is Editor-in-Chief, Anesthesia Patient Safety Foundation (APSF) Newsletter; Vice Chairperson, Education, Department of Anesthesiology; Director of Critical Care Services, Evanston Hospital; NorthShore University HealthSystem; and Clinical Professor, Department of Anesthesiology Critical Care, University of Chicago, Pritzker School of Medicine.
 

Airway management is a complex process that, if not performed in a proper and timely manner, may result in significant morbidity or mortality. The risk of intubation failure and associated adverse events is higher in critically ill patients due to differences in patient condition, environment, and practitioner experience. Even when controlling for provider experience, intubating conditions are worse and success rates are lower in the ICU compared with the controlled environment of the operating room (Taboada, et al. Anesthesiology. 2018;129[2]:321). Furthermore, the risk of injury and adverse events increases with the number of intubation attempts during an emergency (Sakles JC, et al. Acad Emerg Med. 2013;20[1]:71). Unfortunately, the paucity of high-grade evidence leads practitioners to rely on practice patterns developed during training and predicated on common sense airway management principles. The difficulty in evaluating airway management in the critically ill lies in the multi-step and complex nature of the process, including the pre-intubation, intubation, and post-intubation activities (Fig 1). Several recent publications have the potential to change airway management practice in the ICU. We will address the latest information on preoxygenation, use of neuromuscular blockade (NMB), and checklists in this setting.

Preoxygenation: Overrated?

Rapid-sequence intubation (RSI) is a technique intended to minimize the time from induction to intubation and reduce the risk of aspiration by primarily avoiding ventilation. The avoidance of bag-mask ventilation during this apneic period is common, due to concerns that positive pressure can produce gastric insufflation and regurgitation that may lead to aspiration. To attenuate the risk for critical desaturation, preoxygenation is classically provided prior to induction of anesthesia in the operative procedural areas. Although the benefit can be seen in patients undergoing elective intubation, critically ill patients often have difficulty in significantly raising the blood oxygen content despite preoxygenation with 100% oxygen delivered via face mask. As a result, the oxygen saturation can drop precipitously during the process of ICU intubation, especially if multiple or prolonged intubation attempts are required. These factors all contribute to the risk of hypoxemia and cardiac arrest during ICU intubations (De Jong A, et al. Crit Care Med. 2018;46[4]:532), which has led to the debate about the avoidance of ventilation during RSI in the critically ill. Recently, Casey and colleagues (Casey JD, et al. N Engl J Med. 2019;380[9]:811) evaluated the use of bag-mask ventilation (BMV) during RSI. In this ICU study, intubations were randomized to either include BMV or no ventilation after induction. The results suggested that the frequency of critical desaturation was lower in the patients receiving BMV after induction without a concomitant increase in frequency of aspiration. Although not powered to evaluate the difference in the incidence of aspiration, this study supports the use of BMV during the apneic phase of intubation, thereby decreasing the risk for critical desaturation.

Neuromuscular blockade: Yes or no?

Awake intubation, with or without sedation, is often employed for managing the airway in high-risk patients. This technique allows the patient to maintain spontaneous ventilation in the event of repeated intubation attempts and has a lower hypotension risk. However, many critically ill patients cannot be managed in this manner due to lack of patient cooperation, emergent airway management requirements, or practitioner inexperience with this technique. As a result, many of these patients will require an induction agent, and concomitant administration of a neuromuscular blocking agent (NMB) to optimize intubating conditions. However, the avoidance of NMBs in emergent airway scenarios was not uncommon among attending physicians and trainees (Schmidt UH, et al. Anesthesiology. 2008;109[6]:973). The American College of Chest Physicians (CHEST) Difficult Airway Course faculty also recommended to not use NMB because of the high risk of failure to ventilate/oxygenate. Without NMB, the patient might be allowed to recover to spontaneous ventilation. This approach is taken in the American Society of Anesthesiologists Practice Guidelines for the Management of the Difficult Airway but is not necessarily applicable to the critically ill patient (Apfelbaum JL, et al. Anesthesiology. 2013;118[2]:251-70). In the event of “can’t intubate, can’t oxygenate” (CICO), the critically ill patient in extremis may not tolerate an attempt to return to spontaneous ventilation because spontaneous ventilation may have been initially inadequate.

In 2010, Jaber and colleagues demonstrated a lower incidence of hypoxemia and severe hemodynamic collapse with the implementation of an intubation bundle that included the use of NMBs for all rapid-sequence inductions (Jaber S, et al. Int Care Med. 2010;36:248). The safety of using paralytics in critically ill patients was later investigated by Wilcox and colleagues in a prospective, observational study that suggested a decrease in the incidence of hypoxemia and complications when employing NMB (Wilcox SR, et al. Crit Care Med. 2012;40[6]:1808). Although Wilcox et al.’s study was hypothesis-generating by the nature of its design, it was consistent with both Jaber’s findings and a more recent observational study performed by Moser et al (Mosier JM, et al. Ann Am Thorac Soc. 2015;12[5]:734). Furthermore, there is no evidence that NMBs worsen bag mask ventilation in the critically ill patient. NMBs in addition to induction agents might be associated with optimal intubating conditions, reduced complications, and allow for placement of a supraglottic airway device or surgical airway in the event of a CICO (Higgs A, et al. Br J Anaesth. 2018;120[2]:323).
 

Checking the checklists

Checklists are another intervention with the potential to improve outcomes or reduce adverse events. Airway management is often a complex process with significant opportunities for failure. Therefore, having reminders or checklists available to the provider may encourage the use of best practices. Jaber demonstrated that a straightforward, 10-point intubation bundle reduced the incidence of severe complications associated with emergent intubation in the ICU. In the 4th National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society, the use of checklists was recommended as a method to reduce adverse events and increase successful airway management (Cook TM, et al. Br J Anaesth. 2011;106[5]:632). In fact, several mnemonics have been developed to aid the practitioner, including the ‘7 Ps’ in the Manual of Emergency Airway Management (Walls RM, et al. Manual of Emergency Airway Management. 2012) and APPROACH from the CHEST Airway Management Training Team. More recently, Janz and colleagues developed and employed a checklist in a multicenter study and compared it with usual practice (Janz DR, et al. Chest. 2018;153[4]:816). Although the checklist was associated with improved provider compliance with airway assessment, preparation, and verbalization of a plan, it did not go far enough to include the known interventions for optimizing preoxygenation and hemodynamic stability. Two elements that might be included in a checklist include fluids and vasopressors administration during the pre-intubation and post-intubation period, and preoxygenation with noninvasive ventilation. The former is associated with a lower incidence of hypotension, while the latter may reduce the incidence of severe hypoxemia in ICU intubations (Baillard C, et al. Am J Respir Crit Care Med. 2006;174[2]:171).

Keeping apprised of evidence and adjusting practice are crucial to the competent clinician engaging in airway management, as they minimize the risk of harm while maximizing the benefit to the patient. However, the methods to achieve these goals are not always intuitive. Definitive high-level evidence is sparse. The use of neuromuscular blockade and BMV after induction has historically been controversial, but more recent evidence is favoring these approaches for RSI. The use of checklists or guidelines may ensure that the necessary safety steps are followed, especially at institutions that may not have experts in airway management. Over time, the hope is that many of our traditional practices are either supported by quality evidence or better techniques evolve.
 

Dr. Tokarczyk is with the Department of Anesthesia, NorthShore University HealthSystem; and Clinical Assistant Professor, University of Chicago, Pritzker School of Medicine. Dr. Greenberg is Editor-in-Chief, Anesthesia Patient Safety Foundation (APSF) Newsletter; Vice Chairperson, Education, Department of Anesthesiology; Director of Critical Care Services, Evanston Hospital; NorthShore University HealthSystem; and Clinical Professor, Department of Anesthesiology Critical Care, University of Chicago, Pritzker School of Medicine.
 

Airway management is a complex process that, if not performed in a proper and timely manner, may result in significant morbidity or mortality. The risk of intubation failure and associated adverse events is higher in critically ill patients due to differences in patient condition, environment, and practitioner experience. Even when controlling for provider experience, intubating conditions are worse and success rates are lower in the ICU compared with the controlled environment of the operating room (Taboada, et al. Anesthesiology. 2018;129[2]:321). Furthermore, the risk of injury and adverse events increases with the number of intubation attempts during an emergency (Sakles JC, et al. Acad Emerg Med. 2013;20[1]:71). Unfortunately, the paucity of high-grade evidence leads practitioners to rely on practice patterns developed during training and predicated on common sense airway management principles. The difficulty in evaluating airway management in the critically ill lies in the multi-step and complex nature of the process, including the pre-intubation, intubation, and post-intubation activities (Fig 1). Several recent publications have the potential to change airway management practice in the ICU. We will address the latest information on preoxygenation, use of neuromuscular blockade (NMB), and checklists in this setting.

Preoxygenation: Overrated?

Rapid-sequence intubation (RSI) is a technique intended to minimize the time from induction to intubation and reduce the risk of aspiration by primarily avoiding ventilation. The avoidance of bag-mask ventilation during this apneic period is common, due to concerns that positive pressure can produce gastric insufflation and regurgitation that may lead to aspiration. To attenuate the risk for critical desaturation, preoxygenation is classically provided prior to induction of anesthesia in the operative procedural areas. Although the benefit can be seen in patients undergoing elective intubation, critically ill patients often have difficulty in significantly raising the blood oxygen content despite preoxygenation with 100% oxygen delivered via face mask. As a result, the oxygen saturation can drop precipitously during the process of ICU intubation, especially if multiple or prolonged intubation attempts are required. These factors all contribute to the risk of hypoxemia and cardiac arrest during ICU intubations (De Jong A, et al. Crit Care Med. 2018;46[4]:532), which has led to the debate about the avoidance of ventilation during RSI in the critically ill. Recently, Casey and colleagues (Casey JD, et al. N Engl J Med. 2019;380[9]:811) evaluated the use of bag-mask ventilation (BMV) during RSI. In this ICU study, intubations were randomized to either include BMV or no ventilation after induction. The results suggested that the frequency of critical desaturation was lower in the patients receiving BMV after induction without a concomitant increase in frequency of aspiration. Although not powered to evaluate the difference in the incidence of aspiration, this study supports the use of BMV during the apneic phase of intubation, thereby decreasing the risk for critical desaturation.

Neuromuscular blockade: Yes or no?

Awake intubation, with or without sedation, is often employed for managing the airway in high-risk patients. This technique allows the patient to maintain spontaneous ventilation in the event of repeated intubation attempts and has a lower hypotension risk. However, many critically ill patients cannot be managed in this manner due to lack of patient cooperation, emergent airway management requirements, or practitioner inexperience with this technique. As a result, many of these patients will require an induction agent, and concomitant administration of a neuromuscular blocking agent (NMB) to optimize intubating conditions. However, the avoidance of NMBs in emergent airway scenarios was not uncommon among attending physicians and trainees (Schmidt UH, et al. Anesthesiology. 2008;109[6]:973). The American College of Chest Physicians (CHEST) Difficult Airway Course faculty also recommended to not use NMB because of the high risk of failure to ventilate/oxygenate. Without NMB, the patient might be allowed to recover to spontaneous ventilation. This approach is taken in the American Society of Anesthesiologists Practice Guidelines for the Management of the Difficult Airway but is not necessarily applicable to the critically ill patient (Apfelbaum JL, et al. Anesthesiology. 2013;118[2]:251-70). In the event of “can’t intubate, can’t oxygenate” (CICO), the critically ill patient in extremis may not tolerate an attempt to return to spontaneous ventilation because spontaneous ventilation may have been initially inadequate.

In 2010, Jaber and colleagues demonstrated a lower incidence of hypoxemia and severe hemodynamic collapse with the implementation of an intubation bundle that included the use of NMBs for all rapid-sequence inductions (Jaber S, et al. Int Care Med. 2010;36:248). The safety of using paralytics in critically ill patients was later investigated by Wilcox and colleagues in a prospective, observational study that suggested a decrease in the incidence of hypoxemia and complications when employing NMB (Wilcox SR, et al. Crit Care Med. 2012;40[6]:1808). Although Wilcox et al.’s study was hypothesis-generating by the nature of its design, it was consistent with both Jaber’s findings and a more recent observational study performed by Moser et al (Mosier JM, et al. Ann Am Thorac Soc. 2015;12[5]:734). Furthermore, there is no evidence that NMBs worsen bag mask ventilation in the critically ill patient. NMBs in addition to induction agents might be associated with optimal intubating conditions, reduced complications, and allow for placement of a supraglottic airway device or surgical airway in the event of a CICO (Higgs A, et al. Br J Anaesth. 2018;120[2]:323).
 

Checking the checklists

Checklists are another intervention with the potential to improve outcomes or reduce adverse events. Airway management is often a complex process with significant opportunities for failure. Therefore, having reminders or checklists available to the provider may encourage the use of best practices. Jaber demonstrated that a straightforward, 10-point intubation bundle reduced the incidence of severe complications associated with emergent intubation in the ICU. In the 4th National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society, the use of checklists was recommended as a method to reduce adverse events and increase successful airway management (Cook TM, et al. Br J Anaesth. 2011;106[5]:632). In fact, several mnemonics have been developed to aid the practitioner, including the ‘7 Ps’ in the Manual of Emergency Airway Management (Walls RM, et al. Manual of Emergency Airway Management. 2012) and APPROACH from the CHEST Airway Management Training Team. More recently, Janz and colleagues developed and employed a checklist in a multicenter study and compared it with usual practice (Janz DR, et al. Chest. 2018;153[4]:816). Although the checklist was associated with improved provider compliance with airway assessment, preparation, and verbalization of a plan, it did not go far enough to include the known interventions for optimizing preoxygenation and hemodynamic stability. Two elements that might be included in a checklist include fluids and vasopressors administration during the pre-intubation and post-intubation period, and preoxygenation with noninvasive ventilation. The former is associated with a lower incidence of hypotension, while the latter may reduce the incidence of severe hypoxemia in ICU intubations (Baillard C, et al. Am J Respir Crit Care Med. 2006;174[2]:171).

Keeping apprised of evidence and adjusting practice are crucial to the competent clinician engaging in airway management, as they minimize the risk of harm while maximizing the benefit to the patient. However, the methods to achieve these goals are not always intuitive. Definitive high-level evidence is sparse. The use of neuromuscular blockade and BMV after induction has historically been controversial, but more recent evidence is favoring these approaches for RSI. The use of checklists or guidelines may ensure that the necessary safety steps are followed, especially at institutions that may not have experts in airway management. Over time, the hope is that many of our traditional practices are either supported by quality evidence or better techniques evolve.
 

Dr. Tokarczyk is with the Department of Anesthesia, NorthShore University HealthSystem; and Clinical Assistant Professor, University of Chicago, Pritzker School of Medicine. Dr. Greenberg is Editor-in-Chief, Anesthesia Patient Safety Foundation (APSF) Newsletter; Vice Chairperson, Education, Department of Anesthesiology; Director of Critical Care Services, Evanston Hospital; NorthShore University HealthSystem; and Clinical Professor, Department of Anesthesiology Critical Care, University of Chicago, Pritzker School of Medicine.
 

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Imaging of Pulmonary Hypertension: Pictorial Essay
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Infectious Disease Hospitalizations: United States, 2001 to 2014
By Dr. J. L. Kennedy, et al.



Overdiagnosis of COPD in Subjects With Unobstructed Spirometry: A BOLD Analysis
By Dr. L. Sator, et al.

TRANSLATING BASIC RESEARCH INTO CLINICAL PRACTICE

Common Pathogenic Mechanisms Between Idiopathic Pulmonary Fibrosis and Lung Cancer
By Dr. A. Tzouvelekis, et al.

COMMENTARY

Imaging of Pulmonary Hypertension: Pictorial Essay
By Dr. E. Altschul, et al.


ORIGINAL RESEARCH

Epidemiology of Quick Sequential Organ Failure Assessment Criteria in Undifferentiated Patients and Association With Suspected Infection and Sepsis
By Dr. V. Anand, et al.



Infectious Disease Hospitalizations: United States, 2001 to 2014
By Dr. J. L. Kennedy, et al.



Overdiagnosis of COPD in Subjects With Unobstructed Spirometry: A BOLD Analysis
By Dr. L. Sator, et al.

TRANSLATING BASIC RESEARCH INTO CLINICAL PRACTICE

Common Pathogenic Mechanisms Between Idiopathic Pulmonary Fibrosis and Lung Cancer
By Dr. A. Tzouvelekis, et al.

COMMENTARY

Imaging of Pulmonary Hypertension: Pictorial Essay
By Dr. E. Altschul, et al.


ORIGINAL RESEARCH

Epidemiology of Quick Sequential Organ Failure Assessment Criteria in Undifferentiated Patients and Association With Suspected Infection and Sepsis
By Dr. V. Anand, et al.



Infectious Disease Hospitalizations: United States, 2001 to 2014
By Dr. J. L. Kennedy, et al.



Overdiagnosis of COPD in Subjects With Unobstructed Spirometry: A BOLD Analysis
By Dr. L. Sator, et al.

TRANSLATING BASIC RESEARCH INTO CLINICAL PRACTICE

Common Pathogenic Mechanisms Between Idiopathic Pulmonary Fibrosis and Lung Cancer
By Dr. A. Tzouvelekis, et al.

The CHEST Board of Regents (BOR) held their summer meeting for 3 days starting June 20 in Coeur D’Alene, Idaho. The key drivers of the BOR are to continuously assess and adjust our strategic plan to further CHEST’s mission and to be good fiducial stewards in allocating resources. At this meeting, the BOR continued its efforts in both of these areas.

CHEST’s mission is to champion the prevention, diagnosis, and treatment of chest diseases through education, communication, and research. The budget for fiscal year 2019-2020 facilitates the expansion of this mission by allocating more resources for e-learning and for the improving engagement and member experience.

Specifically, the Board is placing significant emphasis for more content to be digital, downloadable, digestible, and (hopefully) addictive. Aside from allocating capital for updates of existing equipment, Board Designated Funds were made available for an aggressive redesign of content delivery. Over the next 2 years, CHEST will achieve single sign on for all our learning platforms; enhance mobile access; and deploy mobile apps for gaming, personalized learning, and just-in-time education. The effort also aims to streamline journal and topic workflows and launch personalized content recommendations for our members.

Our formal strategic planning continued with an external review of our recent environmental scan and 5- year plan by a select group of entrepreneurs and innovators. Board members engaged in a rich debate about ways to better focus the organization. The group noted that the best time for strategic initiatives is now, while the association is doing well and highly functioning, rather than waiting for difficult times to initiate a potentially more painful course correction.

Education is the base for our entire enterprise. The BOR had a vigorous discussion about the development of a clinician educator track with certification and was introduced to CHEST’s new Chief Learning Officer. The CHEST staff plans a deeper dive into needs assessment and developing a business plan around this program.

Communication is also a core part of our mission. The BOR recognizes that more needs to be done to support the NetWorks. For this year’s annual meeting, plans have been made to move the NetWork meetings into two time slots, unopposed by other scientific content, and to rename these meetings “NetWork Featured Lecture and Open Forum.” The rationale for the name change is to make the meetings more inviting by referring to them as “open forums.” CHEST 2019 will feature improved signage in common areas to highlight the NetWork meetings, providing times and locations. The goal is to at least double attendance. Dr. Stephanie Levine, President-Elect of CHEST, is forming a task force to explore other ways of enhancing NetWork engagement.

In order to expand CHEST educational impact, the Board launched a new global events strategy. These global educational programs were another focus of the Board of Regents. Staff provided updates on the CHEST Congress Thailand 2019 in collaboration with the Thoracic Society of Thailand. There were more than 1,000 delegates representing 57 countries. The meeting was supported by our partner, Kenes, which will also be helping with smaller regional meetings, including the June meeting in Athens in collaboration with the Hellenic Thoracic Society. CHEST is in the advanced stages of planning a CHEST Congress in Bologna, Italy, in summer 2020 in conjunction with our colleagues in that country. CHEST is putting together a 5-year plan for regional meetings with a variety of local medical societies throughout the world. To support this, the Governance Committee recommended augmenting the Council of Global Governors with an Executive Committee. This group will serve as a small, strategic set of individuals, appointed by the Governance Committee, to assist in furthering the global strategy and efforts of the organization. Going forward, the Chair of the Executive Committee will serve as a member of the Board of Regents for a 2-year term, to better represent international concerns at a board level.

The BOR addressed additional items, including reviewing the process for selecting Master FCCPs and a very positive update on our CHEST 2019 meeting in New Orleans. They also enhanced coordination with the CHEST Foundation Board of Trustees (BOT) via joint meetings. The CHEST Foundation BOT celebrated success in matching funds for the one million dollar grant to establish the Erin Popovich Endowment. Additional fundraising plans include holding five separate events in the next year, including a repeat of last year’s Feldman Family Foundation Poker Night.
 

The CHEST Board of Regents (BOR) held their summer meeting for 3 days starting June 20 in Coeur D’Alene, Idaho. The key drivers of the BOR are to continuously assess and adjust our strategic plan to further CHEST’s mission and to be good fiducial stewards in allocating resources. At this meeting, the BOR continued its efforts in both of these areas.

CHEST’s mission is to champion the prevention, diagnosis, and treatment of chest diseases through education, communication, and research. The budget for fiscal year 2019-2020 facilitates the expansion of this mission by allocating more resources for e-learning and for the improving engagement and member experience.

Specifically, the Board is placing significant emphasis for more content to be digital, downloadable, digestible, and (hopefully) addictive. Aside from allocating capital for updates of existing equipment, Board Designated Funds were made available for an aggressive redesign of content delivery. Over the next 2 years, CHEST will achieve single sign on for all our learning platforms; enhance mobile access; and deploy mobile apps for gaming, personalized learning, and just-in-time education. The effort also aims to streamline journal and topic workflows and launch personalized content recommendations for our members.

Our formal strategic planning continued with an external review of our recent environmental scan and 5- year plan by a select group of entrepreneurs and innovators. Board members engaged in a rich debate about ways to better focus the organization. The group noted that the best time for strategic initiatives is now, while the association is doing well and highly functioning, rather than waiting for difficult times to initiate a potentially more painful course correction.

Education is the base for our entire enterprise. The BOR had a vigorous discussion about the development of a clinician educator track with certification and was introduced to CHEST’s new Chief Learning Officer. The CHEST staff plans a deeper dive into needs assessment and developing a business plan around this program.

Communication is also a core part of our mission. The BOR recognizes that more needs to be done to support the NetWorks. For this year’s annual meeting, plans have been made to move the NetWork meetings into two time slots, unopposed by other scientific content, and to rename these meetings “NetWork Featured Lecture and Open Forum.” The rationale for the name change is to make the meetings more inviting by referring to them as “open forums.” CHEST 2019 will feature improved signage in common areas to highlight the NetWork meetings, providing times and locations. The goal is to at least double attendance. Dr. Stephanie Levine, President-Elect of CHEST, is forming a task force to explore other ways of enhancing NetWork engagement.

In order to expand CHEST educational impact, the Board launched a new global events strategy. These global educational programs were another focus of the Board of Regents. Staff provided updates on the CHEST Congress Thailand 2019 in collaboration with the Thoracic Society of Thailand. There were more than 1,000 delegates representing 57 countries. The meeting was supported by our partner, Kenes, which will also be helping with smaller regional meetings, including the June meeting in Athens in collaboration with the Hellenic Thoracic Society. CHEST is in the advanced stages of planning a CHEST Congress in Bologna, Italy, in summer 2020 in conjunction with our colleagues in that country. CHEST is putting together a 5-year plan for regional meetings with a variety of local medical societies throughout the world. To support this, the Governance Committee recommended augmenting the Council of Global Governors with an Executive Committee. This group will serve as a small, strategic set of individuals, appointed by the Governance Committee, to assist in furthering the global strategy and efforts of the organization. Going forward, the Chair of the Executive Committee will serve as a member of the Board of Regents for a 2-year term, to better represent international concerns at a board level.

The BOR addressed additional items, including reviewing the process for selecting Master FCCPs and a very positive update on our CHEST 2019 meeting in New Orleans. They also enhanced coordination with the CHEST Foundation Board of Trustees (BOT) via joint meetings. The CHEST Foundation BOT celebrated success in matching funds for the one million dollar grant to establish the Erin Popovich Endowment. Additional fundraising plans include holding five separate events in the next year, including a repeat of last year’s Feldman Family Foundation Poker Night.
 

The CHEST Board of Regents (BOR) held their summer meeting for 3 days starting June 20 in Coeur D’Alene, Idaho. The key drivers of the BOR are to continuously assess and adjust our strategic plan to further CHEST’s mission and to be good fiducial stewards in allocating resources. At this meeting, the BOR continued its efforts in both of these areas.

CHEST’s mission is to champion the prevention, diagnosis, and treatment of chest diseases through education, communication, and research. The budget for fiscal year 2019-2020 facilitates the expansion of this mission by allocating more resources for e-learning and for the improving engagement and member experience.

Specifically, the Board is placing significant emphasis for more content to be digital, downloadable, digestible, and (hopefully) addictive. Aside from allocating capital for updates of existing equipment, Board Designated Funds were made available for an aggressive redesign of content delivery. Over the next 2 years, CHEST will achieve single sign on for all our learning platforms; enhance mobile access; and deploy mobile apps for gaming, personalized learning, and just-in-time education. The effort also aims to streamline journal and topic workflows and launch personalized content recommendations for our members.

Our formal strategic planning continued with an external review of our recent environmental scan and 5- year plan by a select group of entrepreneurs and innovators. Board members engaged in a rich debate about ways to better focus the organization. The group noted that the best time for strategic initiatives is now, while the association is doing well and highly functioning, rather than waiting for difficult times to initiate a potentially more painful course correction.

Education is the base for our entire enterprise. The BOR had a vigorous discussion about the development of a clinician educator track with certification and was introduced to CHEST’s new Chief Learning Officer. The CHEST staff plans a deeper dive into needs assessment and developing a business plan around this program.

Communication is also a core part of our mission. The BOR recognizes that more needs to be done to support the NetWorks. For this year’s annual meeting, plans have been made to move the NetWork meetings into two time slots, unopposed by other scientific content, and to rename these meetings “NetWork Featured Lecture and Open Forum.” The rationale for the name change is to make the meetings more inviting by referring to them as “open forums.” CHEST 2019 will feature improved signage in common areas to highlight the NetWork meetings, providing times and locations. The goal is to at least double attendance. Dr. Stephanie Levine, President-Elect of CHEST, is forming a task force to explore other ways of enhancing NetWork engagement.

In order to expand CHEST educational impact, the Board launched a new global events strategy. These global educational programs were another focus of the Board of Regents. Staff provided updates on the CHEST Congress Thailand 2019 in collaboration with the Thoracic Society of Thailand. There were more than 1,000 delegates representing 57 countries. The meeting was supported by our partner, Kenes, which will also be helping with smaller regional meetings, including the June meeting in Athens in collaboration with the Hellenic Thoracic Society. CHEST is in the advanced stages of planning a CHEST Congress in Bologna, Italy, in summer 2020 in conjunction with our colleagues in that country. CHEST is putting together a 5-year plan for regional meetings with a variety of local medical societies throughout the world. To support this, the Governance Committee recommended augmenting the Council of Global Governors with an Executive Committee. This group will serve as a small, strategic set of individuals, appointed by the Governance Committee, to assist in furthering the global strategy and efforts of the organization. Going forward, the Chair of the Executive Committee will serve as a member of the Board of Regents for a 2-year term, to better represent international concerns at a board level.

The BOR addressed additional items, including reviewing the process for selecting Master FCCPs and a very positive update on our CHEST 2019 meeting in New Orleans. They also enhanced coordination with the CHEST Foundation Board of Trustees (BOT) via joint meetings. The CHEST Foundation BOT celebrated success in matching funds for the one million dollar grant to establish the Erin Popovich Endowment. Additional fundraising plans include holding five separate events in the next year, including a repeat of last year’s Feldman Family Foundation Poker Night.
 

Head to New Orleans this October for CHEST Annual Meeting 2019 for the latest original research, postgraduate courses, interactive case-based discussions, simulation sessions, CHEST Games, and more! CHEST 2019 allows clinician members of the entire health-care team to stay up to date on pulmonary, critical care, and sleep medicine. There are many new and exciting things happening at CHEST 2019, and we are excited to give you a sneak peek.

The simulation sessions are better than ever and include a full day of cadaver-based courses and brand new hands-on sessions in bronchoscopy, advanced critical care echocardiography, and airway management, that will put your skills to the test. You don’t want to miss these simulation sessions that allow you to learn from our expert faculty to advance and develop valuable skills and apply your knowledge.

Visit CHEST in the exhibit hall to see the new additions we have added to amplify your experience. The new FISH Bowl innovation competition will allow you to learn about new solutions and ideas that were submitted in education and clinical disease for pulmonary, critical care, and sleep medicine. The finalists will be presenting live in Experience CHEST and competing for prizes in each category. CHEST games will be back again in a new space in the exhibit hall. Be sure to bring your team to play the popular Nodal Nemesis and the other games that test your skills in new and creative ways.

CHEST 2019 plans to make your life easier by providing you with the latest updates in patient care at the annual meeting, but we are also planning on making it easier in other ways. New this year, you can update your professional headshot in our new complimentary headshot booth. Plan on a visit to the new CHEST Wellness Zone. This area is designed to help you relax and recharge while at CHEST and includes meditation, posture consultants, aromatherapy, foot massage, and yoga. Attend CHEST 2019 with some peace of mind knowing that your children can be cared for at the Kiddie Corp childcare program for kids ages 6 months to 12 years.

According to William Kelly, MD, FCCP, CHEST 2019 Program Chair, “We are excited about these new opportunities that will help you improve your patient care. We’re taking concrete steps to make your learning, your practice, and your life a little easier.”

We look forward to seeing you at CHEST 2019 in New Orleans, Louisiana, October 19-23!

Head to New Orleans this October for CHEST Annual Meeting 2019 for the latest original research, postgraduate courses, interactive case-based discussions, simulation sessions, CHEST Games, and more! CHEST 2019 allows clinician members of the entire health-care team to stay up to date on pulmonary, critical care, and sleep medicine. There are many new and exciting things happening at CHEST 2019, and we are excited to give you a sneak peek.

The simulation sessions are better than ever and include a full day of cadaver-based courses and brand new hands-on sessions in bronchoscopy, advanced critical care echocardiography, and airway management, that will put your skills to the test. You don’t want to miss these simulation sessions that allow you to learn from our expert faculty to advance and develop valuable skills and apply your knowledge.

Visit CHEST in the exhibit hall to see the new additions we have added to amplify your experience. The new FISH Bowl innovation competition will allow you to learn about new solutions and ideas that were submitted in education and clinical disease for pulmonary, critical care, and sleep medicine. The finalists will be presenting live in Experience CHEST and competing for prizes in each category. CHEST games will be back again in a new space in the exhibit hall. Be sure to bring your team to play the popular Nodal Nemesis and the other games that test your skills in new and creative ways.

CHEST 2019 plans to make your life easier by providing you with the latest updates in patient care at the annual meeting, but we are also planning on making it easier in other ways. New this year, you can update your professional headshot in our new complimentary headshot booth. Plan on a visit to the new CHEST Wellness Zone. This area is designed to help you relax and recharge while at CHEST and includes meditation, posture consultants, aromatherapy, foot massage, and yoga. Attend CHEST 2019 with some peace of mind knowing that your children can be cared for at the Kiddie Corp childcare program for kids ages 6 months to 12 years.

According to William Kelly, MD, FCCP, CHEST 2019 Program Chair, “We are excited about these new opportunities that will help you improve your patient care. We’re taking concrete steps to make your learning, your practice, and your life a little easier.”

We look forward to seeing you at CHEST 2019 in New Orleans, Louisiana, October 19-23!

Head to New Orleans this October for CHEST Annual Meeting 2019 for the latest original research, postgraduate courses, interactive case-based discussions, simulation sessions, CHEST Games, and more! CHEST 2019 allows clinician members of the entire health-care team to stay up to date on pulmonary, critical care, and sleep medicine. There are many new and exciting things happening at CHEST 2019, and we are excited to give you a sneak peek.

The simulation sessions are better than ever and include a full day of cadaver-based courses and brand new hands-on sessions in bronchoscopy, advanced critical care echocardiography, and airway management, that will put your skills to the test. You don’t want to miss these simulation sessions that allow you to learn from our expert faculty to advance and develop valuable skills and apply your knowledge.

Visit CHEST in the exhibit hall to see the new additions we have added to amplify your experience. The new FISH Bowl innovation competition will allow you to learn about new solutions and ideas that were submitted in education and clinical disease for pulmonary, critical care, and sleep medicine. The finalists will be presenting live in Experience CHEST and competing for prizes in each category. CHEST games will be back again in a new space in the exhibit hall. Be sure to bring your team to play the popular Nodal Nemesis and the other games that test your skills in new and creative ways.

CHEST 2019 plans to make your life easier by providing you with the latest updates in patient care at the annual meeting, but we are also planning on making it easier in other ways. New this year, you can update your professional headshot in our new complimentary headshot booth. Plan on a visit to the new CHEST Wellness Zone. This area is designed to help you relax and recharge while at CHEST and includes meditation, posture consultants, aromatherapy, foot massage, and yoga. Attend CHEST 2019 with some peace of mind knowing that your children can be cared for at the Kiddie Corp childcare program for kids ages 6 months to 12 years.

According to William Kelly, MD, FCCP, CHEST 2019 Program Chair, “We are excited about these new opportunities that will help you improve your patient care. We’re taking concrete steps to make your learning, your practice, and your life a little easier.”

We look forward to seeing you at CHEST 2019 in New Orleans, Louisiana, October 19-23!

The prevalence and popularity of electronic cigarettes or “vaping” have grown dramatically over the last several years in the United States. Although new studies targeting these products are being done at increasing frequency, there remains a relative paucity of data regarding the long-term risks. Proponents argue that they can be used as a cessation tool for smokers, or failing that, a safer replacement for traditional cigarettes. Opponents make the case that the perception of safety could contribute to increased use in people who may have otherwise never smoked, leading to an overall increase in nicotine use and addiction. This is most readily seen in the adolescent population, where use has skyrocketed, leading to concerns about how electronic cigarettes are marketed to youth, as well as the ease of access.
 

Basics of vaping (devices)

In its most basic form, an electronic cigarette consists of a battery that powers a heating coil. This heating coil applies heat to a wick, which is soaked in liquid, “vape juice,” converting it into a vapor that is then directly inhaled. However, there can be many variations on this simple theme. Early generation products resembled traditional cigarettes in size and shape and were marketed as smoking cessation aids. Newer devices have abandoned this look and strategy. Preloaded cartridges have been replaced by large tanks that the user can fill with the liquid of their choosing. Multiple tanks can be purchased for a single device, enabling the user to have multiple flavors or various levels of nicotine dosing on hand for quick changing, depending on user preference or mood. Additionally, there are variable voltage settings, resulting in different styles of vapor and/or “throat hit” (the description of the desired burning vs smooth effect of the vapor on the oropharynx). This type of device invites experimentation. Multiple flavors can be used in isolation or mixed together at various temperatures. It no longer resembles classic cigarettes, and the flavor and experience are more prominently promoted. One can see that this device has more appeal to a “never smoker” than the original products, and there is concern that it is being marketed as such with some success (Dinakar C, et al. N Engl J Med. 2016;375[14]:1372).
 

E-liquid

Perhaps more important than the devices themselves is an understanding of the components of the liquid used to generate the inhaled aerosol.

Typically, four components are present:

• Propylene glycol

• Vegetable glycerin

• Flavoring

• Nicotine

The first two components are generally considered nontoxic, based on their use as food additives. However, inhalation is a novel route of entry and the long-term effects on the respiratory tract are unclear.

The third component, “flavorings,” is a catch-all term for the hundreds of different flavors and styles of e-liquids available today, ranging from menthol to fruit or candy and everything in between. It is difficult to account for all the potential effects of the numerous flavorings being used, especially when some are combined by the end user to various degrees.

Nicotine is present, specified in varying doses. However, vaping style, experience, and type of device used can dramatically affect how much is absorbed, making dosages difficult to predict. Additionally, labeled doses are prone to wide ranges of error (Schraufnagel DE, et al. Am J Respir Crit Care Med. 2014;190[6]:611).
 

What are the risks?

Cancer

A handful of known carcinogens can be found in inhaled vapor, including formaldehyde, acetaldehyde, acrolein, toluene, and nitrosamines. However, they are present in far lower concentrations than in traditional cigarettes (Goniewicz ML, et al. JAMA Netw Open. 2018;1[8]e185937). This leads to the natural assumption that vaping, while not benign, poses a much lower cancer risk when compared with smoking. Whether that is borne out in the long term remains to be seen.



Pulmonary function

The long-term effect on pulmonary function is not known. Small studies have shown no significant changes to spirometry after acute exposure to vapor. More data are needed in this area (Palazzolo DL. Frontiers Public Health. 2013;1[56]1-20).



Wound healing

An animal study has shown evidence of poor wound healing extrapolated from skin flap necrosis in rats. Exposure to vapor vs smoke yielded similar results, and both were worse than the sham arm (Troiano C, et al. JAMA Facial Plast Surg. 2019;21[1]:5). While it is difficult to know how to apply this clinically, it may be prudent to advise patients to abstain while in preparation for elective surgery.



Cardiovascular/stroke

Much of the cardiovascular toxicity from cigarette use is tied to the myriad of complex toxic particles produced in inhaled smoke, the vast majority of which are not present in e-cigarette vapor. While nicotine itself has known acute cardiovascular effects, including tachycardia and vasoconstriction, a tolerance to these effects occurs over time. Previous evaluations of nicotine replacement therapies and smokeless tobacco for their cardiovascular effects have had mixed results. But, there appears to be a trend toward minimal cardiovascular risk when using “cleaner” products, such as nicotine replacement therapy compared with smokeless tobacco (Benowitz NL, et al. Nature Rev Cardiol. 2017;14[8]:447). Whether this can be extrapolated to electronic cigarette use is unknown but is encouraging.



Alternative toxicity

In addition to the above risks that are in comparison to traditional smoking, vaping also introduces novel toxicities. There are case reports of lipoid pneumonia, ARDS, hypersensitivity pneumonitis, eosinophilic pneumonia, and diffuse alveola hemorrhage. Burns from malfunctioning devices must also be considered, as there is a wide array of products available, at differing levels of build quality.

Toxic oral ingestion of nicotine, especially by children, has led to increased calls to poison centers. For a small child, this can be fatal. Regulation of labels and containers could curtail this issue. But, public education regarding the toxicity of these substances when ingested in large quantities is also important. If there is a lack of understanding about this danger, then typical safeguards are easily overlooked by individual users.

Are there benefits?

Smoking cessation

Compared with other products, such as nicotine patches, gum, and pharmaceutical methods, e-cigarettes most closely mimic the actual experience of smoking. For some, the habit and ritual of smoking is as much a part of the addiction as nicotine. Vaping has the potential to help alleviate this difficult aspect of cessation. Data involving early generation products failed to show a significant advantage. Newer devices that are more pleasurable to use and offer more efficient nicotine delivery may be more effective. Indeed, a recent study in the New England Journal of Medicine from this year demonstrated improved smoking cessation compared with traditional methods, using second generation vape devices (Hajek P, et al. N Engl J Med. 2019;380[7]629). It will be interesting to see if this can be repeatable going forward and if protocols can be established to maximize effectiveness.

As outlined above, it is difficult to make definitive conclusions or recommendations regarding electronic cigarette use at the present time. The risk of cancer and cardiopulmonary disease is likely to be significantly lower but not eliminated. Use as a smoking cessation aid is starting to show promise. Even without cessation, ongoing vaping is likely to be safer than ongoing smoking. Two caveats to this remain: some patients, in an effort to quit smoking, may take up vaping but eventually become “dual users.” This scenario has been associated with higher toxic exposure and possibly worse outcomes. The second caveat is that while there is promise to using this as a cessation tool, it should not yet replace other more well-studied, first-line agents in this regard. It should, perhaps, target patients who are motivated to quit but have failed more traditional methods. Finally, there continues to be concern that vaping could appeal to never smokers, given its perceived safety profile and ease of use in public places. This could lead to an overall increase in nicotine addiction, which could be a significant step backwards.

Dr. Clark is Assistant Professor, Pulmonary and Critical Care Medicine, UT Southwestern Medical Center, Dallas, Texas.

The prevalence and popularity of electronic cigarettes or “vaping” have grown dramatically over the last several years in the United States. Although new studies targeting these products are being done at increasing frequency, there remains a relative paucity of data regarding the long-term risks. Proponents argue that they can be used as a cessation tool for smokers, or failing that, a safer replacement for traditional cigarettes. Opponents make the case that the perception of safety could contribute to increased use in people who may have otherwise never smoked, leading to an overall increase in nicotine use and addiction. This is most readily seen in the adolescent population, where use has skyrocketed, leading to concerns about how electronic cigarettes are marketed to youth, as well as the ease of access.
 

Basics of vaping (devices)

In its most basic form, an electronic cigarette consists of a battery that powers a heating coil. This heating coil applies heat to a wick, which is soaked in liquid, “vape juice,” converting it into a vapor that is then directly inhaled. However, there can be many variations on this simple theme. Early generation products resembled traditional cigarettes in size and shape and were marketed as smoking cessation aids. Newer devices have abandoned this look and strategy. Preloaded cartridges have been replaced by large tanks that the user can fill with the liquid of their choosing. Multiple tanks can be purchased for a single device, enabling the user to have multiple flavors or various levels of nicotine dosing on hand for quick changing, depending on user preference or mood. Additionally, there are variable voltage settings, resulting in different styles of vapor and/or “throat hit” (the description of the desired burning vs smooth effect of the vapor on the oropharynx). This type of device invites experimentation. Multiple flavors can be used in isolation or mixed together at various temperatures. It no longer resembles classic cigarettes, and the flavor and experience are more prominently promoted. One can see that this device has more appeal to a “never smoker” than the original products, and there is concern that it is being marketed as such with some success (Dinakar C, et al. N Engl J Med. 2016;375[14]:1372).
 

E-liquid

Perhaps more important than the devices themselves is an understanding of the components of the liquid used to generate the inhaled aerosol.

Typically, four components are present:

• Propylene glycol

• Vegetable glycerin

• Flavoring

• Nicotine

The first two components are generally considered nontoxic, based on their use as food additives. However, inhalation is a novel route of entry and the long-term effects on the respiratory tract are unclear.

The third component, “flavorings,” is a catch-all term for the hundreds of different flavors and styles of e-liquids available today, ranging from menthol to fruit or candy and everything in between. It is difficult to account for all the potential effects of the numerous flavorings being used, especially when some are combined by the end user to various degrees.

Nicotine is present, specified in varying doses. However, vaping style, experience, and type of device used can dramatically affect how much is absorbed, making dosages difficult to predict. Additionally, labeled doses are prone to wide ranges of error (Schraufnagel DE, et al. Am J Respir Crit Care Med. 2014;190[6]:611).
 

What are the risks?

Cancer

A handful of known carcinogens can be found in inhaled vapor, including formaldehyde, acetaldehyde, acrolein, toluene, and nitrosamines. However, they are present in far lower concentrations than in traditional cigarettes (Goniewicz ML, et al. JAMA Netw Open. 2018;1[8]e185937). This leads to the natural assumption that vaping, while not benign, poses a much lower cancer risk when compared with smoking. Whether that is borne out in the long term remains to be seen.



Pulmonary function

The long-term effect on pulmonary function is not known. Small studies have shown no significant changes to spirometry after acute exposure to vapor. More data are needed in this area (Palazzolo DL. Frontiers Public Health. 2013;1[56]1-20).



Wound healing

An animal study has shown evidence of poor wound healing extrapolated from skin flap necrosis in rats. Exposure to vapor vs smoke yielded similar results, and both were worse than the sham arm (Troiano C, et al. JAMA Facial Plast Surg. 2019;21[1]:5). While it is difficult to know how to apply this clinically, it may be prudent to advise patients to abstain while in preparation for elective surgery.



Cardiovascular/stroke

Much of the cardiovascular toxicity from cigarette use is tied to the myriad of complex toxic particles produced in inhaled smoke, the vast majority of which are not present in e-cigarette vapor. While nicotine itself has known acute cardiovascular effects, including tachycardia and vasoconstriction, a tolerance to these effects occurs over time. Previous evaluations of nicotine replacement therapies and smokeless tobacco for their cardiovascular effects have had mixed results. But, there appears to be a trend toward minimal cardiovascular risk when using “cleaner” products, such as nicotine replacement therapy compared with smokeless tobacco (Benowitz NL, et al. Nature Rev Cardiol. 2017;14[8]:447). Whether this can be extrapolated to electronic cigarette use is unknown but is encouraging.



Alternative toxicity

In addition to the above risks that are in comparison to traditional smoking, vaping also introduces novel toxicities. There are case reports of lipoid pneumonia, ARDS, hypersensitivity pneumonitis, eosinophilic pneumonia, and diffuse alveola hemorrhage. Burns from malfunctioning devices must also be considered, as there is a wide array of products available, at differing levels of build quality.

Toxic oral ingestion of nicotine, especially by children, has led to increased calls to poison centers. For a small child, this can be fatal. Regulation of labels and containers could curtail this issue. But, public education regarding the toxicity of these substances when ingested in large quantities is also important. If there is a lack of understanding about this danger, then typical safeguards are easily overlooked by individual users.

Are there benefits?

Smoking cessation

Compared with other products, such as nicotine patches, gum, and pharmaceutical methods, e-cigarettes most closely mimic the actual experience of smoking. For some, the habit and ritual of smoking is as much a part of the addiction as nicotine. Vaping has the potential to help alleviate this difficult aspect of cessation. Data involving early generation products failed to show a significant advantage. Newer devices that are more pleasurable to use and offer more efficient nicotine delivery may be more effective. Indeed, a recent study in the New England Journal of Medicine from this year demonstrated improved smoking cessation compared with traditional methods, using second generation vape devices (Hajek P, et al. N Engl J Med. 2019;380[7]629). It will be interesting to see if this can be repeatable going forward and if protocols can be established to maximize effectiveness.

As outlined above, it is difficult to make definitive conclusions or recommendations regarding electronic cigarette use at the present time. The risk of cancer and cardiopulmonary disease is likely to be significantly lower but not eliminated. Use as a smoking cessation aid is starting to show promise. Even without cessation, ongoing vaping is likely to be safer than ongoing smoking. Two caveats to this remain: some patients, in an effort to quit smoking, may take up vaping but eventually become “dual users.” This scenario has been associated with higher toxic exposure and possibly worse outcomes. The second caveat is that while there is promise to using this as a cessation tool, it should not yet replace other more well-studied, first-line agents in this regard. It should, perhaps, target patients who are motivated to quit but have failed more traditional methods. Finally, there continues to be concern that vaping could appeal to never smokers, given its perceived safety profile and ease of use in public places. This could lead to an overall increase in nicotine addiction, which could be a significant step backwards.

Dr. Clark is Assistant Professor, Pulmonary and Critical Care Medicine, UT Southwestern Medical Center, Dallas, Texas.

The prevalence and popularity of electronic cigarettes or “vaping” have grown dramatically over the last several years in the United States. Although new studies targeting these products are being done at increasing frequency, there remains a relative paucity of data regarding the long-term risks. Proponents argue that they can be used as a cessation tool for smokers, or failing that, a safer replacement for traditional cigarettes. Opponents make the case that the perception of safety could contribute to increased use in people who may have otherwise never smoked, leading to an overall increase in nicotine use and addiction. This is most readily seen in the adolescent population, where use has skyrocketed, leading to concerns about how electronic cigarettes are marketed to youth, as well as the ease of access.
 

Basics of vaping (devices)

In its most basic form, an electronic cigarette consists of a battery that powers a heating coil. This heating coil applies heat to a wick, which is soaked in liquid, “vape juice,” converting it into a vapor that is then directly inhaled. However, there can be many variations on this simple theme. Early generation products resembled traditional cigarettes in size and shape and were marketed as smoking cessation aids. Newer devices have abandoned this look and strategy. Preloaded cartridges have been replaced by large tanks that the user can fill with the liquid of their choosing. Multiple tanks can be purchased for a single device, enabling the user to have multiple flavors or various levels of nicotine dosing on hand for quick changing, depending on user preference or mood. Additionally, there are variable voltage settings, resulting in different styles of vapor and/or “throat hit” (the description of the desired burning vs smooth effect of the vapor on the oropharynx). This type of device invites experimentation. Multiple flavors can be used in isolation or mixed together at various temperatures. It no longer resembles classic cigarettes, and the flavor and experience are more prominently promoted. One can see that this device has more appeal to a “never smoker” than the original products, and there is concern that it is being marketed as such with some success (Dinakar C, et al. N Engl J Med. 2016;375[14]:1372).
 

E-liquid

Perhaps more important than the devices themselves is an understanding of the components of the liquid used to generate the inhaled aerosol.

Typically, four components are present:

• Propylene glycol

• Vegetable glycerin

• Flavoring

• Nicotine

The first two components are generally considered nontoxic, based on their use as food additives. However, inhalation is a novel route of entry and the long-term effects on the respiratory tract are unclear.

The third component, “flavorings,” is a catch-all term for the hundreds of different flavors and styles of e-liquids available today, ranging from menthol to fruit or candy and everything in between. It is difficult to account for all the potential effects of the numerous flavorings being used, especially when some are combined by the end user to various degrees.

Nicotine is present, specified in varying doses. However, vaping style, experience, and type of device used can dramatically affect how much is absorbed, making dosages difficult to predict. Additionally, labeled doses are prone to wide ranges of error (Schraufnagel DE, et al. Am J Respir Crit Care Med. 2014;190[6]:611).
 

What are the risks?

Cancer

A handful of known carcinogens can be found in inhaled vapor, including formaldehyde, acetaldehyde, acrolein, toluene, and nitrosamines. However, they are present in far lower concentrations than in traditional cigarettes (Goniewicz ML, et al. JAMA Netw Open. 2018;1[8]e185937). This leads to the natural assumption that vaping, while not benign, poses a much lower cancer risk when compared with smoking. Whether that is borne out in the long term remains to be seen.



Pulmonary function

The long-term effect on pulmonary function is not known. Small studies have shown no significant changes to spirometry after acute exposure to vapor. More data are needed in this area (Palazzolo DL. Frontiers Public Health. 2013;1[56]1-20).



Wound healing

An animal study has shown evidence of poor wound healing extrapolated from skin flap necrosis in rats. Exposure to vapor vs smoke yielded similar results, and both were worse than the sham arm (Troiano C, et al. JAMA Facial Plast Surg. 2019;21[1]:5). While it is difficult to know how to apply this clinically, it may be prudent to advise patients to abstain while in preparation for elective surgery.



Cardiovascular/stroke

Much of the cardiovascular toxicity from cigarette use is tied to the myriad of complex toxic particles produced in inhaled smoke, the vast majority of which are not present in e-cigarette vapor. While nicotine itself has known acute cardiovascular effects, including tachycardia and vasoconstriction, a tolerance to these effects occurs over time. Previous evaluations of nicotine replacement therapies and smokeless tobacco for their cardiovascular effects have had mixed results. But, there appears to be a trend toward minimal cardiovascular risk when using “cleaner” products, such as nicotine replacement therapy compared with smokeless tobacco (Benowitz NL, et al. Nature Rev Cardiol. 2017;14[8]:447). Whether this can be extrapolated to electronic cigarette use is unknown but is encouraging.



Alternative toxicity

In addition to the above risks that are in comparison to traditional smoking, vaping also introduces novel toxicities. There are case reports of lipoid pneumonia, ARDS, hypersensitivity pneumonitis, eosinophilic pneumonia, and diffuse alveola hemorrhage. Burns from malfunctioning devices must also be considered, as there is a wide array of products available, at differing levels of build quality.

Toxic oral ingestion of nicotine, especially by children, has led to increased calls to poison centers. For a small child, this can be fatal. Regulation of labels and containers could curtail this issue. But, public education regarding the toxicity of these substances when ingested in large quantities is also important. If there is a lack of understanding about this danger, then typical safeguards are easily overlooked by individual users.

Are there benefits?

Smoking cessation

Compared with other products, such as nicotine patches, gum, and pharmaceutical methods, e-cigarettes most closely mimic the actual experience of smoking. For some, the habit and ritual of smoking is as much a part of the addiction as nicotine. Vaping has the potential to help alleviate this difficult aspect of cessation. Data involving early generation products failed to show a significant advantage. Newer devices that are more pleasurable to use and offer more efficient nicotine delivery may be more effective. Indeed, a recent study in the New England Journal of Medicine from this year demonstrated improved smoking cessation compared with traditional methods, using second generation vape devices (Hajek P, et al. N Engl J Med. 2019;380[7]629). It will be interesting to see if this can be repeatable going forward and if protocols can be established to maximize effectiveness.

As outlined above, it is difficult to make definitive conclusions or recommendations regarding electronic cigarette use at the present time. The risk of cancer and cardiopulmonary disease is likely to be significantly lower but not eliminated. Use as a smoking cessation aid is starting to show promise. Even without cessation, ongoing vaping is likely to be safer than ongoing smoking. Two caveats to this remain: some patients, in an effort to quit smoking, may take up vaping but eventually become “dual users.” This scenario has been associated with higher toxic exposure and possibly worse outcomes. The second caveat is that while there is promise to using this as a cessation tool, it should not yet replace other more well-studied, first-line agents in this regard. It should, perhaps, target patients who are motivated to quit but have failed more traditional methods. Finally, there continues to be concern that vaping could appeal to never smokers, given its perceived safety profile and ease of use in public places. This could lead to an overall increase in nicotine addiction, which could be a significant step backwards.

Dr. Clark is Assistant Professor, Pulmonary and Critical Care Medicine, UT Southwestern Medical Center, Dallas, Texas.

The CHEST Foundation is excited to be a part of this year’s CHEST Board Review in Phoenix, and we can’t wait to see you! We are hosting two receptions and invite you to attend and learn more about how the CHEST Foundation supports you, your colleagues, your patients, and the greater community while also taking the time to relax with your peers and board review faculty. The receptions are scheduled for Saturday, August 17 (for Sleep and Critical Care Board Review), and Wednesday, August 21 (for Pulmonary Board Review) immediately following your scheduled sessions. Please join us for hors d’oeuvres and beverages. This year, we are featuring surprise, guest speakers from CHEST leadership who will share why they are passionate about the Foundation’s mission and offer simple ways you can become further involved with the CHEST Foundation. You won’t want to miss this networking opportunity and the chance to learn more about what the Foundation has been doing!

This summer, we are focused on supporting young and early-career clinicians and are raising money at this year’s at Board Review to support travel grants to CHEST 2019. These travel grants provide early-career clinicians the funds needed to attend CHEST 2019. This program further develops the future leaders of CHEST and allows clinicians to take full advantage of career-development and networking opportunities that the annual meeting offers. If you’re interested in how you can make a difference in someone’s life, visit our website (foundation.chestnet.org), or find us at Board Review! We would love to share more with you about all the great work the Foundation is doing.

We can’t wait to see you in Phoenix to celebrate all your hard work!

The CHEST Foundation is excited to be a part of this year’s CHEST Board Review in Phoenix, and we can’t wait to see you! We are hosting two receptions and invite you to attend and learn more about how the CHEST Foundation supports you, your colleagues, your patients, and the greater community while also taking the time to relax with your peers and board review faculty. The receptions are scheduled for Saturday, August 17 (for Sleep and Critical Care Board Review), and Wednesday, August 21 (for Pulmonary Board Review) immediately following your scheduled sessions. Please join us for hors d’oeuvres and beverages. This year, we are featuring surprise, guest speakers from CHEST leadership who will share why they are passionate about the Foundation’s mission and offer simple ways you can become further involved with the CHEST Foundation. You won’t want to miss this networking opportunity and the chance to learn more about what the Foundation has been doing!

This summer, we are focused on supporting young and early-career clinicians and are raising money at this year’s at Board Review to support travel grants to CHEST 2019. These travel grants provide early-career clinicians the funds needed to attend CHEST 2019. This program further develops the future leaders of CHEST and allows clinicians to take full advantage of career-development and networking opportunities that the annual meeting offers. If you’re interested in how you can make a difference in someone’s life, visit our website (foundation.chestnet.org), or find us at Board Review! We would love to share more with you about all the great work the Foundation is doing.

We can’t wait to see you in Phoenix to celebrate all your hard work!

The CHEST Foundation is excited to be a part of this year’s CHEST Board Review in Phoenix, and we can’t wait to see you! We are hosting two receptions and invite you to attend and learn more about how the CHEST Foundation supports you, your colleagues, your patients, and the greater community while also taking the time to relax with your peers and board review faculty. The receptions are scheduled for Saturday, August 17 (for Sleep and Critical Care Board Review), and Wednesday, August 21 (for Pulmonary Board Review) immediately following your scheduled sessions. Please join us for hors d’oeuvres and beverages. This year, we are featuring surprise, guest speakers from CHEST leadership who will share why they are passionate about the Foundation’s mission and offer simple ways you can become further involved with the CHEST Foundation. You won’t want to miss this networking opportunity and the chance to learn more about what the Foundation has been doing!

This summer, we are focused on supporting young and early-career clinicians and are raising money at this year’s at Board Review to support travel grants to CHEST 2019. These travel grants provide early-career clinicians the funds needed to attend CHEST 2019. This program further develops the future leaders of CHEST and allows clinicians to take full advantage of career-development and networking opportunities that the annual meeting offers. If you’re interested in how you can make a difference in someone’s life, visit our website (foundation.chestnet.org), or find us at Board Review! We would love to share more with you about all the great work the Foundation is doing.

We can’t wait to see you in Phoenix to celebrate all your hard work!

Past President (2006-2007) of the American College of Chest Physicians, leader, educator, mentor, and friend, Dr. Mark Rosen, Master FCCP, died on July 3, 2019. Dr. Rosen’s distinguished career in pulmonary and critical care medicine spanned more than 4 decades, marked by his deep commitments to medical education and patient care. His research and administrative accomplishments at New York City and Long Island hospitals were many, but clinical medicine and teaching were always at the top of his list. Mark’s unmistakable way of incorporating both clarity and humor into his roles of clinician, teacher, colleague, and friend provided us all with respect and adoration for this unforgettable individual.

Mark’s distinguished leadership involvement with CHEST began well before his term as President. Two years after completing his fellowships in pulmonary and critical care medicine, he became an FCCP in 1982, and his engagement with the American College of Chest Physicians began. During the 1990s and into the 2000s, Mark provided CHEST with his teaching expertise serving as faculty and director for the Pulmonary Board Review Courses. In 1998, he was Chair of the CHEST Annual Meeting, and from 1999 to 2005, he served on the ACCP-SEEK Editorial Boards for Pulmonary Disease and Critical Care Medicine. Mark served on the CHEST Board of Regents for many years, on the CHEST Foundation Board of Trustees, and as a Chair or member on numerous CHEST committees, some of which included Education, Nominations, Membership, Marketing, and Finance. He was the CHEST Governor for the City of New York and Chair of the Council of Governors. His leadership in all of these capacities was exemplary, as was his guidance as CHEST President from 2006 to 2007. Most recently, Mark served as CHEST Director of Global Education and Strategic Development (2011-2014) followed by CHEST Medical Director (2014-2016). Mark strived to uphold and strengthen the quality of the education that CHEST provided to all health-care professionals. His imprint on the educational and clinical foundations of CHEST, along with the many friendships he made along the way, will be remembered always.

CHEST extends heartfelt condolences to Mark’s wife of 37 years, Ilene, and the Rosen family and many friends and colleagues.

Past President (2006-2007) of the American College of Chest Physicians, leader, educator, mentor, and friend, Dr. Mark Rosen, Master FCCP, died on July 3, 2019. Dr. Rosen’s distinguished career in pulmonary and critical care medicine spanned more than 4 decades, marked by his deep commitments to medical education and patient care. His research and administrative accomplishments at New York City and Long Island hospitals were many, but clinical medicine and teaching were always at the top of his list. Mark’s unmistakable way of incorporating both clarity and humor into his roles of clinician, teacher, colleague, and friend provided us all with respect and adoration for this unforgettable individual.

Mark’s distinguished leadership involvement with CHEST began well before his term as President. Two years after completing his fellowships in pulmonary and critical care medicine, he became an FCCP in 1982, and his engagement with the American College of Chest Physicians began. During the 1990s and into the 2000s, Mark provided CHEST with his teaching expertise serving as faculty and director for the Pulmonary Board Review Courses. In 1998, he was Chair of the CHEST Annual Meeting, and from 1999 to 2005, he served on the ACCP-SEEK Editorial Boards for Pulmonary Disease and Critical Care Medicine. Mark served on the CHEST Board of Regents for many years, on the CHEST Foundation Board of Trustees, and as a Chair or member on numerous CHEST committees, some of which included Education, Nominations, Membership, Marketing, and Finance. He was the CHEST Governor for the City of New York and Chair of the Council of Governors. His leadership in all of these capacities was exemplary, as was his guidance as CHEST President from 2006 to 2007. Most recently, Mark served as CHEST Director of Global Education and Strategic Development (2011-2014) followed by CHEST Medical Director (2014-2016). Mark strived to uphold and strengthen the quality of the education that CHEST provided to all health-care professionals. His imprint on the educational and clinical foundations of CHEST, along with the many friendships he made along the way, will be remembered always.

CHEST extends heartfelt condolences to Mark’s wife of 37 years, Ilene, and the Rosen family and many friends and colleagues.

Past President (2006-2007) of the American College of Chest Physicians, leader, educator, mentor, and friend, Dr. Mark Rosen, Master FCCP, died on July 3, 2019. Dr. Rosen’s distinguished career in pulmonary and critical care medicine spanned more than 4 decades, marked by his deep commitments to medical education and patient care. His research and administrative accomplishments at New York City and Long Island hospitals were many, but clinical medicine and teaching were always at the top of his list. Mark’s unmistakable way of incorporating both clarity and humor into his roles of clinician, teacher, colleague, and friend provided us all with respect and adoration for this unforgettable individual.

Mark’s distinguished leadership involvement with CHEST began well before his term as President. Two years after completing his fellowships in pulmonary and critical care medicine, he became an FCCP in 1982, and his engagement with the American College of Chest Physicians began. During the 1990s and into the 2000s, Mark provided CHEST with his teaching expertise serving as faculty and director for the Pulmonary Board Review Courses. In 1998, he was Chair of the CHEST Annual Meeting, and from 1999 to 2005, he served on the ACCP-SEEK Editorial Boards for Pulmonary Disease and Critical Care Medicine. Mark served on the CHEST Board of Regents for many years, on the CHEST Foundation Board of Trustees, and as a Chair or member on numerous CHEST committees, some of which included Education, Nominations, Membership, Marketing, and Finance. He was the CHEST Governor for the City of New York and Chair of the Council of Governors. His leadership in all of these capacities was exemplary, as was his guidance as CHEST President from 2006 to 2007. Most recently, Mark served as CHEST Director of Global Education and Strategic Development (2011-2014) followed by CHEST Medical Director (2014-2016). Mark strived to uphold and strengthen the quality of the education that CHEST provided to all health-care professionals. His imprint on the educational and clinical foundations of CHEST, along with the many friendships he made along the way, will be remembered always.

CHEST extends heartfelt condolences to Mark’s wife of 37 years, Ilene, and the Rosen family and many friends and colleagues.

CHEST welcomed Peter J. Mazzone, MD, MPH, FCCP, in July, as the new Editor in Chief of the journal CHEST®. Dr. Mazzone is the Director of the Lung Cancer Program and Lung Cancer Screening Program for the Respiratory Institute at the Cleveland Clinic in Ohio.

His clinical interests include nodule management and the prevention, screening, diagnosis, staging, and characterization of lung cancer; his research has focused on the development of molecular biomarkers for lung cancer detection. Dr. Mazzone has been a member of CHEST since 1999 and an FCCP since 2004. He has served in several CHEST leadership positions, including member of the CHEST Lung Cancer Living Guidelines Steering Committee and program chair for the CHEST 2017 annual meeting, among others. Dr. Mazzone has provided some insights into the structure and strategies of the journal going forward, so don’t miss his editorial in the July issue of CHEST^®.

CHEST welcomed Peter J. Mazzone, MD, MPH, FCCP, in July, as the new Editor in Chief of the journal CHEST®. Dr. Mazzone is the Director of the Lung Cancer Program and Lung Cancer Screening Program for the Respiratory Institute at the Cleveland Clinic in Ohio.

His clinical interests include nodule management and the prevention, screening, diagnosis, staging, and characterization of lung cancer; his research has focused on the development of molecular biomarkers for lung cancer detection. Dr. Mazzone has been a member of CHEST since 1999 and an FCCP since 2004. He has served in several CHEST leadership positions, including member of the CHEST Lung Cancer Living Guidelines Steering Committee and program chair for the CHEST 2017 annual meeting, among others. Dr. Mazzone has provided some insights into the structure and strategies of the journal going forward, so don’t miss his editorial in the July issue of CHEST^®.

CHEST welcomed Peter J. Mazzone, MD, MPH, FCCP, in July, as the new Editor in Chief of the journal CHEST®. Dr. Mazzone is the Director of the Lung Cancer Program and Lung Cancer Screening Program for the Respiratory Institute at the Cleveland Clinic in Ohio.

His clinical interests include nodule management and the prevention, screening, diagnosis, staging, and characterization of lung cancer; his research has focused on the development of molecular biomarkers for lung cancer detection. Dr. Mazzone has been a member of CHEST since 1999 and an FCCP since 2004. He has served in several CHEST leadership positions, including member of the CHEST Lung Cancer Living Guidelines Steering Committee and program chair for the CHEST 2017 annual meeting, among others. Dr. Mazzone has provided some insights into the structure and strategies of the journal going forward, so don’t miss his editorial in the July issue of CHEST^®.

The health care workforce is being transformed by profound demographic changes and the steady growth of the U.S. health sector. In addition, the movement of physicians out of private practice to employment by medical centers has accelerated. And a new generation of health care professionals is demanding a sustainable work/life balance. These trends will combine to change the work environment of chest physicians.

Spending

The United States spends about twice as much on health care as any other industrialized nation and this fact is driving an increasingly urgent public discussion about options and means of reducing costs.¹ Medicare and Medicaid already account for about a quarter of federal government spending and those numbers are expected to rise as baby boomers age.¹ Employer spending on health care as a percentage of wages has doubled since the 1980s.²

Workforce supply

An expanding health care sector means a growing demand for health care labor. Health care occupations are projected to grow 18% from 2016 to 2026, faster than the average for all occupations and adding 2.4 million new jobs to the economy.³ Expert testimony before the U.S. Senate Committee on Health, Education, Labor, and Pensions in May 2018 projected shortages of physicians in the coming years. According to estimates of the Health Resources and Services Administration (HRSA), there is a need for 13,800 additional primary care physicians in areas – especially rural – that are designated as health professional shortage areas. Signs of a worsening situation include projected shortages of 20,000 primary care physicians by 2025, according to HRSA, and 42,600-121,300 physicians by 2030, according to the Association of American Medical Colleges. The demand for physicians will exceed supply by 46,000-90,000 by 2025. An update to that research increased the projected shortage range to 61,700-94,700 by 2025.⁴ These shortages will result in recruiting challenges for many medical centers, especially those in rural areas.

Employment

Private practice is becoming the less common structure of employment for physicians. According to American Medical Association data, physician ownership of practices dropped below 50% for the first time in 2016.⁵ The trend toward employed versus private practice physicians is expected to continue. The size of practices is growing, with about one-third of physicians working in a hospital-owned practice or employed directly by a hospital and around 40% in practices of 10 physicians or more.⁵ Of every 10 physician practices, 3 were hospital owned in 2016.⁶ Physicians are being called upon to do more data entry and administrative work; 21% of physicians’ time is now spent on nonclinical paperwork.⁷ The ripple-out effects of what amounts to a seismic shift in the work structure and work environment for physicians are only beginning to be studied in terms of overall personal satisfaction and impact on patient care.

Stephanie M. Levine, MD, FCCP, the designate president of the American College of Chest Physicians and professor of medicine in the division of pulmonary diseases and critical care medicine at the University of Texas, San Antonio, recognizes the significance of the move from private practice to employment and suggests that advantages could be offset by some potential negatives practicing chest physicians. She noted, “Pros include potentially more job security, more predictable work hours, perhaps a reduction in some of the traditional administrative ‘hassles’ with running a private practice, and possibly a better and healthier work/life balance. Some think that physician input and leadership in the employed model may have more influence on a health care system than in an individual private practice. Nonclinical work may be decreased, but it is not clear that this is true.

“The negatives include a loss of autonomy, a potential loss of personal ownership of our patients’ health, and the loss of a unique personal culture of private practice. Physicians may be subject to metrics imposed by the employer. In addition, we may see more job turnover since physicians could be less invested emotionally and financially; fewer patients seen since the structure is often salary based and not based on productivity; and increased shift work, set work hours, and schedules. Thus, the employer-based model may actually contribute to the ongoing physician shortage.”

Dr. Levine stressed the role of training programs to prepare physicians for what may lie ahead. “Training programs must prepare physicians for what to expect as employees.”

Changing expectations

An evolution of expectations about a healthy work/life balance has occurred in many professions, including the health care profession. While younger practitioners may be more likely to embrace the changes occurring within health care, they are often more vocal about their desire for a healthy work/life balance and may be less likely to spend time away from family and friends rather than completing administrative tasks. Parenting is increasingly regarded by women and men as compatible with a full and rewarding career as a physician. So these changing expectations about work/life balances mean health care institutions will have to adjust their own expectations in order to recruit and maintain top-quality staff.

Stress and burnout

Workforce shortages, overwhelming administrative tasks, and a variety of forces that come with employment in a large medical system are causing stress and burnout in many physicians. In a 2018 Medscape study of more than 15,000 physicians, 42% reported burnout, and 15% admitted to experiencing either clinical or colloquial forms of depression.⁸ Dr. Levine acknowledges that many chest physicians are at risk for burnout. “In our field of medicine, particularly with those that practice in an intensive care setting, we are faced with the high stress and emotional experiences we encounter in the life and death nature of our jobs. We care for the sickest patient population, and are often facing life and death clinical needs as well as end-of-life discussions and care. Burnout is a potential threat to both patient safety and the quality of healthcare that we practice.”

Dr. Levine strongly urges colleagues to remain vigilant to this potentially devastating condition in their fellow physicians and in themselves. She said, “If you suspect you are feeling the symptoms of burnout, or have been told so by a colleague, then talk to a peer or colleague, take personal time to do something you enjoy, and/or join a support group. But better than that, try to preempt burnout by developing a strong emotional peer support group in or out of work, practicing mindfulness training, and paying attention to wellness and self-care.”

Burnout is finally being recognized by medical institutions as a significant factor in physician health and performance, and in the recruitment and attrition of staff. Dr. Levine sees progress in how health care institutions deal with burnout, wellness, and work/life balance among staff and trainees. In a hopeful note, Dr. Levine suggested that institutional responses to burnout and the workplace factors that fuel burnout may improve work conditions for physicians in the future.

These trends in the U.S. economy and workforce will mean a steady growth of the health care sector for the foreseeable future, continued political and social pressure to control costs, fewer physicians in private practice, and a potential move away from unhealthy work/life ratios currently so common among physicians.

Dr. Levine concluded that it is up to training programs to prepare trainees for these sea changes to the practice of medicine.

References

1. https://www.healthleadersmedia.com/finance/healthcare-spending-20-gdp-thats-economy-wide-problem

2. PwC Health Research Institute

3. https://www.bls.gov/ooh/healthcare/home.htm

4. https://www.hfma.org/Content.aspx?id=60811

5. https://www.ama-assn.org/about-ama/research/physician-practice-benchmark-survey

6. http://www.physiciansadvocacyinstitute.org/

7. https://omahamedical.com/wp-content/uploads/2016/12/2016-Survey-of-Americas-Physicians-Practice-Patterns-and-Perspectives.pdf

8. https://www.medscape.com/slideshow/2018-lifestyle-burnout-depression-6009235

The health care workforce is being transformed by profound demographic changes and the steady growth of the U.S. health sector. In addition, the movement of physicians out of private practice to employment by medical centers has accelerated. And a new generation of health care professionals is demanding a sustainable work/life balance. These trends will combine to change the work environment of chest physicians.

Spending

The United States spends about twice as much on health care as any other industrialized nation and this fact is driving an increasingly urgent public discussion about options and means of reducing costs.¹ Medicare and Medicaid already account for about a quarter of federal government spending and those numbers are expected to rise as baby boomers age.¹ Employer spending on health care as a percentage of wages has doubled since the 1980s.²

Workforce supply

An expanding health care sector means a growing demand for health care labor. Health care occupations are projected to grow 18% from 2016 to 2026, faster than the average for all occupations and adding 2.4 million new jobs to the economy.³ Expert testimony before the U.S. Senate Committee on Health, Education, Labor, and Pensions in May 2018 projected shortages of physicians in the coming years. According to estimates of the Health Resources and Services Administration (HRSA), there is a need for 13,800 additional primary care physicians in areas – especially rural – that are designated as health professional shortage areas. Signs of a worsening situation include projected shortages of 20,000 primary care physicians by 2025, according to HRSA, and 42,600-121,300 physicians by 2030, according to the Association of American Medical Colleges. The demand for physicians will exceed supply by 46,000-90,000 by 2025. An update to that research increased the projected shortage range to 61,700-94,700 by 2025.⁴ These shortages will result in recruiting challenges for many medical centers, especially those in rural areas.

Employment

Private practice is becoming the less common structure of employment for physicians. According to American Medical Association data, physician ownership of practices dropped below 50% for the first time in 2016.⁵ The trend toward employed versus private practice physicians is expected to continue. The size of practices is growing, with about one-third of physicians working in a hospital-owned practice or employed directly by a hospital and around 40% in practices of 10 physicians or more.⁵ Of every 10 physician practices, 3 were hospital owned in 2016.⁶ Physicians are being called upon to do more data entry and administrative work; 21% of physicians’ time is now spent on nonclinical paperwork.⁷ The ripple-out effects of what amounts to a seismic shift in the work structure and work environment for physicians are only beginning to be studied in terms of overall personal satisfaction and impact on patient care.

Stephanie M. Levine, MD, FCCP, the designate president of the American College of Chest Physicians and professor of medicine in the division of pulmonary diseases and critical care medicine at the University of Texas, San Antonio, recognizes the significance of the move from private practice to employment and suggests that advantages could be offset by some potential negatives practicing chest physicians. She noted, “Pros include potentially more job security, more predictable work hours, perhaps a reduction in some of the traditional administrative ‘hassles’ with running a private practice, and possibly a better and healthier work/life balance. Some think that physician input and leadership in the employed model may have more influence on a health care system than in an individual private practice. Nonclinical work may be decreased, but it is not clear that this is true.

“The negatives include a loss of autonomy, a potential loss of personal ownership of our patients’ health, and the loss of a unique personal culture of private practice. Physicians may be subject to metrics imposed by the employer. In addition, we may see more job turnover since physicians could be less invested emotionally and financially; fewer patients seen since the structure is often salary based and not based on productivity; and increased shift work, set work hours, and schedules. Thus, the employer-based model may actually contribute to the ongoing physician shortage.”

Dr. Levine stressed the role of training programs to prepare physicians for what may lie ahead. “Training programs must prepare physicians for what to expect as employees.”

Changing expectations

An evolution of expectations about a healthy work/life balance has occurred in many professions, including the health care profession. While younger practitioners may be more likely to embrace the changes occurring within health care, they are often more vocal about their desire for a healthy work/life balance and may be less likely to spend time away from family and friends rather than completing administrative tasks. Parenting is increasingly regarded by women and men as compatible with a full and rewarding career as a physician. So these changing expectations about work/life balances mean health care institutions will have to adjust their own expectations in order to recruit and maintain top-quality staff.

Stress and burnout

Workforce shortages, overwhelming administrative tasks, and a variety of forces that come with employment in a large medical system are causing stress and burnout in many physicians. In a 2018 Medscape study of more than 15,000 physicians, 42% reported burnout, and 15% admitted to experiencing either clinical or colloquial forms of depression.⁸ Dr. Levine acknowledges that many chest physicians are at risk for burnout. “In our field of medicine, particularly with those that practice in an intensive care setting, we are faced with the high stress and emotional experiences we encounter in the life and death nature of our jobs. We care for the sickest patient population, and are often facing life and death clinical needs as well as end-of-life discussions and care. Burnout is a potential threat to both patient safety and the quality of healthcare that we practice.”

Dr. Levine strongly urges colleagues to remain vigilant to this potentially devastating condition in their fellow physicians and in themselves. She said, “If you suspect you are feeling the symptoms of burnout, or have been told so by a colleague, then talk to a peer or colleague, take personal time to do something you enjoy, and/or join a support group. But better than that, try to preempt burnout by developing a strong emotional peer support group in or out of work, practicing mindfulness training, and paying attention to wellness and self-care.”

Burnout is finally being recognized by medical institutions as a significant factor in physician health and performance, and in the recruitment and attrition of staff. Dr. Levine sees progress in how health care institutions deal with burnout, wellness, and work/life balance among staff and trainees. In a hopeful note, Dr. Levine suggested that institutional responses to burnout and the workplace factors that fuel burnout may improve work conditions for physicians in the future.

These trends in the U.S. economy and workforce will mean a steady growth of the health care sector for the foreseeable future, continued political and social pressure to control costs, fewer physicians in private practice, and a potential move away from unhealthy work/life ratios currently so common among physicians.

Dr. Levine concluded that it is up to training programs to prepare trainees for these sea changes to the practice of medicine.

References

1. https://www.healthleadersmedia.com/finance/healthcare-spending-20-gdp-thats-economy-wide-problem

2. PwC Health Research Institute

3. https://www.bls.gov/ooh/healthcare/home.htm

4. https://www.hfma.org/Content.aspx?id=60811

5. https://www.ama-assn.org/about-ama/research/physician-practice-benchmark-survey

6. http://www.physiciansadvocacyinstitute.org/

7. https://omahamedical.com/wp-content/uploads/2016/12/2016-Survey-of-Americas-Physicians-Practice-Patterns-and-Perspectives.pdf

8. https://www.medscape.com/slideshow/2018-lifestyle-burnout-depression-6009235

The health care workforce is being transformed by profound demographic changes and the steady growth of the U.S. health sector. In addition, the movement of physicians out of private practice to employment by medical centers has accelerated. And a new generation of health care professionals is demanding a sustainable work/life balance. These trends will combine to change the work environment of chest physicians.

Spending

The United States spends about twice as much on health care as any other industrialized nation and this fact is driving an increasingly urgent public discussion about options and means of reducing costs.¹ Medicare and Medicaid already account for about a quarter of federal government spending and those numbers are expected to rise as baby boomers age.¹ Employer spending on health care as a percentage of wages has doubled since the 1980s.²

Workforce supply

An expanding health care sector means a growing demand for health care labor. Health care occupations are projected to grow 18% from 2016 to 2026, faster than the average for all occupations and adding 2.4 million new jobs to the economy.³ Expert testimony before the U.S. Senate Committee on Health, Education, Labor, and Pensions in May 2018 projected shortages of physicians in the coming years. According to estimates of the Health Resources and Services Administration (HRSA), there is a need for 13,800 additional primary care physicians in areas – especially rural – that are designated as health professional shortage areas. Signs of a worsening situation include projected shortages of 20,000 primary care physicians by 2025, according to HRSA, and 42,600-121,300 physicians by 2030, according to the Association of American Medical Colleges. The demand for physicians will exceed supply by 46,000-90,000 by 2025. An update to that research increased the projected shortage range to 61,700-94,700 by 2025.⁴ These shortages will result in recruiting challenges for many medical centers, especially those in rural areas.

Employment

Private practice is becoming the less common structure of employment for physicians. According to American Medical Association data, physician ownership of practices dropped below 50% for the first time in 2016.⁵ The trend toward employed versus private practice physicians is expected to continue. The size of practices is growing, with about one-third of physicians working in a hospital-owned practice or employed directly by a hospital and around 40% in practices of 10 physicians or more.⁵ Of every 10 physician practices, 3 were hospital owned in 2016.⁶ Physicians are being called upon to do more data entry and administrative work; 21% of physicians’ time is now spent on nonclinical paperwork.⁷ The ripple-out effects of what amounts to a seismic shift in the work structure and work environment for physicians are only beginning to be studied in terms of overall personal satisfaction and impact on patient care.

Stephanie M. Levine, MD, FCCP, the designate president of the American College of Chest Physicians and professor of medicine in the division of pulmonary diseases and critical care medicine at the University of Texas, San Antonio, recognizes the significance of the move from private practice to employment and suggests that advantages could be offset by some potential negatives practicing chest physicians. She noted, “Pros include potentially more job security, more predictable work hours, perhaps a reduction in some of the traditional administrative ‘hassles’ with running a private practice, and possibly a better and healthier work/life balance. Some think that physician input and leadership in the employed model may have more influence on a health care system than in an individual private practice. Nonclinical work may be decreased, but it is not clear that this is true.

“The negatives include a loss of autonomy, a potential loss of personal ownership of our patients’ health, and the loss of a unique personal culture of private practice. Physicians may be subject to metrics imposed by the employer. In addition, we may see more job turnover since physicians could be less invested emotionally and financially; fewer patients seen since the structure is often salary based and not based on productivity; and increased shift work, set work hours, and schedules. Thus, the employer-based model may actually contribute to the ongoing physician shortage.”

Dr. Levine stressed the role of training programs to prepare physicians for what may lie ahead. “Training programs must prepare physicians for what to expect as employees.”

Changing expectations

An evolution of expectations about a healthy work/life balance has occurred in many professions, including the health care profession. While younger practitioners may be more likely to embrace the changes occurring within health care, they are often more vocal about their desire for a healthy work/life balance and may be less likely to spend time away from family and friends rather than completing administrative tasks. Parenting is increasingly regarded by women and men as compatible with a full and rewarding career as a physician. So these changing expectations about work/life balances mean health care institutions will have to adjust their own expectations in order to recruit and maintain top-quality staff.

Stress and burnout

Workforce shortages, overwhelming administrative tasks, and a variety of forces that come with employment in a large medical system are causing stress and burnout in many physicians. In a 2018 Medscape study of more than 15,000 physicians, 42% reported burnout, and 15% admitted to experiencing either clinical or colloquial forms of depression.⁸ Dr. Levine acknowledges that many chest physicians are at risk for burnout. “In our field of medicine, particularly with those that practice in an intensive care setting, we are faced with the high stress and emotional experiences we encounter in the life and death nature of our jobs. We care for the sickest patient population, and are often facing life and death clinical needs as well as end-of-life discussions and care. Burnout is a potential threat to both patient safety and the quality of healthcare that we practice.”

Dr. Levine strongly urges colleagues to remain vigilant to this potentially devastating condition in their fellow physicians and in themselves. She said, “If you suspect you are feeling the symptoms of burnout, or have been told so by a colleague, then talk to a peer or colleague, take personal time to do something you enjoy, and/or join a support group. But better than that, try to preempt burnout by developing a strong emotional peer support group in or out of work, practicing mindfulness training, and paying attention to wellness and self-care.”

Burnout is finally being recognized by medical institutions as a significant factor in physician health and performance, and in the recruitment and attrition of staff. Dr. Levine sees progress in how health care institutions deal with burnout, wellness, and work/life balance among staff and trainees. In a hopeful note, Dr. Levine suggested that institutional responses to burnout and the workplace factors that fuel burnout may improve work conditions for physicians in the future.

These trends in the U.S. economy and workforce will mean a steady growth of the health care sector for the foreseeable future, continued political and social pressure to control costs, fewer physicians in private practice, and a potential move away from unhealthy work/life ratios currently so common among physicians.

Dr. Levine concluded that it is up to training programs to prepare trainees for these sea changes to the practice of medicine.

References

1. https://www.healthleadersmedia.com/finance/healthcare-spending-20-gdp-thats-economy-wide-problem

2. PwC Health Research Institute

3. https://www.bls.gov/ooh/healthcare/home.htm

4. https://www.hfma.org/Content.aspx?id=60811

5. https://www.ama-assn.org/about-ama/research/physician-practice-benchmark-survey

6. http://www.physiciansadvocacyinstitute.org/

7. https://omahamedical.com/wp-content/uploads/2016/12/2016-Survey-of-Americas-Physicians-Practice-Patterns-and-Perspectives.pdf

8. https://www.medscape.com/slideshow/2018-lifestyle-burnout-depression-6009235