The University Hospital

The University of Michigan Hospitals and the adjacent Taubman Ambulatory Health Care Center constitute a tertiary health care center for the State of Michigan and neighboring regions. The University Hospital is modern and well equipped to handle all medical and surgical problems, including those involving the most sophisticated care. There are 872 beds in the University of Michigan Medical Center; 550 are adult medicine and surgery beds. The hospital is an attractive, efficient, and pleasant place in which to work. There are no dedicated Infectious Diseases beds in the University Hospital and no defined Infectious Diseases inpatient service. Our Division's clinical services are provided entirely by consultations to medical and surgical inpatient units. Consequently, our patients represent the full spectrum of disease admitted to this facility. In addition to the more common medical and surgical problems, we routinely receive consultation requests from our specialized services. These include the five intensive care units - the Coronary Care Unit, Medical Intensive Care Unit, Surgical Intensive Care Unit, Neurosurgical Intensive Care Unit and the Thoracic Intensive Care Unit - a busy Emergency Service with a level 1 Trauma-Burn Center, active solid organ and bone marrow transplantation services, and a growing HIV/AIDS Treatment Program. These resources create an intense and varied learning experience for our trainees. Fellows at the University hospital perform an average of 70 consultations per month and may follow a service of 12 to 24 patients at a time for inpatient concurrent care. On average there are 5 - 10 consultations per month related to solid organ or bone marrow transplantation, 3 - 5 consultations from our Trauma Burn Unit, 2 -3 consultations from the Kellogg Eye Center relating to infections of the eye or orbit, and up to 2 consultations from the Holden Women's Hospital, i.e., gynecologic infections. Approximately 20% to 30% of our consultations are from intensive care units and 2 to 5 consultations per month may be requested by the Emergency Service. There is no inpatient AIDS unit at the University Hospital; however, our fellows typically follow between 2 and 4 inpatients with HIV infection at any given time.

The Ann Arbor Veteran's Affairs Hospital

Approximately 1 mile from the University Hospital is the Ann Arbor Veterans' Affairs Hospital which is the site of the other 50% of our clinical training for fellows. The Ann Arbor VA Hospital has 286 beds. Like most VA hospitals, it is all adult medical and surgical care and predominately male. The patient population consists of individuals with more chronic diseases, often at a more advanced stage of the natural history of their infections. The VA hospital also has an urgent care facility through which many of the patients our fellows see are admitted. Attached to the VA Hospital is a long-term care facility for which we also provide services. This facility provides our fellows with the experience of caring for infections in nursing home patients, and it has also been a resource for fellows interested in the epidemiology and control of nosocomial infections in long term care facilities. The VA Hospital is significantly smaller than the University Hospital, but all of the medical and surgical subspecialties are represented, and there is an equally wide range of challenging medical problems. Because of the expertise available at the Ann Arbor VA, it serves as a referral center for other smaller, outlying VA Hospitals. It therefore tends to include an inpatient population of sicker and more complex patients. Given the special expertise of Dr. Carol Kauffman, many patients with systemic fungal infections are referred to the Ann Arbor VA. The VA outpatient clinic also services approximately 150 patients with HIV and AIDS. Consequently, our fellows follow 2 to 3 patients with AIDS in the hospital at any given time while serving on the inpatient service. At the Ann Arbor Veterans' Affairs Hospital fellows perform about 30 consultations per month and may follow anywhere from 10 to 20 patients at a time.

The experience at the two hospitals is complimentary. The University experience offers exposure to tertiary care patients with infections associated with medical progress as well as to a wide spectrum of naturally-acquired infections. The VA hospital provides an experience with a population of chronically ill patients, often indigent, and exposure to a nursing home population. Both hospitals have adequate facilities for the isolation of patients with Infectious Diseases. The University Hospital has two isolation rooms on each ward. Both the University Hospital the VA Hospital have on-site clinical microbiology laboratories with diagnostic capabilities for bacteriology, immunology, mycology, parasitology, and virology.

AMBULATORY CARE EXPERIENCE

The University of Michigan Clinics

The Taubman Center Clinics were constructed along with the new University Hospital in 1986. The facility includes examination rooms, an outpatient radiologic facility, an outpatient infusion facility, a satellite blood drawing station for the main clinical laboratories, and minor surgery and treatment units. The Infectious Diseases Clinic meets four mornings each week. Patients who are referred or self-referred are seen by faculty and fellows on Tuesday and Thursday mornings. A travel clinic operates concurrently with the Infectious Diseases Clinic on Tuesdays and Thursdays. At the University our fellows have an average of 175 office visits per year in the outpatient setting. Many of these visits are attributable to individual patients that a fellow may follow continuously for the two years of their fellowship. Fellows on the inpatient consult service at the University Hospital are required to follow up on outpatient intravenous antibiotic therapy of discharged patients. Many of these follow-up visits are with patients treated for osteomyelitis, skin and soft tissue infections, deep abscesses, or endocarditis. On Tuesday and Friday mornings, a formal AIDS clinic is held. This clinic is supervised by Dr. Powel Kazanjian and attended by fellows, two full-time clinical nurses, a nutritionist, and two full-time social workers. All of our faculty and fellows follow patients with HIV and AIDS in their outpatient clinics and make use of the facilities and personnel of the AIDS program in the management of theses patients.

The VA Hospital Clinic

The Infectious Diseases Clinic at the Ann Arbor VA Hospital is conducted on Friday mornings. Approximately three quarters of the patients seen in that clinic have HIV or AIDS. The remaining 25% have a variety of other Infectious Diseases problems. The clinic is manned primarily by three Infectious Diseases faculty: Drs. Kauffman, Bradley, and Cinti, and by an Infectious Diseases fellow. Each year, one of our senior fellows transfers to the Ann Arbor VA Hospital ID Clinic for their second year. In this setting, the fellow sees approximately the same number of patients as at the University, and the procedures and levels of responsibility are the same.

The fellows have significant responsibility in these clinics. They are the first to see the patients, assemble all of the necessary data, review it, and develop a management plan. The plan is then discussed with a faculty member who is familiar with the case, and the faculty member either approves or amends the plan.

At both outpatient facilities, patients requiring continuing care are assigned to a specific fellow/faculty pair. However, rescheduled visits always occur in the fellows schedule so that they are always identified as the primary subspecialist physician. Occasionally, more than one faculty member may supervise a case on subsequent visits. Patients are not transferred from fellow to fellow or from fellow to attending until one of the trainees graduates from the program. At that point, all of the patients assigned to a graduating fellow are transferred to an incoming fellow.

Clinics are never held without the physical presence of an attending physician. After evaluating patients, fellows present all of the relevant clinical data to the attending faculty member in the clinic staff room while the patient is still present. The faculty member may use this opportunity for teaching and to supervise specific details of the management. The faculty member will review and confirm critical physical findings. Fellows will then dictate notes concerning the patients' visits, and these written records are reviewed by the faculty before they are added to the medical record.

We offer an optional experience in the management of sexually-transmitted diseases for interested fellows. Each fellow has the option of spending one evening per month at the Washtenaw County Health Department Clinic in Ypsilanti, Michigan. In addition, our fellows have been invited to participate in the Wayne County Tuberculosis Clinic headed by Dr. James Sundstrom of nearby Oakland Hospital.