Year 1

The first year of the fellowship is primarily a clinical year during which the fellows gain experience with a wide variety of patients in inpatient (both ICU and non-ICU) and outpatient settings, develop proficiency in the performance and appropriate utilization of various procedures, and develop proficiency in the utilization and interpretation of pulmonary function and exercise testing. Throughout the year, emphasis is placed on developing: 1) an understanding of basic mechanisms and pathophysiology of respiratory disease and critical illness; 2) the ability to efficiently formulate clinical assessments and therapeutic plans; 3) the ability to critically analyze the relevant medical literature; and 4) skills in teaching medical students and house staff. 

The first year fellow spends the year rotating among five different services: 1) Pulmonary Consultation Service at University Hospital; 2) Critical Care Medicine Unit (Medical ICU) at University Hospital; 3) Pulmonary Function Laboratory at University Hospital; 4) Procedures Unit, University Hospital; 5) Pulmonary Service at the VA Medical Center (includes consults, medical ICU, and diagnostic services.) These rotations are briefly described below. 

1. Consultation Service (University Hospital)
The consult fellow evaluates patients directly or supervises students and house staff in consultations throughout the University Hospital . After initial evaluation, all patients are discussed in detail with a member of the attending staff. Concurrent care is provided as required on all patients seen by the consultation service. The consultation service is also responsible for following all inpatients with lung transplants. Approximately 50-70 new consultations are performed per month. 

2. Critical Care Medicine Unit (University Hospital)
This service is responsible for all patients under the care of the Department of Internal Medicine who require critical care and are not candidates for the Cardiac Intensive Care Unit. Eight house officers and four fourth year medical students are assigned to this 20-bed unit service, and are supervised by the fellow. A faculty member in the Division serves as the attending physician, conducting both patient care rounds and didactic teaching rounds daily with house staff and fellows. In addition to his or her clinical supervisory role, the fellow is also responsible for performing and/or supervising invasive procedures in the Unit, including bronchoscopy, endotracheal intubation, Swan-Ganz catheterization, thoracostomy placement, etc.  The fellow will gain extensive experience with a variety of ventilators and monitoring techniques during this rotation.  The fellow will actively collaborate with the nursing staff to ensure optimal and efficient patient care throughout, and will also have the opportunity to evaluate patients who might be candidates for various ongoing clinical studies.  Fellows share call responsibilities at night, providing pulmonary and critical care consultative services for acutely ill patients, and assisting house staff with the evaluations of newly admitted patients as well as those already on the CCMU service.

3a. Medical Procedures Unit, University Hospital
This state-of-the-art facility is utilized for endoscopic procedures performed by the Pulmonary and Critical Care as well as Gastroenterology divisions.  The facility includes preoperative preparation, video endoscopy and fluoroscopy facilities, and recovery room facilities.  More than 950 bronchoscopies, were performed in 2001.

3b. Pulmonary Function Laboratory, University Hospital
The fellow gains extensive experience with the indications, performance, and interpretation of clinical and physiologic studies.  These include spirometry, flow volume loops, lung volumes (by plethysmography and nitrogen washout), airways resistance, lung compliance, diffusion capacity, arterial blood gas studies, respiratory muscle function studies, measurement of bronchial reactivity, and sophisticated cardiopulmonary exercise testing. 

4. Pulmonary Service (VA Medical Center)
The fellow evaluates patients directly or supervises house staff and/or students in all pulmonary consultations.  In addition, the service supervises the care of all patients in the medical intensive care unit by the ward medical teams. This "open" ICU experience supplements the "closed unit" experience gained in the University Hospital Critical Care Medicine Unit.  During this rotation, the fellow also performs all invasive procedures at the VA Medical Center, including bronchoscopies, pleural biopsies, and thoracostomy tube placements.  Approximately 150-200 bronchoscopies are performed yearly.  During this rotation, the fellow also participates in a weekly VA outpatient pulmonary clinic.

5. Outpatient Pulmonary Clinic (University or VA Hospitals)
Beginning in the first year and continuing throughout the three-year fellowship, each trainee attends a pulmonary outpatient clinic weekly.  New patients are seen each week, and the fellow also obtains a longitudinal patient care experience by following his/her patients throughout the fellowship period.  Fellows are supervised by attending physicians in the clinic.

Years 2 and 3

Although the primary focus of the second and third year is the development of skills and experience in research (see below), senior fellows continue to participate in certain clinical activities.  First, they maintain their longitudinal outpatient clinic experience throughout these years.  Senior fellows will also actively participate in the Divisional conferences.  In addition, senior fellows rotate through the inpatient clinical services, albeit on a limited basis.  Third year fellows spend approximately three months on clinical rotations (one month each on critical care medicine unit and procedures rotation at University Hospital and one month on the VA rotation).  Second year fellows do a single month-long rotation, spending their mornings on the inpatient pulmonary service and their afternoons rotating through various clinics at University Hospital as well as satellite facilities that they ordinarily do not experience. This rotation complements the previous inpatient and outpatient experiences.

Approximately midway through the first year, fellows are expected to identify a research area (and faculty mentor) in which the subsequent two years will be focused. Together, the trainee and mentor develop a project for investigation that is of interest to the trainee and within the expertise of the faculty member; in certain instances, joint mentorship provided by two faculty members within the Division, or by one divisional faculty member and a collaborator from another unit, is appropriate. Toward the end of the first year, the fellow presents a conference in which he/she synthesizes existing knowledge, presents the problem for investigation, and describes the proposed plan of investigation.  The faculty members and fellows in attendance provide feedback to the fellow and mentor about the proposed project; this process of peer review provides a useful experience for the fellow and often strengthens the experimental approach. 

During the second and third years, the trainee carries out the proposed work in the laboratory or clinical research facilities of the faculty mentor(s).  The trainee also benefits from interactions with other trainees, technicians, and collaborating investigators.  The trainee also participates in laboratory meetings and journal clubs specific to individual laboratories or research groups.  Presenting research findings at regional and national meetings and submitting work for publication are both important aspects of the investigative endeavor.  The trainee will receive guidance and specific assistance in learning to prepare data for oral and written presentation, to prepare graphics, and to organize talks and prepare slides.  Throughout the two-year research training period, it is anticipated that the fellow will assume increasing intellectual responsibility and technical independence.  Trainees may also have the opportunity to prepare grant applications to fund advanced research training.  Experience preparing protocols for animal studies and human studies institutional review board approval will also be gained. 

Research Training Pathways

Selection of a research project and mentor is subject to the approval of the director of the fellowship program and the division chief. Fellows may elect either laboratory-based or clinically-based research training pathways. Fellows electing a clinically-based research training pathway will be advised to seek either informal input or formal instruction in research design and statistical analysis from one or more of a number of programs and resources available on the medical campus. These include CHOICES (Consortium for Health Outcomes Innovation and Cost Effectiveness Studies), the Robert Wood Johnson Clinical Scholars Program, and the statistical consulting service of the School of Public Health . In certain instances, fellows may have the opportunity to pursue a Masters Degree in Public Health if it is appropriate for their research career goals. For all research fellows, a research advisory committee will be selected by the fellow and mentor. This committee will monitor the progress of research fellows and provide advice regarding research training and career development.

Advanced Research Training

After completing the traditional three-year fellowship program, selected trainees have the opportunity to further advance their training in either basic or clinical research. Such advanced training is invariably necessary for individuals with serious designs on an academic research-oriented career. Two additional years of research training can often be funded by the division's NIH training grant, or by a variety of alternative mechanisms.

Track Record in Preparing Graduates for Academic Careers

Over the last 15 years, approximately two-thirds of our graduates have been appointed to academic positions. Of these individuals, >80% have received some type of research funding and >60% have received peer-reviewed, federal funding (NIH, VA, Medical Research Council of Canada), indicating their active and respected role as investigators. Over the last 20 years, our graduates have been appointed to faculty positions at academic institutions including:

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