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 seven different services: 1) Pulmonary Consultation Service at University Hospital (10 weeks); 2) Critical Care Medicine Unit (Medical ICU) at University Hospital (14 weeks); 3) Lung Transplantation (2 weeks); 4) Pulmonary Procedures (6 weeks); 5) Pulmonary Physiology - including Pulmonary Rehabilitation (2 weeks); 6) Pulmonary Service at the VA Medical Center (includes consults, medical ICU, and diagnostic services) (8 weeks); 7) Night Medicine at University Hospital (6 weeks). 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 Cardiovascular Intensive Care Unit. In this 20-bed unit care is provided by two teams, each consisting of a divisional faculty member and fellow, four house officers and fourth year medical students. The attending physician leads 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.
3. Lung Transplantation (University Hospital)
The fellow will explore all aspects of lung transplantation from outpatient evaluation and management, listing, in-patient care of pre- and post- transplanted patients.
4. 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 2008.
5. Pulmonary Physiology, 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. Additionally, the fellow will spend 4 half-days in the Pulmonary Rehabilitation clinic.
6. Pulmonary Service (VA Medical Center)
The fellow evaluates patients directly or supervises house staff and/or students in all pulmonary consultations. In addition, the fellow and a divisional faculty member supervise the care of all patients in the medical intensive care unit by a dedicated medical team. 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.
7. Night Medicine (University Hospital)
This service is responsible for management of intensive care patients and pulmonary consultations (see description above) from 8:00 PM to 8:00 AM.
8. Outpatient Pulmonary Clinic (University or VA Hospitals)
First year fellows attend a general pulmonary outpatient clinic weekly, alternating between the VA and University Hospitals. 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.
The second year fellow spends half the year rotating among seven different services: 1) Critical Care Medicine Unit (Medical ICU) at University Hospital (6 weeks); 2) Procedures Unit at the University Hospital including Pulmonary Function Laboratory at University Hospital (4 weeks); 3) Pulmonary Service at the VA Medical Center (includes consults, medical ICU, and diagnostic services)(4 weeks); 4) Surgical ICU at University Hospital (4 weeks); 5) Trauma-Burn ICU at University Hospital (4 weeks); 6) Night Medicine at University Hospital (4 weeks). The other half of the year is devoted to research (22 weeks). General pulmonary outpatient clinic is held weekly at University Hospital.
Although the primary focus of the 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 general outpatient clinic experience throughout this year. Addtionally, they have a 6 month subspecialty clinic (one half day per week) split up as follows: 2 months in Pulmonary Hypertension, 2 months in Sleep, 2 months in an elective (Cancer, Allergy, etc.). Third year fellows rotate in the Cardiovascular ICU (4 weeks) and rotate in Night Medicine (2 weeks), the remaining time is spent in Research (44 weeks).
In the spring of the first year, fellows are expected to identify a research area (and faculty mentor) in which the subsequent two years will be focused. To assist first year fellows in this process, they participate in a research orientation program during the winter. 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. Early in the second year the fellow presents a research 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.
To enhance the research training experience, each fellow and mentor assembles a research advisory committee including 2-4 additional faculty members. Twice yearly, the fellow presents an update of his/her progress, and the Committee provides the fellow and mentor with advice regarding the research project as well as career development.