INTRODUCTION

The Pulmonary and Critical Care Medicine Division at The University of Michigan Health System is widely recognized for the excellence of its clinical care and for its educational and research programs pertaining to lung health and disease.

A 3-year fellowship program is designed to develop academicians, consultant-caliber clinicians, and leaders for the pharmaceutical and health care industries.

The notable strengths of the fellowship program include:
 • an unusual balance of excellence in both clinical and research training
 • 34 dynamic faculty members whose expertise spans a wide range of clinical and research arenas; many are national leaders in their fields, and many have a demonstrated track records mentoring fellows
 • two hospitals (University and VA) which provide complementary patient populations and ICU experiences
 • opportunities for research training in fields including cell and molecular biology, biochemistry, immunology, clinical physiology, clinical trials, epidemiology, health services research, and medical education
 • superb physical facilities and intellectual environment across the Medical Center and the University

THE ENVIRONMENT

The Department of Internal Medicine has a long tradition of excellence. It ranks eleventh among Departments nationally in NIH funding, its clinical and research programs continue to grow, and its house staff are excellent.

The expertise and resources of numerous other excellent units are available for intellectual cross-fertilization. These include other divisions within the Department of Internal Medicine, other departments (such as Pathology and Biological Chemistry), a Howard Hughes Medical Research Institute, the Schools of Public Health and Pharmacy, and numerous NIH-funded research centers and core laboratory facilities. Our NIH-funded Clinical Research Center has the largest operating budget of any in the United States.

The University of Michigan was the first medical school in the U.S. to have its own hospital. The current hospital complex (University Hospital, Mott Children’s Hospital, and Women’s Hospital) is a modern 865-bed, state-of-the-art facility, which has been consistently named one of the top ten hospitals in the nation.  It serves as a referral center for the State of Michigan and the entire Midwest.

The Ann Arbor VA Medical Center is located about one-half mile from University Hospital and is staffed entirely by University of Michigan faculty and house staff. It has approximately 200 beds. A brand new clinical addition was occupied in the fall of 1998.  It includes new outpatient clinics, intensive care units, and endoscopy facilities.

The University of Michigan is one of the nation’s leading universities, and has garnered more extramural research funding than any U.S. university. Besides the Medical School, it boasts outstanding undergraduate, graduate, and professional schools as well as renowned programs in music, theater, and athletics.

Ann Arbor offers a stimulating cultural environment, albeit with the conveniences of a small town. It consistently ranks among the nation’s top ten places to live. It has an excellent school system, offers diverse recreational opportunities, and is only 25 minutes from the Detroit Metropolitan Airport.

OVERVIEW OF THE PULMONARY AND CRITICAL CARE MEDICINE DIVISION

Clinical Services include inpatient, outpatient, and consultative services, diagnostic procedures (bronchoscopy, pulmonary function testing, exercise testing), respiratory therapy, and pulmonary rehabilitation. Specialized initiatives include a lung volume reduction (pneumoplasty) program, lung transplantation, a cystic fibrosis center, an asthma-airways clinic, and a dyspnea clinic. Information of use to patients and physicians is available on the Division’s World Wide Web site:

http://www.med.umich.edu/intmed/pulmonary

Research Programs in the Division are robust, as evidenced by the level and quality of publications and of funding.

Research reports have been published in prestigious journals such as Science, New England Journal of Medicine, Annals of Internal Medicine, Cell, Journal of Experimental Medicine, Journal of Biological Chemistry, Journal of Immunology, Journal of Clinical Investigation and American Journal of Physiology. Research funding totaled $10.751 million in 2002, and has more than doubled over the last five years.

The Division’s expertise and reputation have resulted in its designation by the NIH as 1) a Specialized Center of Research (SCOR) in Fibrotic Lung Disease, 2) a SCOR in Acute Lung Injury, 3) a participant in the national ARDS Clinical Research Network and 4) a Clinical Center in The National Emphysema Treatment Trial (for lung volume reduction surgery for emphysema). The Division also is the recipient of an NIH Training Grant to fund the postdoctoral training of individuals with M.D. or Ph.D. degrees in basic and clinical investigation. As a part of The Department of Veterans Affairs’ new Research Enhancement Award Program (REAP), our VA Pulmonary Section was recently named a Center of Excellence to study genetic determinants of pulmonary infection; research training fellowships are another important component of that program.

Research facilities based at the University Hospital occupy 12,322 square feet in the new Medical Science Research Building III.  Research facilities based at the VA Medical Center occupy approximately 4,500 square feet of contiguous laboratory space in a newly constructed research building.

Educational Programs
The Division plays a prominent role in the education of both medical students and house staff, and its teaching effectiveness is consistently ranked among the best of all divisions by the departmental house staff. Pulmonary and Critical Care rotations had the best aggregate rankings of any division in the 1998 Senior Resident evaluations.

Besides postdoctoral fellows, the Division participates in research training for undergraduates, as well as graduate students in various basic science departments.

In addition to the extensive conference schedules of the Department and other Departments, weekly Divisional conferences include: Clinical Conference, Research Conference, Joint Pulmonary/Thoracic Surgery Conference, Fellow’s Conference and VA Joint Pulmonary/Thoracic Conference. Approximately six nationally and internationally renowned basic and clinical pulmonary scientists visit the Division each year through the Visiting Professor Program.

The annual update on Pulmonary and Critical Care Medicine presented by the Division is one of the Medical Center’s most popular and successful continuing education programs.

PHILOSOPHY AND GOALS OF FELLOWSHIP TRAINING

We seek to prepare individuals for careers emphasizing the development of new knowledge, which will result in improvements in the prevention, diagnosis, and treatment of lung disease. To that end, the training program emphasizes the provision of a knowledge base in lung biology and disease, clinical skills and acumen, teaching skills, and investigative skills.  We view fellowship as a special phase of your training in which you have been presented with the time, expertise, resources, and facilities necessary to learn and contribute to a specialized body of knowledge. Few trainees appreciate how unique an opportunity this is until their fellowship has been completed. It is our expectation that fellows will apply themselves with enthusiasm, intellectual rigor, and creativity in order to derive the greatest benefit from this opportunity and the best possible preparation for future career endeavors. 

STRUCTURE OF THE FELLOWSHIP PROGRAM

Year 1

The first year of the fellowship is primarily a clinical year during which time 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 and Medical Procedures Unit, University Hospital; 4) 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 and throughput, 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 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 years 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 which 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:

University of Michigan Washington University Northwestern University Brown University University of Utah University of Toronto University of Iowa University of Pittsburgh

Johns Hopkins University University of Maryland University of Calgary University of Pennsylvania University of California at Los Angeles Medical College of Wisconsin University of Texas-Southwestern Emory University

UMHS is committed to mentoring minority candidates and women as an Equal Employment Opportunity/Affirmative Action Employer.