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TABLE OF CONTENTS

PREFACE ...............................................................................................................................................................1

INTRODUCTION.....................................................................................................................................................2

INTERDEPARTMENTAL RELATIONSHIPS.........................................................................................................3

SUPERVISION........................................................................................................................................................4

GRADED RESPONSIBILITY AND MANAGEMENT SKILLS ..............................................................................5

TRAINING PROGRAM ROTATION SCHEDULE .................................................................................................6

NIGHT CALL SCHEDULE .....................................................................................................................................7

VACATION..............................................................................................................................................................8

VACATION REQUEST FORM ...............................................................................................................................8

WEEKLY SCHEDULE ON THE PULMONARY INPATIENT CONSULTATION SERVICE ................................9

MICU DAILY SCHEDULE ....................................................................................................................................10

PROCEDURE TRAINING AND DOCUMENTATION IN PULMONARY AND CRITICAL CARE MEDICINE...11

INVASIVE PROCEDURE LOG ............................................................................................................................12

BRONCHOSCOPY PROCEDURE LOG .............................................................................................................13

TRAINING PROGRAM EVALUATION PROCESS.............................................................................................14

PULMONARY & CRITICAL CARE FELLOWSHIP FORMS REGISTER...........................................................15

FORM FOR EVALUATION OF CLINICAL COMPETENCE (FORM 1)..............................................................16

FORM FOR EVALUATION OF CLINICAL COMPETENCE (FORM 2)..............................................................19

COMMUNICATION, INTERPERSONAL SKILLS, AND PROFESSIONALISM EVALUATION........................21

FELLOW PROCEDURAL SKILL ASSESSMENT FORM BRONCHOSCOPY .................................................22

COMMUNICATION, INTERPERSONAL SKILLS, AND PROFESSIONALISM EVALUATION FORM(PATIENT FORM).................................................................................................................................................24

FORM FOR EVALUATION OF FACULTY ..........................................................................................................25

FELLOW ROTATION EVALUATION ..................................................................................................................26

SUBSPECIALTY CONSULTATION EVALUATION EXERCISE........................................................................28

EVALUATION OF RESEARCH PROGRESS .....................................................................................................30

EDUCATIONAL PROGRAMS .............................................................................................................................31

OUTPATIENT EDUCATION ......................................................................................................................................32Pulmonary Ambulatory Center......................................................................................................................32Northwestern Medical Center Outpatient Clinic ...........................................................................................33Pulmonary Rehabilitation Program...............................................................................................................34Cystic Fibrosis Clinic .....................................................................................................................................35Allergy and Immunology Clinic .....................................................................................................................36Sleep Disorders Clinic...................................................................................................................................37Pulmonary Physiology and Pulmonary Function Testing.............................................................................38

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INPATIENT EDUCATION..........................................................................................................................................39Pulmonary Medicine Consultation Service...................................................................................................39Medical Intensive Care Unit ..........................................................................................................................40Surgical Intensive Care Unit .........................................................................................................................42Anesthesia ....................................................................................................................................................43Infectious Disease Rotation ..........................................................................................................................44Pulmonary medicine fellowship elective in thoracic radiology .....................................................................46

TEACHING CONFERENCES: PULMONARY ANDCRITICAL CARE MEDICINE -................................................................48Summary of Conferences: ............................................................................................................................48Critical Care Medicine and Inpatient Pulmonary Case Conference (2nd & 3rd Thursday) ............................49Outpatient Pulmonary Case Conference (4th Thursday)..............................................................................50Pulmonary Pathology with Radiographic Correlation (1st Thursday) ...........................................................51Pulmonary and Critical Care Teaching Conferences (Fridays Noon)..........................................................52Critical Care Topics:......................................................................................................................................52Pulmonary Topics .........................................................................................................................................53Multidisciplinary Chest Tumor Conference (Thursday 7:45 AM) .................................................................55Pulmonary and Critical Care Journal Club(4th Friday)..................................................................................56Department of Medicine Subspecialty (Fellowship) Training Programs ......................................................57Fellows Lecture Series..................................................................................................................................58

FELLOW QUALITY ASSESSMENT AND IMPROVEMENT PROGRAM .......................................................59RESEARCH ..........................................................................................................................................................60

Training Program In Pulmonary Disease & Critical Care Medicine .............................................................60DIDACTIC TEACHING & CONFERENCES ..................................................................................................................61

Vermont Lung Center Research in Progress Seminar.................................................................................61Department of Medicine Training Seminar Series .......................................................................................62Seminars in Investigative Medicine ..............................................................................................................62

CLINICAL CURRICULUM AND EDUCATIONAL PROCESS............................................................................64

GOAL ONE........................................................................................................................................................64OBJECTIVE 1: (PULMONARY MEDICINE KNOWLEDGE AREAS) ..................................................................................64OBJECTIVE 2: (CRITICAL CARE MEDICINE KNOWLEDGE AREAS) ...............................................................................68GOAL TWO:......................................................................................................................................................69GOAL THREE: ..................................................................................................................................................72GOAL FOUR: ....................................................................................................................................................74GOAL FIVE:.......................................................................................................................................................74GOAL SIX:.........................................................................................................................................................75GOAL SEVEN: ..................................................................................................................................................75

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PrefaceThe Pulmonary and Critical Care Medicine division is proud to welcome you into our fellowship trainingprogram. The University of Vermont has a long tradition of training outstanding academic and clinicalpulmonary physicians and intensivists. Our alumni are spread throughout the country in academia, privatepractice, and industry.

Today marks the real beginning of your career. You can anticipate that your training will be exciting, mentallystimulating, intriguing and sometimes frustrating. We hope that you will find it to be as personally andprofessionally rewarding as we have. Stretch your mind and body with us, and you will be well served for yourfuture. The faculty is committed to your education and to you as an individual. My position on this faculty is atestimony to our fellowship program and my personal commitment to your training. Your success is ourgreatest pride. Many exciting things are already happening – welcome aboard!

Polly E. Parsons, M.DProfessor of Medicine

Director, Pulmonary and Critical Care Medicine UnitFellowship Program Director

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Introduction Enclosed in this notebook you will find the outline of your 3-year curriculum and general guidelines for yourentire fellowship program. Details of the educational program are located in Section Four. This book shouldserve as a reference point and as a place to keep your personal documentation.

While pulmonary and critical care medicine are uniquely intertwined, the curriculum varies enough to warranttwo separate educational tracks. It is expected that each fellow attend all conferences that are listed on themonthly-published calendar. Twice yearly individual evaluations of fellow performance will be conducted by theprogram director. You will also be expected to evaluate the faculty and the training program. Over the three-year period of training, fellows will be expected to have increasing responsibility for patient care andinvolvement in administrative tasks.

Pulmonary/Critical Care Fellows are expected to exhibit the highest level of professionalism at all times.

Research is a core component to the training program. Each fellow must identify a research mentor early in theprogram and develop a substantive research project. A careful evaluation process will also guide the researchaspect of the program.

Please review the entire contents of this notebook and refer to it as needed throughout your training.

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Interdepartmental Relationships1. Relationship with Department of Medicine

The director of the Pulmonary and Critical Care Medicine Unit, Dr. Polly Parsons, reports to the physicianLeader of the Medicine Health Care Service/Chairman of the department of Medicine, Burton E. Sobel, MD andserves at his direction. The status of clinical services, research programs, faculty development includingpromotion and educational activities are reviewed on a regular basis.

The level of performance of the trainees in Pulmonary and critical Care Medicine is reported to the Chair of theDepartment of Medicine on an annual basis. He is required to sign all forms indicating satisfactoryperformance, completion of training, and eligibility for subspecialty certification. All offers of appointment fornew trainees are issued jointly by the Chair of Medicine as well the Pulmonary and Critical Care Medicineprogram director. The Chair of Medicine is directly involved in faculty performance evaluations, advancementand assignment of responsibilities. Trainees in Pulmonary and Critical Care Medicine participate in developingwritten evaluations of medical residents and students who have served with them on the Pulmonaryconsultation and MICU services.

2. Relationship with Internal Medicine Training Program

The Director of the Internal Medicine Residency Program, Mark A. Levine, MD is directly involved in planningPulmonary and Critical Care Medicine training activities, preparing for periodic review and recertification of thetraining program, and developing a coordinated educational program with residents in Internal Medicine. TheDirector of the Pulmonary and Critical Care Medicine Unit and fellowship training program, Dr. Polly Parsons,works closely with Dr. Levine to coordinate teaching and learning opportunities for trainees, includingorganizing core curriculum lectures for the Internal Medicine residents provided by the Pulmonary and CriticalCare Medicine faculty and trainees and key didactic lectures on Pulmonary and Critical Care Medicine topics.An example of the success of this close working relationship between the two program directors is the revisedMICU rotation which includes a defined rounding schedule, scheduled didactic lectures, and a weeklyconference with representatives from Ethics, Psychiatry, social work and nursing focused on Psycho-socialissues in the ICU.

The Director of the Pulmonary and Critical Care Medicine training program also establishes guidelines fortrainees when they are in supervisory roles, such as supervising residents in technical procedures in the ICU.

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Supervision

I. Inpatient Services:

On both of the inpatient services (MICU and Pulmonary Consult), an attending physician rounds with the trainees seven daysa week and is available on call 24 hours a day, 7 days a week to supervise the trainees. The trainees notify the attending ofall admissions and consults. Each patient seen by a trainee is seen by the PCCM attending. This oversight includes thepresentation of the patient by the trainee including past medical records, history, physical and laboratory data, and review ofall pertinent radiographs. The data is then corroborated at the bedside with the trainee including key historical and physicalexam items. The differential diagnosis and approach to diagnostic testing and treatment are reviewed. All active patients arereviewed in detail regarding clinical course, new problems, results of diagnostic testing, and response to therapy on dailyfollow-up rounds.

II. Clinic

An Attending physician from the faculty who has no other responsibilities during that clinic staffs each fellows’ clinic. To allowthe trainees to be supervised by a number of attendings to maximize their learning experience while balancing the patientsneed for continuity of care, two attendings are assigned to each of the fellows’ clinics and those two attendings alternateweeks. Fellow trainees attend their clinic independent of their other service activities. Faculty do not attend the clinic whenthey are assigned to the MICU to allow them to cover the ICU when the fellow is absent to attend clinic and to ensure thattheir attention is not diverted away from the clinic.

III. Conference organization is supervised by a sub committee of the Education Committee. Drs. Kaminsky, Dixonand Weiss, are currently the responsible faculty members. The fellows are responsible for preparing and presentingat the following conferences:

1. Clinical case conferences: These are held weekly and are attended by the entire division, as well as, residents andmedical students on the MICU and consult rotations. The conference consists of presentations of two to three cases bythe fellows with discussion from the fellows and the faculty. The cases presented included ICU cases, cases from thepulmonary consult service, and cases from the ambulatory clinic. The cases chosen for presentation either havesignificant educational value or they present diagnostic or therapeutic challenges. Pertinent radiographs are reviewedwith each case. Once a month this conference is a Radiology-Pathology correlates session. Again the cases arepresented by the Pulmonary and Critical Care Medicine residents but the radiographs are presented and discussed bythe Radiology attending staff and the relevant pathologic specimens are reviewed by the Pathology Attending staff. Theorganization of these conferences is the joint responsibility of the two first year fellows. The are assisted by theattendings responsible for the Pulmonary Consult service and the MICU service at the time of the conferences.

2. Journal Club: This conference is held once a month. The trainee chooses the articles (usually two) to be presented,reviews them with an assigned faculty member, and then presents the articles with a prepared discussion. Theorganization of this conference is the responsibility of the third year fellows under the direction of Dr. David Kaminsky.

3. VLC Research Conferences: This is the research-in-progress conference for the division which is held weekly under the direction of Dr. Charles Irvin. Each fellow is expected to present his/her research once a year during the second and third year of training.4. MICU didactics: During the MICU rotation didactic presentations are scheduled for the residents and medical students twice a week. The Attending physician is responsible for the organization of these conferences but the Pulmonary and Critical Care trainees participate by developing and presenting some of the topics. When the fellows rotate in the MICU during their third year, they serve as junior attendings and take an even more active role in this conference.

5. Northern New England Fellows Conference and the New Hampshire/Vermont American Lung Association Conference: These conferences are currently both directed by Dr. David Kaminsky. The fellows’ conference is attended by fellows and faculty from Maine Medical Center, Dartmouth Medical Center, UVM, and Albany Medical Center. Fellows from each of the institutions present cases and radiographs with formal didactic discussions and selected fellows present their research. Similar presentations are made by our trainees at the ALA conference.6. National Meetings: Fellows are encouraged to submit abstracts for presentation at national meetings. Individual research mentors are responsible for supervising this activity.

IV. Mentors:

Each fellow is assigned a faculty member from the Pulmonary and Critical Care Medicine Unit to be their mentor at thebeginning of the first year of fellowship. These mentors are responsible, in conjunction with all the faculty, for the well-beingof their assigned fellow. In addition, the fellow will choose a research mentor at the beginning of the second year offellowship. These mentors are responsible for guiding the research careers of their fellows.

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Graded Responsibility and Management Skills An important part of the training program is the development of skills that will be important in the practice ofmedicine after fellowship. These include developing professional relations with colleagues and staff, refiningteaching and presentation skills, fostering independent decision making, and understanding administrativeaspects of Pulmonary and Critical Care Medicine. To develop those skills, graded levels of responsibility havebeen designed into the curriculum. In general, they encompass the following areas:

Teaching: Fellows will develop skills in teaching. In the first year of training, this will include active participation in teachingrounds and didactic lectures. In the second year, fellows will be expected to give one major teachingconference to attendings and housestaff. In the third year, fellows will be expected to assist in the teachingcurriculum for first and second year fellows including organizing lectures and conferences.

Patient Care: Fellows will develop practice skills and independent decision making in two areas of patient care

Procedures – Trainees will assume graded levels of responsibility in performing invasive procedures based onfaculty evaluations. Fellows will observe the proper technique for a specific procedure. Fellows will thenperform the procedure under direct supervision. Based on faculty approval, Fellows will be permitted to instructand supervise other trainees under the direct supervision of a faculty member.

Medical Intensive Care Unit (MICU) Service – Fellows will serve as “acting attending” for the MICU servicein their third year of training under the supervision of an attending physician.

Management: Fellows will participate in the MICU QA process as outlined in the critical care curriculum. Additionalopportunities to gain knowledge in managerial aspects of Pulmonary and Critical Care Medicine can beprovided and may include participation on other hospital QA committees, the nutrition services committee, andthe hospital pharmacy committee. Fellows may also participate in the management of aspects of thepulmonary division including bronchoscopy services, outpatient services, and sleep clinic.

Research: Research is a major portion of the curriculum and the specific guidelines for graded responsibility are outlinedbeginning on page 59.

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Training Program Rotation ScheduleJUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN

3rd Yr FellowsFellow A MICU* MICU SICU* MICU

Fellow B MICU* MICU SICU MICU*

2nd Yr FellowsFellow A MICU Consult MICU SICU

Fellow B MICU Consult MICU SICU

1st Yr FellowsFellow A MICU Consult MICU PFT Anesthesia Consult MICU Consult Sleep Consult MICU Consult

Fellow B Consult MICU Consult Anesthesia PFT MICU Consult Sleep Consult MICU Consult MICU

Breakdown:

Pulmonary: Pulmonary & Critical Care: Critical Care:

Consults - 6 MICU - 4 MICU - 5PFT - 1 SICU - 2Sleep - 1 Anesthesia - 1

Administrative Tasks3rd Year Fellows: Call Schedules/Conference and Journal Club Schedules

2nd Year Fellows: Quality Assurance Projects

1st Year Fellows: Collation of Rad-Path Conferences/Thursday Pulmonary Conferences/MICU M&M

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Night Call SchedulePulmonary and Critical Care Fellows are expected to take night call as part of the training program. When afellow is “On call”, a faculty member is always assigned to the trainee as well. Night call for the Pulmonary andCritical Care division involves the coverage of the Inpatient and Outpatient Pulmonary Medicine services andthe Medical Intensive Care Unit. Fellows will be expected to see and evaluate all patients admitted to eitherservice and present the patient to the attending physician on call. Fellows are expected to have developed adifferential diagnosis and treatment plan prior to case presentation. In the second and third year of training,fellows will be given more autonomy in decision making but still are expected to inform the attending physicianon call of any admissions or significant changes in a patient’s status. Specific admitting guidelines for eachservice are contained under the goals and objectives for MICU and Inpatient Pulmonary rotations.

Approximate call expectations will be:

Year 1 – 1 night in 4 with 1 weekend per month.

Year 2 – 1 night in 5 with 1 weekend per month.

Year 3 – 1 night in 8 with 1 weekend per month. Call will be 1 night in 4 when rotating as an acting attending.

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VacationEach fellow is allotted vacation per FAHC contract guidelines. Vacation policy as it pertains to the PulmonaryDisease/Critical Care Medicine training program is outlined below:

� Requests for vacation must be submitted, in writing, using the detachable form below. All requests mustbe approved by the program director.

� Requests for vacation must be submitted one month in advance.

� Vacation may be taken during elective time and research time only.

� Vacation time should not exceed two consecutive weeks unless approved by the program director.

� Vacation may be permitted on inpatient service rotation months by special permission when there are twofellows on a rotation.

� Arrangements for adjustment of clinic schedules, procedures, and conferences are the responsibility of theFellow taking vacation. Outpatient continuity clinics may be cancelled if vacation is scheduled more than 2months in advance. Otherwise, it is the responsibility of the fellow to reschedule patients with an availableattending.

………………………………………………………………………………………………

VACATION REQUEST FORM

NAME………………………………………………………… DATE…….……….……

DATES REQUESTED ..……………..……………………………………………………

ROTATION……………………………………………………………………………….

ROTATION ATTENDING ……………………………………………………………….

APPROVED BY …………………………………………………………………………..

Revised 6/30/01

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Weekly Schedule on the Pulmonary Inpatient Consultation ServiceTime Sat Sun Mon Tues Wed Thurs Fri

7:45 AMChest TumorConference

8:00 AM Grand Rounds

9:00 AM

10:00 AM

11:00 AM

Rounds* Rounds* Rounds* Rounds* Rounds* Rounds* Rounds*

12:00 PM Conferences Journal Club orDidactic

1:00 PM

2:00 PM

3:00 PM

4:00 PM

5:00 PM

2nd YearFellowsClinic

1st YearFellowsClinic 3rd Year

FellowsClinic

*Additional Rounds as needed each afternoon

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MICU Daily SchedulePROCESS MON TUE WED THUR FRI SAT SUN

7:15 – 7:30 AM 7:30 – 7:45 7:30 – 7:45

Morning Sign-In X X X X X X X7:30 AM 7:45 7:45

Identify ICU to ward transfers X X X X X X X7:30 - 9 AM 7:45 - 9 7:45 - 9

Pre Rounds X X X X X X X9 – 11:30 AM

Attending Rounds X X X X X X X11:30 AM – 12 PM

ICU Didactic X X12 – 1 PM

Pulmonary and Critical CareConference X X1 2 PM

Psychosocial Rounds X1:30 – 2 PM

Multi-disciplinary Rounds X4 – 4:30 PM

Afternoon Sign-Out X X X X X

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Procedure Training and Documentation In Pulmonaryand Critical Care Medicine

The Accreditation Council for Graduate Medical Education (ACGME) requires that trainees develop acomprehensive understanding of the technical procedures integral to your training. This includes cognitive aswell as technical competence as determined by the faculty. Documentation of your experience in proceduraltraining and competence is required. The following guidelines outlined below have been established to achievethose goals.

Procedural Training

Instructions in specific procedures pertinent to the discipline of Pulmonary and Critical Care medicine areoutlined in the curriculum for each specific training experience. Trainees should understand the indications,contraindications, limitations, complications, techniques, and interpretation of results for each of thoseprocedures.

Documentation of Procedure Experience

Documentation of procedure performance is required for all procedures and is the responsibility of the trainee.The training program provides a procedure documentation form. These should be kept in a personal logbook.The logbook should be photocopied periodically and the copies submitted to the training program director.

Technical Evaluation

After completing a procedure, attestation of technical competence should be obtained from the supervisingattending physician. This is accomplished by his/her signature endorsement of your logbook.

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Invasive Procedure Log

Date

Patient Name MRN PS

CentralLine

ArterialLine

ChestTube

Thorac-entesis

PleuralBiopsy

Other Supervising Attending

P=performed S=supervised

Fellow (Print name, sign, and date)

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Bronchoscopy Procedure Log# Date Patient Name MRN Bronch:

DiagnosticBronch:BAL

Bronch:TBBx

Bronch:Needle Bx

Bronch:Other

Supervising Attending

Check all that apply for each bronchoscopy Attending Comments (optional)

# Evaluation of performance

Fellow (Print name, sign, and date)

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Training Program Evaluation ProcessFormal evaluation and feedback are essential to insure that both fellows and faculty are meeting the expectedtraining requirements. It also provides an opportunity to identify specific areas of concern to fellows and staff.Finally, it gives the trainee feedback as to areas that may need change or improvement. Below outlines theprocess of evaluation and feedback for the Pulmonary and Critical Care Medicine training program.

� Trainees will be evaluated each month they are on a clinical service by the attending physician. Theseevaluations will be based on clinical performance, including inpatient and outpatient clinical care,conference presentations, and journal club presentations. This will be a written evaluation (see enclosed“Form for Evaluation of Clinical Competence“) by individual faculty members. These evaluations will kepton file in the department as part of your permanent record.

� Trainees will meet semi-annually with the program director to review the evaluations. Fellows will be givena written composite of the faculty reviews that will be kept on file as part of the permanent record.

� Trainees will evaluate the attending staff for each month of clinical service. The trainees will use writtenforms provided by the training program for their evaluation (see enclosed “Form for Evaluation of Faculty“).The program director will review these evaluations with the faculty on a semi-annual basis.

� Trainees will evaluate each monthly rotation using the “Rotation Evaluation Form." This will be used toevaluate each rotation as to it meeting the written goals and objectives. These will be reviewed semi-annually by the faculty.

� The Department of Medicine conducts a departmental review, which allows trainees to bring concerns toan independent group for review. Trainees will meet with William Hopkins, M.D. (or his designee) at leastonce yearly to critique the Pulmonary and Critical Care training program. This critique will be reviewed withthe fellowship program director.

� Trainees will undergo specific evaluation exercises in Pulmonary history and physical examination skills(see enclosed “Subspecialty Consultation Evaluation Exercise”) at the end of the first year of training.Written evaluation of critical care skills will occur at the end of the second year of training. These will beincluded in the evaluation records of each trainee.

� Trainees will undergo a specific evaluation of research project progress by their faculty mentor. (seeenclosed “Evaluation of Research Progress”). The program director will review these evaluations with thetrainees on a semi- annual basis. The program director will review these evaluations with the faculty on asemi-annual basis

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Pulmonary & Critical Care Fellowship Forms Register(YEAR APPLICABLE)

Form Name Assigned to When

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

Evaluation of Research Progress for PulmonaryDisease & Critical Care Medicine Trainees Faculty February & June

Research Performance Evaluation Form Faculty End of Fellowship

Evaluation of Clinical Competence Faculty End of Month (except Clinic)

Evaluation of Clinical Competence Faculty February (Clinic Rotation)

Form for Evaluation of Pulmonary Faculty Fellow End of Month (except Research & Clinic)

Form for Evaluation of Pulmonary Faculty Fellow February (Clinic)

Form for Evaluation of Pulmonary Faculty Fellow February & June (Research)

Subspecialty Consultation Evaluation Exercise Faculty End of 1st Year (June)

Fellow Rotation Evaluation Fellow End of Month (except Clinic & Research)

Fellow Rotation Evaluation Fellow February (Clinic Rotation)

Fellow Rotation Evaluation Fellow February & June (Research)

Bronchoscopy Evaluation Faculty After Each Procedure

Patient Satisfaction Surveys Clinic February (Clinic)

360o Evaluations Clinic February (Clinic)

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Form For Evaluation of Clinical Competence (form 1)Pulmonary Disease & Critical Care Medicine

Please return this form to Polly E. Parsons, MD, Director, Fellowship Training Program for Pulmonary & Critical Care (Patrick 311)

Fellow: «Fellow» Rotation: «Rotation»

Attending: «Attending» Rotation Period: «Month» Evaluation Date: __________________

Unsatisfactory Satisfactory Superior

1. Patient CareIncomplete, inaccurate medical interviews, physicalExaminations, and review of other data; incompetentPerformance of essential procedures; fails to analyzeClinical data and consider patient preferences whenMaking medical decisions

� Insufficient contact to judge

1 2 3 4 5 6 7 8 9 Superb, accurate, comprehensive, medicalinterviews physical examinations, review of otherdata, and procedural skills; always makesdiagnostic and therapeutic decisions based onavailable evidence, sound judgment, and patientpreferences

2. Medical KnowledgeLimited knowledge of basic and clinical sciences;Minimal interest in learning; does not understandComplex relations, mechanisms of disease


1 2 3 4 5 6 7 8 9 Exceptional knowledge of basic and clinicalsciences, highly resourceful development ofknowledge; comprehensive understanding ofcomplex relationships, mechanisms of disease

3. Practice-Based LearningImprovement

Fails to perform self-evaluation; lacks insight,Initiative; resists or ignores feedback; fails to useInformation technology to enhance patient care orPursue self-improvement


1 2 3 4 5 6 7 8 9 Constantly evaluates own performance,incorporates feedback into improvement activities;effectively uses technology to manage informationfor patient care and self-improvement

4. Interpersonal and CommunicationSkills

Does not establish even minimally effectiveTherapeutic relationships with patients and families;Does not demonstrate ability to build relationshipsThrough listening, narrative or nonverbal skills; doesNot provide education or counseling to patients,Families, or colleagues


1 2 3 4 5 6 7 8 9 Establishes a highly effective therapeuticrelationship with patients and families;demonstrates excellent relationship buildingthrough listening, narrative and nonverbal skills;excellent education and counseling of patients,families, and colleagues; always “interpersonally”engaged

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EVALUATION OF CLINICAL COMPETENCE Fellow: «Fellow» Evaluator: «Attending»

Unsatisfactory Satisfactory Superior

5. ProfessionalismLacks respect, compassion, integrity, honest;Disregards need for self-assessment; fails toAcknowledge errors; does not consider needs ofPatients, families, colleagues; does not displayResponsible behavior


1 2 3 4 5 6 7 8 9 Always demonstrates respect, compassion,integrity, honesty; teaches/role models responsiblebehavior; total commitment to self-assessment;willingly acknowledges errors; always considersneeds of patients, families, colleagues

6. System-Based LearningUnable to access/mobilize outside resources;actively Resists efforts to improve systems of care;does not use Systematic approaches to reduceerror and improve Patient care


1 2 3 4 5 6 7 8 9 Effectively accesses/utilizes outside resources;effectively uses systematic approaches to reduceerrors and improve patient care; enthusiasticallyassists in developing systems’ improvement

Resident’s Overall ClinicalCompetence on Rotation

1 2 3 4 5 6 7 8 9

Attending’s Comments

__________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________

Signatures: Fellow’s_________________________________________Attending’s___________________________________________

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Form for Evaluation of Clinical Competence (form 2)Pulmonary Disease & Critical Care Medicine

Please return this form to Polly E. Parsons, MD, Director, Fellowship Training Program for Pulmonary & Critical Care (Patrick 311)

Fellow: «fellow» Rotation:«Rotation» Evaluator: «Attending» Date: «Month»

It is expected that all evaluations be discussed with the fellow. Was this done? _______ Yes ______ No

Unsatisfactory --Satisfactory – Superior1. Patient CareClinical Skills� Incomplete, inaccurate medical interviews� Incomplete, inaccurate physical examinations� Poor procedural skills� Incomplete review and summary of other data sources (FAHC and outside records)Patient Management Skills� Poor synthesis of clinical data� Poor clinical judgement� Ignores valid evidence� Ignores patient preference

� Insufficient exposure to evaluate

1 2 3 4 5 6 7 8 9

Specific comments recognizing excellent performance orareas for improvement________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Clinical SkillsComplete, accurate medical interviewsComplete, accurate physical examinationsExcellent procedural skillsExcellent review and summary of other data sources (FAHC and outside records)Patient Management SkillsExcellent synthesis of clinical dataExcellent clinical judgementMakes excellent use of valid evidenceAlways considers patient preference

2. Medical Knowledge

� Limited basic science/clinical fund of knowledge� Minimal interest in learning� Cannot explain mechanisms of disease


1 2 3 4 5 6 7 8 9

Specific comments recognizing excellentperformance or areas for improvement________________________________________________________________________________________________________________________________________________________________________________________

Exceptional basic science/clinical fund of knowledgeExceptional interest in learningConsistently able to explain mechanisms of disease

3. Practice-Based Learning

� Fails to perform self-evaluation� Lacks insight� Lacks initiative� Fails to use information sources


1 2 3 4 5 6 7 8 9

Specific comments recognizing excellent performance orareas for improvement____________________________________________________________________________________________________________________________________________________________________________________________________________

Constantly evaluates own performanceExcellent insightExcellent initiativeExcellent use of information sources

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EVALUATION OF CLINICAL COMPETENCE Fellow: «Fellow» Evaluator: «Attending»

4. Communication and Interpersonal Skills Unsatisfactory—Satisfactory—Superior

� Does not use listening skills that facilitate the collection ofaccurate information

� Poor written documentation of patient care (disorganized, incomplete, inaccurate notes)� Poor oral presentations (disorganized, incomplete, inaccurate)

� Poorly written hospital summaries (unclear, inaccurate,inappropriate length)


1 2 3 4 5 6 7 8 9

Specific comments recognizing excellent performanceor areas for improvement________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Consistently uses excellent listening skills

Excellent written documentation of patient care (organized, complete, accurate notes)Excellent oral presentations (organized, complete, Accurate)Excellent written hospital summaries (concise, accurate, appropriate length)

5. Professionalism

� Does not demonstrate empathy and compassion� There are concerns about honesty and integrity� Fails to accept responsibility appropriate for level of ability

� Poor motivation for self-improvement� Poor teamwork with teammates, including nursing and Allied Health staff


1 2 3 4 5 6 7 8 9

Specific comments recognizing excellent performanceor areas for improvement________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Consistently empathetic and compassionateAlways honest; always behaves with integrityAlways accepts responsibility appropriate for level of AbilityHighly motivated for self-improvementConsistently supports teammates, including nursing and Allied health staff

6. Systems-Based Practice

� Does not use information resources (electronic resources, Practice guidelines) independently� Resists efforts to improve systems of care� Poor understanding and application of principles of Evidence-based medicine


1 2 3 4 5 6 7 8 9

Specific comments recognizing excellent performanceor areas for improvement_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Consistently and independently uses information resourcesHigh level of interest in improving systems of careExcellent understanding and application of principles Of evidence-based medicine

Any additional comments regarding this resident’s performance

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________________________

Fellow’s Signature: _________________ Attending’s Signature: ___________________________________

COMMUNICATION, IPROFESSIO

Physician: ______________________________ Date: __

Physicians in the Pulmonary and Critical Care Medicineinterpersonal, and professionalism skills that promote caattributes, you are being asked to complete this evaluatiothe form by checking “needs improvement” or “satisfactoryplease leave it blank. All “needs improvement” responsconfidential.

Communication/Interpersonal skillsConsistently demonstrates willingness to listen to paConsistently demonstrates willingness to listen to nursing Consistently explains information to patients and families utermsConsistently keeps patients, families, nursing, and allied din the care planTypically cooperative if approached by nursing and allied sProfessionalism Altruism/EmpathyAccepts inconvenience when necessary to meet the need RespectConsistently respects patient privacy when conducting exaConsistently uses respectful language when discussing pahealth staffConsistently courteous and receptive to nursing and allied ResponsibilityConsistently responds in timely manner when paged or caUsually manages correspondences in a timely mannerConsistently careful when handling patient’s medical mat IntegrityMaintains punctualityMaintains composure during stressful situations

Please provide specific comments to substantiate an__________________________________________________________________________________________________________________________________________

Do you have any additional concerns regarding this physicskills?__________________________________________________________________________________________________________________________________________

Please provide information if this physician has consistent__________________________________________________________________________________________________________________________________________

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NTERPERSONAL SKILLS, ANDNALISM EVALUATION

_________________ Evaluator: __________________________________

Program at Fletcher Allen are expected to demonstrate the communication,re delivered in the “best interest of the patient.” In an effort to assess these

n based on your interactions with the above-named physician. Please complete” in the space provided after each statement. If you cannot comment on an item,es require explanation in the space provided below. Your answers will remain

NeedsImprovement

Satisfactory NotApplicable

tients and familiesand allied staffsing clear, understandable

esk staff informed of changes

taff with questions

s of the patient

minationstients with nursing and allied

health staff

lled

erials

y “needs improvement” response___________________________________________________________________________________________________________________________________________________________________________________________________________________

ian’s communication, interpersonal, or professionalism

_______________________________________________________________________________________________________________________________________________________________________________________

ly performed in an outstanding manner_______________________________________________________________________________________________________________________________________________________________________________________

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FELLOW PROCEDURAL SKILL ASSESSMENT FORMBRONCHOSCOPY

Fellow___________________________________ Attending__________________________________Date___/___/___ Pt. Initials_______________

1) Pre-Procedure Assessment � Not ApplicableUnderstands indication and objectives for bronchoscopy, obtains history & physical exam. Recognizes allergies,risks,coagulopathies,etc. Proper informed consent.

� Inadequate (0) � Incomplete (1) � Satisfactory (2) � Excellent (3) Total________

2)Sedation � Not ApplicableAware of comorbid conditions affecting sedation. Sedates with incremental doses to desired level of patient comfort.Monitors patient for discomfort and stability, appropropriately reacts to changes in vital signs.


3) Bronchoscope Manipulation � Not Applicable Under direct visualization smoothly manipulates the scope to visualize the vocal cords, trachea, main carina, all segmentsand major subsegments. � Inadequate (0) � Incomplete (1) � Satisfactory (2) � Excellent (3) Total________

4) Endoscopic Efficiency � Not Applicable Performs full exam in time efficient manner .

� Inadequate (0) � Incomplete (1) � Satisfactory (2) � Excellent (3) Total________ 5) Therapy � Not Applicable� endobroncial biopsy � removal of foreign body � needle aspiration �

transbroncial biopsy� bronchoalveolar lavage � use of fluoroscopy � Other

Has understanding of clinical situation and shows good judgement. Understands and uses the accessories necessary toproperly perform diagnostic and/or therapeutic maneuvers.


6) Interpretation of Findings � Not ApplicableRecognizes and correctly identifies abnormalities. Normal exam is recognized as normal.


7) Recovery Properly recovers patient from conscious sedation and follows up on post-procedure clinical status and chest x-ray (if

applicable).


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FELLOW PROCEDURAL SKILL ASSESSMENT FORM (cont’d)BRONCHOSCOPY

Fellow___________________________________ Attending__________________________________Date___/___/___ Pt. Initials_______________

8) Final Assessment and Plan � Not ApplicableAssimilates all data and develops an appropriate plan of management and follow up


FinalScore______/_______=________%

Comments:

Fellow Signature: __________________________ Attending Signature: ________________________

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COMMUNICATION, INTERPERSONAL SKILLS, ANDPROFESSIONALISM EVALUATION FORM (PATIENT

FORM)

Date: ____________

As part of an evaluation process at the fellowship program in Pulmonary and Critical Care Medicine at FletcherAllen Health Care, you are being asked to complete this brief questionnaire about Dr._____________________.

Your answers to the following questions will remain confidential. Participation will not affect your current orfuture care at Fletcher Allen Health Care.

How is Dr. _________________________ at:

Excellent VeryGood

Good Fair Poor Unable toEvaluate

Listening carefully to youUsing words you can understand whenexplaining your evaluation and treatmentSeeking your input before making decisionsAddressing your questionsShowing interest in your condition

Additional Comments:

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________

Please place the completed form in the survey collection box next to the door as you leave the clinic. Thankyou for your time and input.

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Form for Evaluation of FacultyPulmonary Disease & Critical Care Medicine

Faculty: Evaluator:

Period of Evaluation:

CONTACT SITE FOR THIS PERIOD:

The purpose of this evaluation process is to help improve our teaching program by identifying strengths and areas needingimprovement among our faculty. Please assess performance in each of the listed areas based on your contacts with the facultymember during the period indicated.

Please return the completed form to my office as soon as possible. I will review these evaluations with each of the faculty when allevaluations have been received. Thank your for your help with this process

Polly E. Parsons, MDProfessor of Medicine

Director, Fellowship Training Program for Pulmonary & Critical Care

Rarely Usually Always No ContactDIDACTIC SKILLS:Lectures or seminars well organizedUses visual aids effectivelyClear and effective speakerAppropriate information prioritiesTEACHING ATTITUDES:Enthusiastic, energetic teacherTakes extra time to teachProvides positive encouragementConveys empowerment to learnersCOMMITMENT TO SCHOLARSHIP:Exhibits a high level of knowledgeDisplays intellectual curiosityDocuments opinions with citationsProvides appropriate literatureHUMANISTIC QUALITIES:Shows concern & compassionRelates well to patients and familiesPromotes dignity for othersRelates well to colleaguesPATIENT CARE SKILLS:Obtains detailed informationDevelops logical plansDemonstrates procedural skillsExhibits high level of expertise

GENERAL COMMENTS:

Signature of Evaluator

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Pulmonary & Critical Care Medicine

FELLOW ROTATION EVALUATION (to be completed by Fellow)

Fellow:

Rotation:

Dates:

This form should be completed at the conclusion of each monthly rotation. It is intended for review of the clinical and educational experience, not hespecific faculty preceptor.

StronglyDisagree Disagree Agree

StronglyAgree

There was an appropriate volume of clinical material

The diversity of patients and disease was excellent

The clinical experience was representative of the broad range ofconditions seen in this field

The experience had substantial applicability for Pulmonary andCritical Care training

The quality of the overall educational experience was high

A defined curriculum was shared with me early in the rotation

The rotation allowed me to accomplish many of the goals andobjectives of the defined curriculum

Formal teaching interactions with the faculty occurred and wereof high quality

Informal teaching interactions with the faculty occurred and wereof high quality

The faculty stimulated me and guided me in self-learning

The faculty were excellent role models

The working environment was excellent (office, staff, wards) andfacilitated my accomplishment of the rotation’s goals andobjectives

The rotation was structured in a manner optimal to learning

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StronglyDisagree Disagree Agree

StronglyAgree

My role was clearly defined and appropriate

I received proper orientation and discussed my goals with thefaculty

Service requirements were appropriate

An appropriate degree of patients management responsibilitywas given to me

I had a clear understanding of the criterial upon which I was ableto be evaluated

Evaluation and feedback were provided

Resources materials (books, articles, slides) were provided andhelpful

Reading time was available

The rotation contributed in a substantial manner to my overallFellowship training

Please provide comments regarding any of the above or concerning any other issues you wish to address:

SignatureDate

28

SUBSPECIALTY CONSULTATION EVALUATION EXERCISE

These guidelines and form are recommended for use by staff physicians in conducting and documenting the consultation evaluation exercise ofpulmonary trainees.

Trainee’s Name

Evaluator’s Name

Date of Evaluation

� The 90-minute exercise is conducted by a staff physician, preferably a member of the evaluation committee. The inpatient or outpatientselected for the exercise must be familiar to the evaluator but unknown to the trainee. Specific questions as though from the referring physicianshould be developed beforehand by the evaluator. About one-half should be designated for the evaluator to observe the trainee interview thepatient and perform a focused physical examination. During this time, the evaluator should remain inconspicuous. However, when necessary,the evaluator should go to the patient to demonstrate proper techniques to the trainee or elicit findings that the trainee omitted.

� After leaving the patient, about thirty to forty-five minutes should be provided for the trainee’s presentation of the history and physicalexamination, initial diagnostic impression, review of X-rays, ECGs, lab data, and other diagnostic information and plans for diagnostic studiesand medical care. At this juncture, the evaluator’s questions should be addressed.

� At the conclusion of the exercise, the evaluator and the trainee should discuss in detail the strengths and weaknesses observed in his/herclinical performance. Later, the trainee should provide a written consultation note for review by and feedback from the evaluator. This note maybe included as part of the record of consultation exercise and placed in the trainee’s file.

� The standard expected must be that of a well-trained internist who has now undertaken clinical training as a subspecialist. The performanceshould clearly exceed that expected of a third-year resident in internal medicine.

� Circle the category which best describes the trainee’s skills and abilities for each component of clinical competence.

1.CLINICAL SKILLS - HISTORY-

Demonstrates consideration for the patient during the interview. Quickly recognizes and interprets nonverbal clues. Allows the patientadequate time to tell about the illness in his/her own words, yet directs smoothly and effectively to obtain pertinent and necessary information.Develops in chronological sequence an accurate description of the pertinent symptoms and events in the present illness. Obtains appropriatelycomplete information about the past history, family history, and occupational and social history. Exhibits sophistication in the specificity, relevance,and clarity of questions. Avoids unnecessary repetitions. Focuses on the subspecialty issues presented by the patient.

Unsatisfactory Marginal Satisfactory Very Good Superior

Comments:

2. CLINICAL SKILLS - PHYSICAL EXAMINATION

Demonstrates concern for the patient's comfort and modesty. Enlists the patient's cooperation. Positions patient properly, applies skillfullythe fundamental techniques of examination to each region. Follows a selective and logical sequence of examination from one region to another,emphasizing those areas of importance suggested by the interview. Applies special techniques to help gather complete information about anabnormality. Modifies the examination to adapt to patient limitations imposed by illness. Records relevant physical findings in the consultation notein a well-organized, thorough manner.


Comments:

3. CLINICAL JUDGMENT AND SYNTHESIS (as elicited by case presentation)

Spends appropriate time for the complexity of the problem. Uses terminology that is meaningful and unambiguous. Presents informationconcisely in logical sequence. Reports accurately the information related by the patient and the observations made during the physical examination.Relates information about major problems in adequate detail without significant omissions or digressions.

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Comments:

4. HUMANISTIC QUALITIES

Demonstrates the necessary humanistic qualities and professionalism which allow the development of appropriatepatient-physician relationships. Demonstrates personal integrity, respect, compassion, and empathy for the patient'swishes, opinions, and need for information. Exemplifies that the primary concern is for the patient's welfare.

Appreciates the patient's perception of illness. Is careful to place the patient's problems in the context of the patient's life and history.Displays sensitivity to the patient's needs for comfort and encouragement.


Comments:

5. MEDICAL CARE (including utilization of laboratory tests and procedures)

Understands in physiologic terms, the meaning of the patient's abnormal findings and interrelates them to explain logically the patient'sillness. Is able to develop a differential diagnosis with an appreciation for priorities in each of the diagnoses considered. Identifies all of the patient'smajor problems.

Validates and incorporates known diagnostic information into plans. Uses a logical sequence in planning further diagnostic tests andprocedures. Integrates diagnostic studies with the diagnostic impression, proceeding from simpler tests to more complex ones.

Demonstrates clinical judgment in selecting the most effective care with the least risk to the patient. Plans treatment to deal with all of thepatient's major problems. Designs a succinct and explicit consultation note with specific recommendations to the referring physician.


Comments:

6. OVERALL CLINICAL COMPETENCE AS A CONSULTANT SUBSPECIALIST IN PULMONARY DISEASE (as demonstrated in this exercise)


Comments:

Signature: _____________________________________________ Date:___________________________________________

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Evaluation of Research ProgressPulmonary Disease & Critical Care Medicine Trainees

Trainee: Evaluator:

Period of Evaluation From: To:

Contact Site/Activity:

Trainees will be evaluated semi-annually in regards to their research activities to assure that they are making progress towards the definedgoals and objectives. The results of these evaluations will be provided to both the Trainee and the Program Director. The criteria forevaluation should be appropriate for the year and training level of the individual.

Satisfactory Unsatisfactory Not Applicable Comment

Year 01:1. Surveying faculty research programs

2. Identifying and planning a project

3. Diligence in literature review

4. Participation in research conferences

Year 02:1. Developing detailed research plans

2. Developing relevant research methods

3. Diligence in research data collection


Year 03:1. Diligence in research data collection

2. Diligence in research data analysis


4. Submission of research results for

presentation at scientific meetings

5. Submission of research for publication

Additional Comments:

31

EDUCATIONAL PROGRAMSThis section contains specific goals, objectives, teaching methods and evaluation processes for each trainingexperience in the Pulmonary and Critical Care Medicine fellowship program. Fellows are expected to assumeincreasing levels of responsibility in patient care with advances in training and as outlined in the curriculum.Within each section you will also find the general guidelines and expectations for fellows rotating on thoseservices. These educational programs are referenced in the following section (Curriculum and EducationalProcess) and individually contribute to achieving the goals and objectives for the entire training program.

Outpatient Education

1. Pulmonary Ambulatory Center2. Northwestern Medical Center3. Pulmonary Rehabilitation Program4. Cystic Fibrosis Clinic5. Allergy and Immunology Clinic6. Sleep Disorders Clinic7. Pulmonary Physiology and Pulmonary Function Testing

Inpatient Education

1. Pulmonary Medicine Consultation Service2. Medical Intensive Care Unit3. Surgical Intensive Care Unit4. Anesthesia5. Infectious Disease Rotation6. Thoracic Radiology

Teaching Conferences

1. Pulmonary/Critical Care Departmental Teaching Conferences2. Critical Care Teaching Conferences3. Multidisciplinary Chest Tumor Conference4. Pulmonary and Critical Care Journal Club5. Outpatient Pulmonary Case Conference6. Curriculum – Department of Medicine Subspecialty (Fellowship) Training Programs7. Department of Medicine – Fellows Lecture Series

Quality Assessment and Improvement

Research

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Outpatient Education

Pulmonary Ambulatory Center

GoalTo provide education and training in the care of ambulatory patients with pulmonary diseases.

ObjectivesTo learn the evaluation and management of new outpatient consults. To learn the longitudinal management of patients withpulmonary disease as the patient’s primary pulmonary physician. To acquire skills in communication with referring physiciansas a subspecialty consultant. To learn the pathophysiology, natural history, diagnostic tests and treatment options ofoutpatients with pulmonary diseases.

Educational ExperienceFellows will attend a weekly “Fellow’s Clinic” during their entire fellowship. This clinic provides the fellow with the opportunityto evaluate new outpatient consults, to see patients following discharge from the hospital, and to see patients who requirecontinued follow-up over an extended period of time as their primary pulmonary physician.

Each patient will be discussed with the assigned pulmonary teaching attending. The discussion will provide direction indeveloping differential diagnoses, directing patient management, and illustrating educational points. In addition, it is expectedthat fellows will do outside reading relevant to the patient’s problems. A prepared log of the patients each fellow sees will bekept by the fellow and organized by problem category. A list of recommended reading accompanies each problem category(see “Case Mix –Logbook and Reading List”) and is enclosed at the end of this section.

Fellows will be expected to present cases at the monthly outpatient case conference as assigned.

Evaluation and FeedbackFellow presentations will be critiqued informally by faculty members present at the time of presentation. This will includefeedback on content and presentation.

Written evaluation will occur annually (in the month of February) by the faculty members assigned to the clinics. Also on anannual basis, the trainees will provide written evaluation of faculty assigned to their clinic.

Annually, the program director will formally review this educational program with the fellows and the faculty. Fellows will beexpected to submit outpatient logs at this evaluation.

Fellows will be formally evaluated for Pulmonary Consultation Skills (see Section 3 - Evaluation Process) at the end of thefirst year of training in the outpatient clinic. This will be conducted by a designated faculty member.

General GuidelinesThe fellows’ clinic occurs one half day per week at the Medical Office Building, Room 305, Fanny Allen Campus. Fellows areexpected to attend this clinic above all other responsibilities unless on vacation or attending a meeting. It is the fellows’responsibility to coordinate their clinic and communicate with the office staff. Each fellow will see 1-2 new patients and 3-5follow-up patients per clinic. The assigned teaching attending will review history and physical exam findings with the fellow.The fellow will then finalize testing and treatment plans with the patient. Internal action sheets provided with each patient willcoordinate plans with the clinic staff. The fellows are expected to follow up on all aspects of patient care including tests andcommunication with referring physicians.

One fellow will be assigned to read the daily PFT’s for the outpatient clinic. This will be reviewed with an assigned attending.All of the fellows are encouraged to participate in the PFT review exercise.

Forms for documenting new patient and follow-up visits will be attached to each chart. Fellows are responsible fordocumentation as it applies to their patients. Current institutional documentation requirements necessitate that the attendingphysician dictates a note to the referring physician as well as the chart record.

Some patients will require diagnostic bronchoscopies or thoracenteses/pleural biopsies. These must be scheduled inadvance and performed with an attending physician. The secretarial staff can assist fellows in scheduling these procedures. Itis the responsibility of the fellow to assist in coordinating these procedures.

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Northwestern Medical Center Outpatient Clinic

GoalTo provide trainees additional ambulatory pulmonary consultation experience in a rural health care setting.

ObjectivesTo learn the pathophysiology, natural history, diagnostic test and treatment options of outpatients withpulmonary diseases. Provide experience in caring for outpatients in a rural health care setting. Provideexperience in inpatient pulmonary consultation in a small community hospital.

Educational ExperienceOutpatient evaluation – In the second year of training, a fellow may choose to attend a monthly outpatientpulmonary consultation clinic at the Northwestern Medical Center, under the direction of Dr. Gerald Davis. Thisclinic provides the fellow with opportunities to evaluate new outpatient consults in a rural health care setting.Each patient will be discussed with the assigned pulmonary attending. The discussion will provide direction indeveloping differential diagnoses, directing patient management and illustrating educational points. Fellowsshould include patients seen as part of their case mix-log book and reading list.

Inpatient consultation – Occasionally physicians at the Northwest Medical Center will ask for pulmonaryconsultations on inpatients. Fellows, under the supervision of the pulmonary attending, will evaluate and makerecommendations on their pulmonary problems.

Pulmonary Function Testing – A respiratory therapist accompanies the pulmonary team to this facility. A fullcompliment of pulmonary function equipment is available for inpatient and outpatient pulmonary functiontesting. Fellows are expected to interpret pulmonary function tests performed on patients under thesupervision of an attending physician.

Evaluation and FeedbackFellow presentations will be critiqued informally by faculty members present at the time of presentation. Thiswill include feedback on content and presentation.

Written evaluation will occur annually (in the month of February) by faculty members. Also on an annual basis,the trainees will provide written evaluation of faculty members and the quality of the rotation.

The program director will review all evaluations and monitor the quality of the outpatient experience. Theprogram director will formally review the educational program in the established semi-annual meetings with thefellows and the faculty.

General GuidelinesPulmonary clinic at the Northwestern Medical Center occurs twice monthly on Tuesday mornings. Fellows willbe assigned a monthly clinic day beginning in their second year and continuing through their second and thirdyear of training. Fellows should check with the attending physician on a day prior to their clinic for specifictimes and transportation arrangements.

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Pulmonary Rehabilitation Program

Goals and ObjectivesTo provide the trainee experience and knowledge in the assessment of patients for participation in a pulmonaryrehabilitation program. To provide the trainee experience and knowledge regarding the components of apulmonary rehabilitation program, and how patients respond to these interventions. To provide the traineesome knowledge about the administration of a pulmonary rehabilitation program including information aboutreimbursement and expenses.

Educational ExperiencePulmonary Rehabilitation Program at Fanny Allen Campus - The Pulmonary Disease and Critical CareMedicine Unit and the Respiratory Care Department provide a series of comprehensive six-week outpatientpulmonary rehabilitation programs for patients with disabling COPD and other chronic lung diseases. Residentswill be expected to participate in these programs in their first year during their Pulmonary Function rotation.Second or third year fellows will have the opportunity to take an elective in Pulmonary Rehabilitation.Experience with evaluating patients for possible enrollment will occur in the resident’s continuity clinicthroughout their training. The resident will attend at least three of the twelve sessions of education andsupervised exercise during the six-week program. The fellow will lead one of the educational sessions and isexpected to observe and supervise at least one of the exercise sessions. The trainee will work with the medicaldirector and the program coordinator of the program (Theodore Marcy, MD and Sherri Stubblefield, RT) toreview the educational program and exercise prescriptions for each participant. The trainee will also work withthe program coordinator (Sherrie Stubblefield, RT) on selecting appropriate candidates and participating in thepre-course evaluation of the participants.

Evaluation and FeedbackThe medical director and program coordinator will give verbal feedback to the fellow during the program and atits conclusion. The medical director will include the evaluation of performance in pulmonary rehabilitation in thewritten quarterly evaluations.

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Cystic Fibrosis Clinic

Advances in the care and understanding of cystic fibrosis have led to many patients with this disease survivinginto adulthood. It is important for the practicing pulmonary physician to be involved in the transition frompediatric to adult care.

GoalTo provide trainees education in the care and management of patients with cystic fibrosis.

ObjectivesTo learn the pathophysiology, natural history, diagnostic test and treatment options of patients with cysticfibrosis. To learn the longitudinal management of patients with cystic fibrosis. To gain experience in the careand management of patients with cystic fibrosis undergoing lung transplantation.

Educational ExperienceClinic – Fellows may elect to attend adult cystic fibrosis clinic once monthly beginning in their second year.This clinic is comprised of a multidisciplinary team, which manages the care of patients with cystic fibrosis.This includes a nurse, respiratory therapist, nutritionist, and a pediatric pulmonologist. Initially, fellows will seepatients with the pediatric pulmonologist. Once experience in the clinic is gained, fellows will see patientsindividually and present the case to the multidisciplinary team for management discussion. Fellows will thencarry out those management plans in discussions with the patient.

Inpatient Service - The pulmonary consultation service is available to manage complicated pulmonary andtransplant issues for this patient population.

Didactic Teaching - Basic Science Lecture – The pediatric pulmonologist will give a once yearly conferenceon the basic science of cystic fibrosis to the pulmonary division or trainees. Didactic Teaching in managementissues will occur as part of the clinic experience for trainees rotating through that clinic. The pediatricpulmonologist will oversee one journal club per year, which will include a review of the most recent literature inthe care, management, and basic science advances relevant to patients with cystic fibrosis.

Evaluation and FeedbackFellow presentations will be critiqued informally by the pediatric pulmonologist on this rotation. This will includefeedback on content and presentation. Written evaluation will occur as part of the established quarterlyevaluation process. Trainees as part of their quarterly evaluation will critique this rotation.

The program director will review all evaluations and monitor the quality of the lecture series. The programdirector will formally review the educational program semi-annually with the fellows and the faculty.

General GuidelinesAmbulatory experience on cystic fibrosis is provided through the Vermont State Cystic Fibrosis Center programdirected by Thomas Lahiri, MD. An ambulatory clinic for teens and adults with cystic fibrosis is held one half-day per week, twice monthly. The clinic is held in a newly renovated space in the McClure wing of the MCHVCampus. A trainee may elect to attend the ambulatory cystic fibrosis clinic one half-day clinic per month in theirsecond and third years of fellowship training.

36

Allergy and Immunology Clinic

GoalTo provide trainees educational experience in the evaluation and management of patient with allergic diseases.

ObjectivesTo learn the pathophysiology, natural history, diagnostic test and treatment options of outpatients referred forallergy evaluation. To learn the longitudinal management of patients with allergies. To gain experience andunderstanding of testing procedures in allergy management.

Educational ExperienceAllergy Clinic – Fellows who elect to do so will have the opportunity to have a concentrated clinic effort inallergy. Fellows will see patients under the guidance of Dr. Edward Kent at the Timberlane Allergy Center inSo. Burlington, VT. In the second year of training, fellows will have a one-month experience in which they havea concentrated effort in allergy immunology. They will approximately spend half of their outpatient time in theallergy clinic learning the care and management and testing associated with management of allergy patientswith allergic diseases. This will include history and physical examination, participation in skin testing anddevelopment of management plans in consultation with the attending allergist.

Didactic Teaching - During their rotation, fellows will attend a didactic session on the basic science related toallergy. Additionally, one journal club per year will be designated for current allergy and immunology literaturereview overseen by one of the attending allergists.

Evaluation and FeedbackFellow presentations will be critiqued informally by the attending allergist at the time of presentation. This willinclude feedback on content and presentation. Written evaluation will be submitted at the end of the one monthexperience.

Trainees will submit a separate evaluation form for this rotation at the end of their clinical rotation through thisservice. The program director will review all evaluations and monitor the quality of the educational experience.The program director will formally review the educational program semi-annually with the fellows and thefaculty.

Fellows should keep an outpatient log of patients seen with a variety of allergy diseases.

General GuidelinesTimberlane Allergy is located in the Timberlane medical facility in So. Burlington, VT. Fellows are responsiblefor making specific schedule arrangements with Dr. Edward Kent, two-months prior to their scheduled rotation.

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Sleep Disorders ClinicThe Vermont Regional Sleep Disorders Center (VRSDC) is a regional referral area for patients with sleepdisorders from Vermont and upstate New York. The Center is composed of, neurologists, ENT surgeons, oralsurgeons, general dentists, and clinical psychologists. The Center operates a testing facility which carries out afull range of diagnostic testing for patients with sleep disorders including laboratory polysomnograms, homesleep tests, overnight oximetry, and multiple sleep latency tests. Other laboratory and physiologic testing isavailable through the Fletcher Allen Health Care laboratories and through the Pulmonary Function Laboratory.The core physicians in the Center oversee the management of the patients.

GoalsTrainees will learn the physiology of sleep and ventilatory control during sleep, and the pathophysiology of thecommon sleep disorders. Trainees will become familiar with the diagnostic tests available for evaluating sleep,sleep-disordered breathing, and other sleep disorders. Trainees will learn to diagnose and manage patientswith sleep disorders.

Objectives Provide trainees with education in the physiology and pathophysiology of sleep and sleep disorders. Providetrainees with experience in carrying out and interpreting the diagnostic tests used to evaluate patients withsleep disorders. Provide trainees with clinical experience in the recognition, diagnosis, and treatment of sleepdisorders.

Educational ExperiencePulmonary Fellows Seminars – Didactic Seminars will be conducted by the director the Sleep Laboratory,and will focus on the physiology of sleep, the physiology of ventilatory control during sleep, and thepathophysiology of various sleep disorders. Attendance is mandatory for all trainees.

Sleep Laboratory Experience - Trainees will gain experience with the following diagnostic tests: laboratorypolysomnogram, home sleep tests, overnight oximetry, and multiple sleep latency tests. The Sleep Laboratorydirector will oversee this experience. Trainees will observe a minimum of two of each of the diagnostic tests asthey are carried out. This includes participating in the scoring of the laboratory polysomnograms. Trainees willparticipate in the interpretation of a minimum of five of each of the diagnostic tests.

Sleep Disorders Clinic - Trainees will begin their experience with sleep disorders with a concentratedexperience for one month in the first year in order to familiarize them with the management of patients withsleep disorders.

Evaluation and FeedbackEvaluation of the level of preparedness of the fellows for the seminars and discussions will occur as part of theestablished quarterly evaluation by the faculty members. The Sleep Laboratory director will evaluate traineeson their knowledge base and clinical progress as part of the established quarterly evaluation of trainees.Fellows will evaluate their experience in the Sleep Disorders Clinic as part of their quarterly evaluation process.Trainees will document the tests that they observed and interpret, and report this to the program director at asemiannual evaluation in the second year.

General GuidelinesSleep Disorders training is coordinated by the Fellowship Program director and the Sleep Laboratory director.Fellows should contact the Sleep Laboratory director prior to beginning the rotation for specific details as to thetime and location of the clinic.

38

Pulmonary Physiology and Pulmonary Function Testing

GoalTo educate trainees in pulmonary physiology and pulmonary function testing.

ObjectivesTo provide a physiological basis for the understanding and performance of pulmonary function testing andinterpretation. To provide a working knowledge of the techniques involved in pulmonary function testing. Toprovide direct, hands-on experience in performing and supervising pulmonary function testing.

Educational ExperienceDidactic Seminars -All pulmonary/critical care fellows will attend a series of monthly hour-long seminars givenby Dr. Kaminsky during their rotation through the PFT lab that will address the physiological basis of each ofthe following aspects of pulmonary function:

� flow-volume loops and spirometry� lung volumes� pressure-volume relationships� bronchial challenge testing� gas exchange and lung diffusing capacity� symptom-limited exercise challenge testing� research topics in pulmonary physiology

A set of reading on each of the above topics, including all up-to-date ATS guidelines, will be provided for eachfellow.

Pulmonary Function Testing Interpretations - Each pulmonary fellow will interpret all PFT’s performed at theMCHV campus while on-service for the pulmonary consultation service. These PFT interpretations will besupervised by the attending on-service that month. In addition, each fellow will interpret the outpatient PFT’sperformed at the Fanny Allen campus during their month long rotation through the PFT lab, and during theirweekly clinic day, again under the supervision of an attending physician. The total number of tests expected tobe interpreted is approximately 1350 the 1st year (MCHV: 6/day X 30 days/mo X 5 mo = 900 + FA: 10/day X 1day/wk X 45 wks = 450), and 990 the 2nd year.

Practical Experience in the PFT Lab - Each pulmonary fellow will observe the performance of at least 6 ofeach of the pulmonary function tests conducted in the PFT lab, including relevant calibration and set-up. Inparticular, fellows will participate in the supervision required during all exercise testing. Each fellow will also beasked to have their own pulmonary function measured which will allow them to directly experience each test.

Evaluation and FeedbackEach faculty member will be asked to comment in their routine quarterly reports on the performance of thefellows in the area of pulmonary function testing interpretation. In addition, Dr. Kaminsky will directly addressthe performance of each fellow not only in the area of PFT interpretation, but also in the area of PFT testing,based on his direct observation of each fellow in the lab as well as feedback from the PFT technologists. Dr.Kaminsky will provide direct feedback to the fellows regarding their performance in these areas, and will invitethe comments and criticism of each fellow regarding the curriculum in this area.

39

Inpatient Education

Pulmonary Medicine Consultation Service

Goal To teach fellows basic and advanced skills in diagnosing and managing hospitalized patients with simple andcomplex pulmonary illnesses.

Objectives To assist fellows in improving their ability to examine inpatients with pulmonary disorders at the bedside. Toteach fellows to effectively communicate clinical and administrative information to colleagues, nurses, andstudents. To teach fellows to coordinate and integrate information derived from pulmonary function testing,radiographic studies, bronchoscopy, and other pulmonary and non-pulmonary tests in assessing individualpulmonary inpatients. To assist fellows in enhancing skills in communicating with medical professionals, andwith patients and their families through verbal and written communication. To teach fellows to administer aninpatient consultation service that provides effective, appropriate and timely service in a teaching hospitalsetting.

Educational ExperienceBedside Teaching -Fellows will attend rounds daily with the attending teaching physician and visit selectedpatients.

Fellows will visit inpatients within 18 hours of receiving a new consultation and daily (or as frequently asappropriate) thereafter. At each visit, fellows will carry out an appropriately focused bedside exam and reviewrelevant laboratory data, consultations, and radiographic information.

Didactic Sessions - The fellow assigned to the pulmonary consultation service will attend routinely scheduleddidactic session including case conferences, grand rounds, journal club, and textbook review sessions. Fellowswill complete appropriate readings regarding key inpatients in textbooks, journals, and other scholarly sources.

It can be anticipated that each fellow will consult on at least 20 new patients during each month on the clinicalconsultation service.

Evaluation and FeedbackWritten evaluation will be completed by the attending physician(s) at the end of each rotation on the consultservice. The fellowship program director will provide feedback to the fellows regarding their performances in thescheduled semi-annual meeting.

The trainees will provide written evaluation of the attending and the rotation at the end of each month’s rotation.

Concerns or issues regarding fellows' performance that are raised by medical staff outside the pulmonarytraining program will be brought to the attention of the program director who will address them individually withthe fellow.

40

Medical Intensive Care Unit

GoalTo provide training and education in the care and management of critically ill medical patients.

ObjectivesTo provide direct, hands-on experience in caring for critically ill patients. To provide education and experiencein performing and supervising procedures necessary for the practice of critical care medicine. To provideexperience and knowledge in managing an intensive care unit.

Educational ExperienceFellows will rotate on the MICU service as outlined in the general schedule. Fellows will actively participate inall aspects of the care of patients on the medical ICU service. This should include but is not limited to medicalmanagement, procedures, family meetings, communication with referring physicians, and bed managementissues. All admissions will be seen by the fellow and subsequently discussed with the attending physician.Fellows will document a complete history and physical examination in the hospital chart for each newadmission. As training advances, fellows will take on increasing responsibilities for patient care in the MICU.

Fellows in their first year of training will attend 2 MICU Quality Assurance Committee meetings. In the secondyear, fellows will develop a QA project to be completed by the third year of training. Fellows will present theresults to the MICU QA committee and to the Pulmonary/Critical Care Faculty.

In the third year of training, fellows will complete a one month rotation as the “Acting Attending” for the MICUservice. The fellow will have complete responsibility for the MICU management under the guidance of anattending physician. This will serve the specific goal of preparing fellows for their final step beyond fellowshiptraining and into a practicing physician.

Evaluation and FeedbackFellows will be informally critiqued on case management and performance of invasive procedures whilerotating on the MICU service.

Fellows will be formally evaluated each month. Fellows will evaluate their educational experience on the MICUrotation and the attending faculty each month.

The program director will formally review this educational program semiannually with the fellows and thefaculty.

General Guidelines McClure 4 intensive care is a combined medical and cardiac intensive care unit. The 20-bed unit is under thejoint direction of a cardiology and a pulmonary/critical care faculty member. The key components to the healthcare team is the staff of nurses, respiratory therapists and others who are highly trained and experienced inICU care. The unit is committed to the team approach to ICU care. Communication is of utmost importance.

Admission Policy – MICU - All admissions to the MICU (regardless of origin) must be approved by the MICUfellow or attending physician. Emergency admissions from the regular floor should be seen by the seniorresident prior to transfer. A call schedule for the MICU service is listed on the unit and is known to the hospitaloperator. The charge nurse must be informed by the senior resident or fellow of all patient admissions andtransfers.

Daily Rounds, Responsibilities, and Codes - Formal rounds begin at 9 AM. All Fellows are expected to haveevaluated their patients and collected pertinent data prior to the beginning of rounds. Fellows are expected toattend morning check-in rounds at 7:15 AM and to have done the same pre-round evaluation and to supervisethe residents in initiating daily care plans and weaning from mechanical ventilation. X-rays will be reviewed inthe Radiology Department as part of attending rounds from 9 – 11:30 AM. Daily progress notes should becompleted in a timely fashion.

Afternoon rounds are conducted at 4PM daily. Residents and fellows are expected to attend. Follow up on dailyprogress and diagnostic tests are reported at this time. These rounds are an important part of effective ICUcommunication and planning for the on-call team.

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Residents and fellows are expected to attend all critical care conferences. Residents and fellows are excusedfor any continuity clinic duties related to the training program.

The MICU team also is responsible for directing in house “code 99’s.” The senior resident should be in chargeof running the code with the assistance of the fellow. Fellows should assume responsibility for airwaymanagement at all codes.

The resident physicians write all orders. Transfer and discharge orders are written by the MICU service.Transfer notes (admission and discharge) for MICU patients are the responsibility of the respective services.

Procedures - Procedures will be performed and documented as outlined in the Procedure Training andDocumentation section. Fellows are expected to actively supervise and teach residents in procedure training.

Psycho-social rounds – Fellows are expected to attend these rounds weekly when they are on the MICUrotation. These rounds are attended by the Director of Medical Ethics, Psychiatry, Social Services, Nursing,and MICU physician staff. Discussion is centered on clinical ethics, patient and family communication, and theimpact of psychiatric illness in the ICU.

Conferences -Fellows are expected to attend the weekly critical care conference. This conference providesthe didactic teaching curriculum as outlined above. In addition fellows will be expected to attend and participatein the monthly Pulmonary and Critical Care Journal Club. Fellows will also be expected to assist with didacticteaching conferences for residents rotating on the critical care service. Fellows are expected to attend theDepartment of Medicine Morbidity and Mortality conferences one Friday a month at 9 AM when MICU patientsare presented. The Chief Medical Resident will notify the Fellows of the date of this conference.

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Surgical Intensive Care Unit

GoalsTo gain knowledge skills in the care of patients with a variety of surgical problems. To gain knowledge andskills in procedures unique to the care of SICU patients. To gain knowledge of the unique management needsof surgical patients.

ObjectivesThe surgical intensive care unit cares for all critically ill surgical patients. This provides the trainee with anopportunity to become familiar with the care of a wide variety of surgical problems. Trainees will becomeexperienced in the care and management of patients in the following areas: trauma, neurosurgery, generalsurgery, vascular surgery, and cardiothoracic surgery.

Educational ExperienceExperience will be accomplished by caring for SICU patients as a member of the Surgical Critical Care Service.Care of patients in the surgical intensive care unit is a collaborative effort between the surgical team and thecritical care team. Pulmonary Critical Care Fellows will rotate as a member of the SICU team. The team iscomprised of one senior and one junior surgical resident and an attending physician. Fellows will rotate on theservice in the second and third year of training. Bedside teaching and procedure training will occur as part ofthe daily work rounds. Fellows should document all procedures performed in the SICU.

An informational packet regarding SICU policies and procedures will be distributed to each fellow prior to theirfirst SICU rotation. Fellows are expected to follow these guidelines.

General GuidelinesFellows will attend all SICU teaching conferences as part of the SICU team. Fellows are expected to attend the½ day Pulmonary continuity clinic as scheduled and the Thursday and Friday Pulmonary and Critical Careconferences. Night call will be taken as part of the regular Pulmonary and Critical Care Medicine call schedule.Fellows are encouraged to participate in the care of SICU patients as much as possible when on call for thePulmonary and Critical Care Medicine division.

Evaluation and FeedbackFellows will be informally critiqued on case management and performance of invasive procedures whilerotating on the SICU service.

Fellows will be formally evaluated on a rotation basis by the surgical ICU attending physician. Fellows willevaluate their educational experience on the SICU rotation and the SICU attending(s) at the end of eachrotation.

The program director will formally review this educational program semiannually with the fellows and thefaculty.

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Anesthesia

GoalsTo acquire knowledge of and competence in airway management. To acquire knowledge in the physiology andpharmacology related to managing patients undergoing general anesthesia.

ObjectivesUnderstand the indications, contraindications, and complications for general, regional, and local anesthesia.Obtain competence in: establishment of the airway; maintenance of the airway in the non-intubated,unconscious, paralyzed patient; oral and nasotracheal intubation; use of the laryngeal mask airway; andventilation by bag or mask. Acquire knowledge of and experience in the use of paralytic agents.

Educational ExperienceFellows will participate in a one-month rotation with the Department of Anesthesia in the first year of training.Fellows will be assigned to an operating room under the supervision of the anesthesia staff. They willparticipate in the care of the patients in that room from preoperative evaluation to the recovery room. This willinclude direct supervision and teaching in monitoring requirements, selection of the type of anesthesia,induction of anesthesia, monitoring and management of the patient during surgery, and patient recovery. Asthe rotation progresses, fellows will be given increasing responsibility in the management of cases.

The members of the anesthesia department will provide direct supervision and instruction in airwaymanagement techniques.

Didactic teaching in anesthesia pharmacology and specifically paralytic agents will be provided as part of thecritical care lecture series.

Fellows will be expected to do additional text and journal reading as assigned by Department of Anesthesia.

Fellows will keep a log of all procedures performed as part of this rotation.

Evaluation and FeedbackTrainees will be evaluated for cognitive and technical skills by the supervising anesthesia physician(s).

Trainees will evaluate the rotation and supervising physicians following the month rotation using the standardevaluation form (see section 3.).

The program director will review these evaluations at the semi-annual evaluation.

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Infectious Disease Rotation

Goals

1. Learn to recognize, diagnose, and manage common Infectious Disease syndromes.

2. Gain knowledge of the antimicrobial agents available and their appropriate use.

3. Learn how to interpret gram stain and culture results and how to use the microbiology lab appropriately.

Teaching Methods

Didactic lectures Housestaff noon lectures Infectious Disease Conferences Oral Case presentation and discussion (inpatient and outpatient)Bedside teaching Self-directed learning

Curriculum

Urinary Tract InfectionsPneumoniaCentral Nervous System Infections Endocarditis and Intravascular InfectionsSkin and Soft Tissue InfectionsBone and Joint InfectionsIntra-abdominal Infections Sexually Transmitted DiseasesTuberculosis Management of HIVTravel Medicine Adult VaccinationSepsis Fever and RashInterpretation of Culture Results Infections in Immunocompromised Patients

Neutropenia Transplantation Hematologic malignancies Immune suppressive therapy

Antimicrobials (mechanisms of action and resistance, spectrum of activity, toxicities)Considerations in choice of antimicrobial agentPenicillins Cephalosporins, monobactams, carbapenems Quinolones, aminoglycosides, metronidazole, and clindamycin Macrolides, sulfonamides, tetracyclines, vancomycin, strptogramins, oxazolidinonesAntifungals and Antivirals

Activities ( see calender)

Core lectures given at 9 am Mon - Thurs. Daily clinical rounds each afternoon Infectious Disease Conference or Journal Club each Thurs at 8 amAttend outpatient clinic one morning per weekAttend Travel clinic one morning per monthWork up at least one new consultation each dayFollow 3 - 5 consult patients on a daily basisFormal 15 minute presentation on a topic of his/her choice

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Criteria for Evaluation

Fund of knowledge Understanding of the role of the consultantQuality of data collection and assessmentQuality of notes and flow sheetsQuality of interactions with patients and all members of the health care team.

Readings

Principles and Practice pf Infectious Diseases, Mandell, Bennett, and Dolin. Fifth Edition.

A Practical Approach to Infectious Diseases, Reese and Betts, Fourth Edition

Selected Papers in the Infectious Disease Core Reading File

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Pulmonary medicine fellowship elective in thoracic radiologyJeffrey Klein, M.D.

Goals:After completion of the rotation in thoracic radiology, the fellow will be able to:1. Define the role of the radiologist as a consultant to the pulmonary/critical care physician2. Detail the relative utility of the various thoracic imaging techniques in the evaluation of the patient with

chest disease3. Define the use of imaging studies in guiding invasive diagnostic procedures including bronchoscopy, pleural biopsy, and pleural aspiration and drainage procedures4. Understand the complementary role of thoracic imaging with clinical and physiologic measurements of chest disease5. Recognize the knowledge-based objectives listed below

Objectives:Interstitial lung disease1. List and identify on a chest radiograph and chest CT four patterns of interstitial lung disease (ILD)2. Make a specific diagnosis of ILD when supportive findings are present in the history or on radiologic imaging(e.g. dilated esophagus and ILD in scleroderma, enlarged heart and a pacemaker or defibrillator in a patientwith prior sternotomy and ILD suggesting amiodarone drug toxicity) 3. Identify Kerley A and B lines on a chest radiograph and explain their etiology 4. Recognize the changes of congestive heart failure on a chest radiograph – enlarged cardiac silhouette,pleural effusions, vascular redistribution, interstitial and/or alveolar edema, Kerley lines5. Define the terms “asbestos-related pleural disease” and “asbestosis;” identify each on a chest radiographand chest CT6. Describe what a “B” reader is as related to the evaluation of pneumoconiosis7. Identify honeycombing on a radiograph and high resolution chest CT (HRCT), state the significance of thisfinding (end-stage lung disease), and list the common causes of honeycomb lung8. State the radiographic classification of sarcoidosis9. Recognize progressive massive fibrosis/conglomerate masses secondary to silicosis or coal worker’spneumoconiosis on radiography and chest CT10. Recognize the typical appearance of irregular lung cysts and/or nodules on chest CT of a patient withLangerhan’s cell histiocytosis11. List four causes of unilateral ILD12. List three causes of lower lobe predominant ILD13. List two causes of upper lobe predominant ILD14. Identify a secondary pulmonary lobule on HRCT 15. Identify lymphangioleiomyomatosis on a chest radiograph and HRCT16. Identify and give appropriate differential diagnoses when the patterns of septal thickening, perilymphaticnodules, bronchiolar opacities (“tree-in-bud”), air trapping, cysts, and ground glass opacities are seen on HRCT

Alveolar lung disease1. List four broad categories of acute alveolar lung disease (ALD)2. List five broad categories of chronic ALD3. Name three pulmonary-renal syndromes4. List five of the most common causes of adult respiratory distress syndrome5. Name four predisposing causes of bronchiolitis obliterans organizing pneumonia (BOOP)6. Suggest a specific diagnosis of ALD when supportive findings are present in the history or on the chestradiograph (e.g. broken femur and ALD in fat embolization syndrome, ALD and renal failure in a pulmonary-renal syndrome, ALD treated with bronchoalveolar lavage in alveolar proteinosis)7. Recognize a pattern of peripheral alveolar lung disease on radiography or chest CT and give an appropriatedifferential diagnosis, including a single most likely diagnosis when supported by associated radiologic findingsor clinical information (e.g. peripheral lung disease associated with paratracheal and bilateral hilar adenopathyin an asymptomatic patient with ”alveolar’ sarcoidosis, peripheral lung disease associated with a markedlyelevated blood eosinophil count in a patient with eosinophilic pneumonia, peripheral opacities associated withmultiple rib fractures and pneumothorax in a patient with acute chest trauma and pulmonary contusions)

Atelectasis, Airways and Obstructive Lung Disease1. Recognize partial or complete atelectasis of the following on a chest radiograph: right upper lobe, rightmiddle lobe, right lower lobe, right upper and middle lobe, right middle and lower lobe, left upper lobe, left lowerlobe2. Recognize complete collapse of the right or left lung on a chest radiograph and list an appropriate differentialdiagnosis for the etiology of the collapse

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3. Distinguish lung collapse from massive pleural effusion on a frontal chestradiograph4. Name the 4 types of bronchiectasis and identify each type on a chest CT5. Name 5 common causes of bronchiectasis6. Recognize the typical appearance of cystic fibrosis on a radiograph and chest CT7. Name the important things to look for on a chest radiograph when the patienthistory is “asthma’”8. Define tracheomegaly9. Recognize tracheal and bronchial stenosis on chest CT and name the most common causes10. Name the 3 types of pulmonary emphysema and identify each type on a chest CT 11. Recognize alpha-1-antitrypsin deficiency on a chest radiograph and chest CT12. Recognize Kartagener’s syndrome on a chest radiograph and name the 3components of the syndrome13. Define the term giant bulla, differentiate giant bulla from pulmonary emphysema and state the role ofimaging in patient selection for bullectomy14. State the imaging findings used to identify surgical candidates for giant bullectomy and for lung volumereduction surgery

Solitary and Multiple Pulmonary Nodules1. State the definition of a solitary pulmonary nodule and a pulmonary mass 2. Name the three most common causes of a solitary pulmonary nodule3. Name four important considerations in the evaluation of a solitary pulmonary nodule4. Name six causes of cavitary pulmonary nodules5. Name four causes of multiple pulmonary nodules6. State the indications for percutaneous biopsy of a solitary pulmonary nodule7. State the indications for percutaneous biopsy when there are multiple pulmonary nodules8. State the complications and the frequency with which complications occur due to percutaneous lung biopsyusing CT or fluoroscopic guidance9. State the indications for chest tube placement as a treatment for pneumothorax nrelated to percutaneouslung biopsy10. State the role of positron emission tomography (PET) in the evaluation of a solitary pulmonary nodule

Benign and Malignant Neoplasms of the Lung and Esophagus1. Name the four major histologic types of bronchogenic carcinoma, and state the difference between non-small cell and small cell lung cancer2. Name the type of non-small cell lung cancer that most commonly cavitates3. Name the types of bronchogenic carcinoma that are usually central4. Describe the TNM classification for staging non-small cell lung cancer, including the components of eachstage (I, II, III, IV, and substages), and the definition of each component (T1-4, N0-3, M0-1)5. State the staging of small cell lung cancer6. Name the four most common extrathoracic sites for non-small cell lung cancer and small cell lung cancer tometastasize 7. State which stages of non-small cell lung cancer are potentially resectable8. Recognize abnormal contralateral mediastinal shift on a post-pneumonectomy chest radiograph and statefive possible etiologies for the abnormal shift9. Name the most common location for adenoid cystic and carcinoid tumors to occur10. Suggest the possibility of radiation change as a cause of new apical opacification on a chest radiograph ofa patient with evidence of mastectomy and/or axillary node dissection11. Describe the acute and chronic radiographic and CT appearance of radiation injury in the thorax (lung,pleura, pericardium, esophagus) and the temporal relationship to radiation therapy12. State the role of MR in lung cancer staging (e.g. chest wall invasion, superior sulcus or Pancoast tumor)13. State the role of positron emission tomography (PET) in lung cancer staging14. Describe the TNM classification for staging esophageal carcinoma, including the components of each stage(I, II, III, IV) and the definition of each component (T, N and M)15. State the role of imaging in the staging of esophageal carcinoma16. State which stages of esophageal carcinoma are potentially resectable17. State the classification of lymphoma, the role of imaging in the staging oflymphoma, and the typical and atypical manifestations of thoracic lymphoma18. Define primary pulmonary lymphoma19. Describe the typical chest radiograph and chest CT appearances of Kaposi sarcoma

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Teaching Conferences: Pulmonary andCritical Care Medicine -

GoalTo provide learning opportunities for trainees in Pulmonary and Critical Care Medicine. Attendance at allconferences is mandatory.

PULMONARY AND CRITICAL CARE MEDICNE TEACHING CONFERENCES SCHEDULEMonday Tuesday Wednesday Thursday Friday

07:45 AMto8:45 AM

Chest TumorConference

08:15 AMto9:15 AM

ResearchConference

11:30 AMto12:00 PM

ICU Didactic ICU Didactic

12:00 PM to1:00 PM

1st Wk – Rad/Path2nd Wk – MICU Cases3rd Wk –Consult4th Wk – OutpatientPulmonary Cases

1st Wk –Pulmonary/CriticalCare Lecture2nd Wk – Same3rd Wk – Same4th Wk – Journal Club

1:00 PM to2 PM

PsychosocialRounds

Summary of Conferences:1. Psycho-Social ICU Rounds (on page 39)2. Pulmonary and Critical Care Research Session (on page 593. ICU Housestaff Didactic Series (on page 37)4. Inpatient Pulmonary and Critical Care Case Conference (on page 48)5. Outpatient Pulmonary Case Conference (on page 49)6. Pulmonary Pathology with Radiographic Correlation (on page 50)7. Pulmonary and Critical Care Didactic Teaching Conference (on page 51)8. Multidisciplinary Chest Tumor Conference (on page 54)9. Pulmonary and Critical Care Journal Club (on page 55)10. Department of Medicine Fellows Lecture Series (on page 56)

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Critical Care Medicine and Inpatient Pulmonary Case Conference (2nd & 3rd

Thursday)

ObjectivesTo provide trainees opportunity to present pulmonary and critical care hospital consultations for peer review. Toprovide trainees the opportunity to learn presentation skills. To learn the pathophysiology, diagnosis andmanagement of patients hospitalized with pulmonary disease and critical illnesses. To review historic andcurrent literature relevant to the cases presented for discussion.

Educational ExperienceThis once monthly conference will focus on inpatient pulmonary and critical care medicine consultations. Theeducational objectives will be obtained by the following methods:1. The inpatient consultation service will select three cases for presentation.2. Cases will be presented and relevant laboratory and radiographic material will be available for review.3. Following each case presentation, a discussion of the relevant literature will take place4. A reference list or copies of relevant articles should be available for distribution at the conference for all

participants.


General GuidelinesThe trainees and/or faculty members responsible for the inpatient pulmonary consultation service are expectedto prepare and present this conference. It is expected that trainees will present a minimum of six conferences inthe course of the training program.

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Outpatient Pulmonary Case Conference (4th Thursday)

Goal To provide additional training in the management of outpatients with pulmonary disease

ObjectiveTo learn management issues specific to outpatients with pulmonary diseases. To enhance skills in casepresentations to peers. To review relevant literature to the management of outpatients with pulmonary disease.

Educational ExperienceThis conference is held once per month in the MICU conference room. Three to four cases will be presented.The format will be a five-minute presentation followed by a 10-minute discussion. Each presenter will provideone journal article relevant to the presented case. Second and third year fellows will manage and present thisconference under the guidance of a faculty member.


The program director will review all evaluations and monitor the quality of the conference series. The programdirector will formally review this educational program semiannually with the fellows and the faculty.

General GuidelinesA senior fellow will be assigned to coordinate this conference for the academic year. Requests for radiographsshould be submitted to the radiology file room no later than 2 days prior to the conference. It is eachpresenter’s responsibility to obtain all relevant materials for the conference.

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Pulmonary Pathology with Radiographic Correlation (1st Thursday)

ObjectivesTo provide trainees didactic training in lung pathology. To understand the radiographic correlates in lungpathology

Educational ExperienceThis once monthly conference is a multidisciplinary conference directed at learning lung pathology and theradiographic correlates. The pulmonary division will present three cases and a chest radiologist will discuss theradiographic features. The pathologist will then show the corresponding pathology and discuss the pathologicfeatures as well as relevant diagnostic techniques such as special stains. Trainees are encouraged to bringjournal articles relevant to their cases for group discussion.

General GuidelinesA designated trainee will coordinate the pathology/radiology conference.

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Pulmonary and Critical Care Teaching Conferences (Fridays Noon)

GoalTo provide specific, detailed knowledge of critical care medicine topics.

ObjectivesTo provide education in the basic science and the physiology of critical care medicine. To provide instruction inspecific multidisciplinary critical care medicine topics. To provide education in the indications, contraindications,and complications of common ICU procedures.

Educational ExperienceAll pulmonary/critical care fellows will attend a series of weekly hour-long seminars given by faculty members ofthe Pulmonary/Critical Care Division as well as by faculty in other related disciplines such as Medicinesubspecialties, Surgery, Anesthesia and Obstetrics/Gynecology. The outline for these topics, to be completedover 2 years, is as follows (~75 lectures):

Critical Care Topics:

Cardiovascular Disease� cardiopulmonary resuscitation� cardiogenic shock� myocardial infarction� arrythmias� pericardial and valvular diseases� cardiomyopathy� hypertensive crisis� vascular emergencies� hemodynamic monitoring/temporary pacers

Respiratory Disease� acute respiratory failure� status asthmaticus� pneumonia� pulmonary, air embolism� aspiration, chemical pneumonitis, drowning,

smoke inhalation/burns� hemoptysis� mechanical ventilation and monitoring� upper airway obstruction� pulmonary hypertension

Renal Disease� acute renal failure� acid-base disorders� metabolic derangements (Ca++, Mg++, etc.)� dialysis

Neurologic Disease� coma� seizures� Myasthenia, Guillaine-Barre� cerebral vascular disease

Endocrine/Dermatlogic Diseases� thyroid – myxedema, storm, sick euthyroid� adrenal crisis, pheochromocytoma� diabetes: DKA, HNK� nutrition

� TEN, Stevens-Johnson

Infectious Diseases� sepsis, septic shock� antimicrobials� immunocompromised hosts (including AIDS)� nosocomial infections� community-acquired (toxic shock,

meningococcus, SBE)

Hematologic Diseases� acute coagulation defects� anticoagulation, fibrinolytic therapy� acute hemolytic disorders (including sickle

cell)� acute neoplastic crisis’� blood component therapy

Gastrointestinal Diseases� upper and lower GI bleeding� acute pancreatitis� acute hepatic failure� acute biliary disease� acute imflammatory bowel disease� acute vascular bowel disease� toxic megacolon� acute perforations, ruptures

Rheumatologic� vasculitis

Genitourinary, obstetric-gynecologic diseases� obstructive uropathy� urinary tract bleeding� complications of pregnancy (toxemia, etc.)

Surgical issues� head trauma� chest trauma� abdominal trauma� skeletal trauma

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� crush injury� burns� necrotizing fasciitis, soft-tissue infections� transplant issues

Anesthesia issues� airway maintenance� paralytics� perioperative complications

Poisonings� acetominophen, aspirin, alcohol, cocaine

TCA, MAO, neuroleptic, opiates� other – carbon monoxide

Monitoring� hemodynamic� cerebral� respiratory� metabolic� imaging� biomechanics

Ethical, administrative issues� ethical and legal considerations� psychosocial aspects of critical illness� JCAHO guidelines

Pulmonary Topics

Airway diseases� Asthma� COPD� Bronchiolitis� Cystic fibrosis

Parenchymal diseases� IPF� ILD – occupational/environmental, collagen

vascular, orther (sacoid, LAM, EG, HSP, etc.)

Vascular diseases� Pulmonary hypertension� Vasculitis, alveolar hemorrhage� Pulmonary embolism

Malignancy� Bronchogenic carcinoma� Metastatic disease� Carcinoid, tracheal tumors, etc.

Infections� Pneumonia� Immunocompromised hosts� TB, atypical mycobacterial disease

Lung Injury� ARDS� Radiation, inhalation, trauma

Pleural disease� Empyema� Malignancy

� Other etiologies: asbestos, collagen vasculardisease, Dressler’s

Occupational/environmental disease� Occupational disease� Drug-induced lung disease

Mediastinal disorders

Pulmonary manifestations of systemic diseaseand pregnancy� Collagen vascular disease� Sepsis, endocarditis� Renal, hepatic disease� Pregnancy

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Pulmonary physiology� PFT’s� Exercise testing� Pulmonary rehabilitation

Pulmonary radiology� CXR� CT� Nuclear� Other: Angio, PET, MRI

Pulmonary pathology

Pulmonary procedures

Respiratory care

Sleep medicine� Physiology� Sleep-testing� Clinical disorders

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Multidisciplinary Chest Tumor Conference (Thursday 7:45 AM)

GoalTo understand the evaluation and management of chest tumors from a multidisciplinary perspective

ObjectivesTo understand the diagnostic evaluation of patients with chest tumors. To understand the indications for andlimitations of diagnostic studies in the evaluation of chest tumors. To understand lung cancer staging andimplications for treatment. To develop professional skills in working with colleagues in other disciplines.

Educational ExperienceThis conference is held weekly in the radiology department. The multidisciplinary team comprises chestradiologists, thoracic surgeons, medical oncologists, radiation oncologists and pulmonologists. The physiciansubmits cases in advance for presentation. The diagnostic strategy and management is discussed. Furtherdiagnostic studies or treatment is then planned based on the group consensus. Time for follow-up reports onpatient progress is provided. Patients with lung cancer are staged and entered into the tumor registry based therecommendations of this conference. Fellows are expected to present pertinent cases and follow-up on therecommendations made at the conference. Attendance by the fellows is mandatory in the first two years oftraining.

General GuidelinesThis conference is held in the radiology department at 7:45 AM each Thursday. Cases should be submitted tothe Chest radiology division by Tuesday of that week.

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Pulmonary and Critical Care Journal Club(4th Friday)

Goal To provide an educational experience in literature review relevant to pulmonary medicine.

ObjectiveTo provide trainees a review of current literature in Pulmonary and Critical Care Medicine. To provide traineesan understanding of statistical methodology used in research articles. To develop skills in evaluating the qualityof published pulmonary and critical care literature.

Educational ExperienceThis conference will be held once per month. Fellows are expected to present 1 or 2 articles for detailed review.Assigned trainees will select the article(s) one week prior to the scheduled conference. A faculty member willbe assigned to review the article with the trainee prior to the conference presentation. The trainee will presentthe journal article(s) at the conference and lead the discussion. Each trainee will present at this conference 2times per year. Faculty and Fellow attendance is mandatory.


The program director will monitor the quality of the conference series. The program director will formally reviewthis educational program semiannually with the fellows and the faculty.

General GuidelinesJournal club is held on the last Friday of each month in the MICU conference room. Fellows should submitarticles to the unit secretary for distribution one week prior to the conference.

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CURRICULUMDepartment of Medicine Subspecialty (Fellowship) Training Programs

2002-2003

Goals/Objectives:

The following curriculum has been developed for the subspecialty residents (fellows) in all Department ofMedicine subspecialty training programs. The objective is to increase the knowledge of subspecialty residents(fellows) in the areas that are important but not specific to their particular subspecialty including:

Gene TherapyMedical Ethics Risk Management and Medical Legal IssuesMedical Informatics Epidemiology and randomized clinical trialsPatient Oriented ResearchImmunology

The curriculum is designed to be both useful to the subspecialty clinician and to stimulate potential researchinterest in the above areas.

Teaching Methods:

1. Core Lecture Series. The following one hour lectures/seminars have been scheduled (see schedule).

� Gene therapy: An overview (Gerry Silverstein)� Gene therapy at FAHC: Treatment of coronary artery disease (Matthew Watkins) � Risk management: Malpractice and the medical legal environment (Joseph Mailloux)� Ethics and the medical subspecialist (Robert Orr)� Epidemiology vs randomized clinical trials: What have we learned from the hormone replacement

debacle? (Richard Pinckney) � Medical Informatics: What is it? (Richard Pinckney) � Immunology in the new millennium: Who are the players and what do they do? (Ralph Budd)� Patient Oriented Research: What is it and who should do it? (Richard Galbraith)

Attendance at the seminars/lectures is mandatory. See schedule below.

2. Research Seminars. A research seminar/conference is scheduled the first Friday of each month in AustinAuditorium immediately following the Department of Medicine Grand Rounds (9:00 - 10:00 AM). Theseminars/conferences are given by the faculty of the Department of Medicine and emphasize originalresearch in both the basic and clinical sciences. Through regular participation in the ongoing seriessubspecialty residents (fellows) are exposed to topics and investigative techniques in immunology,molecular biology, genetics, biostatistics, clinical trial design, and epidemiology. The conferences/seminarsare formatted to stimulate discussion and are attended by medical students, residents, fellows, clinicalfaculty, research faculty, research technicians, and research nurses.

3. Conferences. Each subspecialty training program has a regular conference series and journal club.Journal club is used to emphasize findings germane to the specific subspecialty as well as emphasizelessons in clinical trial design, epidemiology, and biostatistics.

4. Course work. The subspecialty residents (fellows) have the option of taking a course on designing clinicalresearch. The course emphasizes clinical trial design, biostatistics, and epidemiology. It encompasses oneacademic semester and is taught by Ben Littenberg, :MD. By the end of the semester participants in thecourse are expected to design and write a clinical research proposal that meets the requirements forsubmission to appropriate funding agencies.

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Fellows Lecture SeriesDepartment of Medicine Subspecialty (Fellowship)

Training Programs(Cardiology Classroom: 12-1 PM)

Date: Title:

10/04/02: Patient Oriented Research: What Is It and Who Should Do It?(Richard Galbraith)

10/18/02: Gene Therapy: An Overview (Gerry Silverstein)

11/01/02: Gene Therapy at FAHC: Treatment of Coronary Artery Disease(Matthew Watkins)

11/15/02: Risk Management: Malpractice and the Medical Legal Environment(Joseph Mailloux)

12/06/02: Immunology in the New Millennium: Who are the Players and What Do TheyDo? (Ralph Budd)

12/20/02: Ethics and the Medical Subspecialist(Robert Ocr)

01/10/03: Medical Informatics: What is It?(Richard Pinckney)

01/24/03: Epidemiology vs Randomized Clinical Trials: What Have We Learned From TheHormone Replacement Debacle?(Richard Pinckney)

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FELLOW QUALITY ASSESSMENT AND IMPROVEMENT PROGRAM

Pulmonary and Critical Care Medicine Unit

SECTION 1: OVERVIEW

Purpose of Program: To involve the Fellow in the monitoring, assessment and improvement of the quality and safetyof health care services provided by Fletcher Allen Health Care. This is accomplished by including the fellow in thereview, evaluation and continuous improvement of the care delivered by the Pulmonary and Critical Care Medicine Unitand the Department of Medicine.

SECTION 2: LEARNING OBJECTIVES

1. Utilize evidence-based medicine to support decision making and diagnostic and treatment plans.2. Learn to critically analyze the literature to determine its relevance to patient care.3. Understand how practice patterns reflect evidence-based medicine and how practice guidelines can improve clinical

outcome.4. Learn to develop and implement quality assessment tools.5. Learn to assess effectiveness of quality assessment tools.

SECTION 3: METHODS

Mechanisms for participation of Fellows in the organizations Performance Improvement process include but are notlimited to the following:

1. Department of Medicine Morbidity and Mortality Conference2. Participation in service specific or organizational performance improvement initiatives.3. Involvement in Root Cause Analysis4. Completion of performance improvement and patient safety module of the mandatory competency inservice.5. Involvement in review of performance improvement indicators such as:

� Patient Satisfaction� Medical record review� Sedation for Procedure� Bronchoscopy complications

6. Didatic Lectures7. Journal Club

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Research

Training Program In Pulmonary Disease & Critical Care Medicine

OverviewSubstantive experience in research is a key element in the education of a sub-specialist in Pulmonary Diseaseand Critical Care Medicine (PDCCM). The research experience linked with didactic teaching and independentlearning activities will prepare the Trainee to meet the challenges of rapidly changing technology and newbodies of knowledge. For some Trainees, the research experience will become the catalyst for careerdevelopment and life-long pursuits as an investigator. For Trainees primarily directed towards clinical practiceand teaching, the research experience will serve as foundation for a critical appreciation of how new knowledgebecomes a part of medical practice. For all Trainees, our collective experience is that research, whether basicor clinic, is a stimulating and rewarding experience.

Training GoalsThe overall goals of research experience as part of the Training Program are: � To enhance understanding of the process through which new biomedical knowledge is acquired. � To prepare the Trainee to critically evaluate new research developments and to be prepared to implement

them into clinical practice. � To prepare the Trainee for further career development in biomedical research.

Specific ObjectivesAll Trainees will devote a substantial portion of their three-year program to research, and each will participate inone or more research projects during the course of training. All Trainees will become familiar with and gaindirect experience in:

� Essential research concepts which form the foundation of a research caeer, including:� Formulation of a research question� Formulation of a testable hypothesis� Study design� Selection and development of appropriate methods� Performance of experiments and / or data collection� Research ethics� Analysis of data� Organization of results� Formulation of conclusions� Peer review with presentation & publication of research findings

� Basic statistical concepts and methods as related to experimental design and data analysis.� Modern concepts of molecular biology, cell biology, immunology, and related fields as they relate to new

developments in medical diagnosis and therapy.� Participation in a research project designed and executed with the Trainee.� Presentation and publication of research results through the peer review process.

Individual Trainees will become familiar with specific concepts, research methodology, and procedures,depending on their particular research project. These may include:

� Ethical, legal, and practical issues in research with human subjects, including:� Principals of ethical study design� Principals of informed consent� Obligations and interactions with an Institutional Review Board (IRB) (Human Studies Committee).� Fair compensation for human research subjects.� Recruiting human subjects for biomedical research.� Reporting, record keeping, and confidentiality issues in human research.� Techniques of humane anesthesia and restraint

� Ethical and practical issues in research utilizing living animals, including:� Principals of ethical study design� Obligations and interactions with an Institutional Animal Care and Use Committee (IACUC).� Reporting and record keeping in animal research.

� Acquisition of specific skills related to human studies research, such as:� Development and application of questionnaires and study instruments.

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� Performance of specialized procedures (e.g. bronchoalveolar lavage, lung physiology measurements,metabolic observations, etc.)

� Population-based data collection and survey methodology

� Acquisition of specific skills related to animal research, such as:� Maintenance and monitoring of rodents for laboratory research.� Development and breeding of genetically modified mouse strains.� Interventions to create animal models of disease (e.g. acute and chronic drug administration,

inhalation toxicology, immunization and sensitization, etc.).� Physiologic measurements in laboratory animals (e.g. metabolic parameters, immune responses,

pulmonary physiology).� Recovery of organs and tissues from experimental animals (e.g. small animal surgery and dissection,

bronchoalveolar lavage, blood sampling, harvest of spleen or lymph node immune cells, etc.)� Histological or immunocytochemical techniques and quantative histological analysis

� Acquisition of general and specific laboratory skills, such as:� Basic techniques in cell culture and propagation.� Common techniques in molecular biology (nucleic acid extraction, Northern analysis, PCR expansion,

etc.)� Basic methods in laboratory immunology (antibody purification and measurement, lymphocyte

proliferative responses, cell surface antigen phenotype expression, flow cytometry, etc.).� Approaches to tissue pathology (conventional histologic staining, immunohistochemistry, in situ

hybridization, simple morphometry).� Fundamentals of biomedical laboratory procedures (solutions and buffers, sterile technique, weights

and measures, centrifugation, spectrophotometry, etc.).

� Acquisition of specific skills related to epidemiology, public health, and the promotion of healthy behaviors,such as:� Development and implementation of survey instruments.� Development of intervention tools to influence skills, knowledge, attitudes or resources and thus

change behavior and outcome as related to health risks (smoking prevention, smoking cessation, airpollution, etc.).

� Analysis of large group and public health statistical information.� Analysis of health outcomes data.

ActivitiesTrainees will work towards the overall goals and specific objectives listed above through didactic one-on-oneteaching with a research mentor, seminars, and reading directed to research-related topics, throughparticipation in research presentations, and by carrying out one or more research projects during the course oftheir training. Some of these activities will be uniform and applicable to all Trainees, such as the Departmentof Medicine Research Education Seminar series or the Vermont Lung Center (COBRE) educational series.Other activities will be individual and will be based on the nature and progress of the research projectundertaken, such as a progress report delivered at an immunology lab meeting by a Trainee engaging in arelevant project.

Didactic Teaching & ConferencesA wide variety lectures, seminars, and conferences relevant to lung research occur on a regular basis withinthe UVM College of Medicine and Fletcher Allen health Care. Trainee attendance at several of theseconferences is required (*), while at other conferences attendance would be based on personal interest.Regular scheduled conferences include:

Vermont Lung Center Research in Progress Seminar (Tuesdays A265 Pathology Classroom UVM, 8:15 - 9:15 AM)This conference is scheduled as one of our weekly Division conference series. Each Trainee is expected topresent their personal research plans or results twice a year in the 2nd and 3rd years of training. This researchconference encompasses:

� Presentation of recent research findings by PDCCM faculty members.� Presentation of relevant research by other UVM / FAHC faculty.� Presentation of personal research by visiting scientists.� Presentation of research project planning and results by Trainees.

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Department of Medicine Training Seminar Series (1st & 3rd Wednesday Austin Auditorium 4:30 - 5:30)This conference series presents lectures by senior faculty on key topics relevant to all training programs inInternal Medicine, including research methodology, biostatistics, ethics and medico-legal issues. SeniorTrainees present their own research findings at designated conferences.

Seminars in Investigative Medicine (Weekly Clinical Research Center 1:00 - 1:45)This seminar series is coordinated by the Office of Patient-Oriented Research and the General ClinicalResearch Center of the University of Vermont. Local faculty and visiting scientists present their researchfindings related to human subjects.

Year 01� The Trainee will meet with members of the PDCCM faculty, faculty in other Units, and investigators in

other Departments of the University to learn about ongoing topics of research related to lung disease andcritical illness.

� The Trainee and faculty will identify a research mentor with whom the Trainee will primarily work. Thementor will be a senior faculty member with substantial research experience. The mentor may be amember of PDCCM faculty, but may also be a basic scientist and/or a member of another department.The Trainee and the mentor will develop a research topic, and will the plan study design, and will beginmethods development. A total of two months elective time during the first year will be reserved for theprocess of planning a research project to begin at the start of the second year.

� The Trainee will attend the weekly VLC Research Conferences of the PDCCM Unit.� The Trainee will present one VLC Research Conference during the second half of the year to explain the

research problem and the study design that has been selected.� The Trainee will attend the bi-weekly conferences of the Department of Medicine Training Series.� The Trainee will attend research conferences related to his / her chosen area of research after the initial

planning and selection of topic are underway.� The Trainee may, if appropriate, attend one or two day-long courses in research methodology (transgenic

mice, basics of molecular biology, lung physiology in small animals, etc.) put on each spring at the AnnualMeeting of the American Thoracic Society.

Year 02� The Trainee will begin in the second year to carry out the laboratory or clinical research project designed

during the first year. The Trainee will devote a minimum of four months, and up to eight months if needed,to this project. During these months the Trainee will not be assigned in-patient responsibilities except fornight and weekend call. The Trainee will participate in ambulatory patient care up to two half-days perweek.

� The Trainee and the mentor will meet on a regularly scheduled basis to review progress and plan activities(typically, this is in the form of a weekly laboratory group meeting).

� The Trainee will attend the weekly VLC Research Conferences of the PDCCM Unit.� The Trainee will present two Research Conferences during the year to provide progress reports on

research accomplishments and planned activities.� The Trainee will attend the bi-weekly conferences of the Department of Medicine Training Series.� The Trainee will attend University research conferences related to his / her chosen area of research.� The Trainee will attend one national or regional conference focused specifically on their topic of research.

Year 03� The Trainee will continue in the third year to carry out their laboratory or clinical research project. When

appropriate, the Trainee may choose to pursue an additional research project in the same or anotherdiscipline. For example, a Trainee involved primarily with laboratory research might participate in a limitedclinical research project in order to gain experience with human studies. The Trainee will devote aminimum of four months, and up to eight months if needed, to research projects. During these months theTrainee will not be assigned in-patient responsibilities except for night and weekend call. The Trainee willparticipate in ambulatory patient care up to two half-days per week.

� The Trainee and the mentor will meet on a regularly scheduled basis to review progress and planactivities.

� The Trainee will attend the weekly VLC Research Conferences of the PDCCM Unit.� The Trainee will present one Research Conference during the first half of the year to provide a progress

report on research accomplishments and planned activities, and will during the second half of the year willprovide a final summary of results and conclusions.

� The Trainee will attend the bi-weekly conferences of the Department of Medicine Training Series.� The Trainee will attend University research conferences related to his / her chosen area of research.

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� The Trainee will be encouraged to submit and present their research findings at a national scientificmeeting.

� The Trainee will be encouraged to submit their research findings for peer review and publication.� The third year Trainee will assist with research training and supervision of graduate students, and first or

second year Trainees engaged in similar research activities.� The third year Trainee will assist with seminar and didactic research teaching through the activities of the

mentor and through the regular conference schedule of the division.

Year 04� A fourth year of intensive research training is highly desirable for physicians planning an academic career

with research activities. This fourth year is not part of the accredited training program, but is available atour institution. Trainees with a research career goal will be encouraged to remain at the institution for anadditional year, and to devote 80% of their time to research. During their third year they will beencouraged to apply for national career development awards through the National Institutes of Health andthrough private agencies and foundations. The activities during the fourth year will be similar to thoselisted for the third year.

EvaluationTrainees will be evaluated semi-annually in regards to their research activities to assure that they are makingprogress towards the goals and objectives listed above. The results of these evaluations will be provided toboth the Trainee and the Program Director in writing. The means and criteria for evaluation will be appropriatefor the specific activities of each year of training, and will include:

� Progress towards identifying, planning, and performing a research project as judged by the directobservation of the research mentor and the training faculty.

� Effective presentation of research progress reports at the scheduled Research Conferences.� Attendance and diligence in the research project.� Attendance at research conferences.� Submission of grant requests.� Submission of research results for presentation at scientific meetings.� Submission of research results for publication.

Research mentors will be evaluated in writing semi-annually. The results of these evaluations will be providedto the Faculty and Program Director.

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CLINICAL CURRICULUM AND EDUCATIONAL PROCESSNote: Notations following each listed learning experience reference specific goals, objectives, educationalexperiences found in Section 4 – Educational Programs

GOAL ONEFellows will demonstrate knowledge of physiology, pathophysiology, diagnosis, and therapy of problemspertinent to Pulmonary and Critical Care Medicine.

Objective 1: (Pulmonary Medicine knowledge areas)Fellows will learn pathophysiology and how to diagnose and manage patients with obstructive lung diseases,including:

� Asthma� Chronic obstructive pulmonary disease (COPD)� Emphysema� Chronic bronchitis� Bronchiectasis� Cystic fibrosis

Educational ProcessPrimary Learning Experiences

� Pulmonary Ambulatory Center (on page 31)� Pulmonary Consult Service (on page 38)

Supplemental Learning Areas� Northwest Medical Center (on page 32)� Cystic Fibrosis Clinic (on page 34)� MICU (on page 39)� Pulmonary/Critical Care Department Teaching Conferences (on page 47)� Pulmonary and Critical Care Journal Club (on page 55)� Outpatient Pulmonary Conference (on page 49)

Fellows will learn pathophysiology and how to diagnose and manage patients with interstitial and inflammatorylung diseases, including:

� Sarcoidosis� Idiopathic pulmonary fibrosis� Pneumoconiosis, including:

� Asbestosis� Silicosis

� Pulmonary hemorrhagic disorders, including:� Wegener's granulomatosis� Goodpasture's Syndrome

� Vasculitis of the lung� Collagen-vascular diseases� Bronchiolitis obliterans organizing pneumonia (BOOP)� Eosinophilic granuloma� Allergic bronchopulmonary aspergillosis (ABPA)� Hypersensitivity pneumonitis� Drug-induced lung disease� Alveolar proteinosis



Supplemental Learning Areas� Northwest Medical Center (on page 32)� Cystic Fibrosis Clinic (on page 34)

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� MICU (on page 39)� Pulmonary/Critical Care Department Teaching Conferences (on page 47)� Pulmonary and Critical Care Journal Club (on page 55)� Outpatient Pulmonary Conference (on page 49)

Fellows will learn pathophysiology and how to diagnose and manage patients with occupational andenvironmental lung diseases.




Fellows will learn pathophysiology and how to diagnose and manage patients with pulmonary vasculardiseases, including:

� Deep venous thrombosis (DVT)� Acute pulmonary embolism� Recurrent pulmonary embolism� Chronic thromboembolic disease� Primary pulmonary hypertension� Secondary pulmonary hypertension




Fellows will learn pathophysiology and how to learn and diagnose and manage patients with lung infections,including:

� Community-acquired pneumonia� Nosocomial pneumonia� Lung abscess� Aspiration pneumonitis� Tuberculosis, including tuberculous infection and active tuberculosis� Nontuberculous mycobacterial infections� Fungal infections of the lung



Supplemental Learning Areas� Northwest Medical Center (on page 32)

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� Cystic Fibrosis Clinic (on page 34)� MICU (on page 39)� Pulmonary/Critical Care Department Teaching Conferences (on page 47)� Pulmonary and Critical Care Journal Club (on page 55)� Outpatient Pulmonary Conference (on page 49)

Fellows will learn pathophysiology and how to diagnose and manage patients with pulmonary manifestations ofAcquired Immune Deficiency Syndrome (AIDS) and other immunodeficiency diseases.




Fellows will learn physiology, pathophysiology, and how to manage patients who have undergone lungtransplantation.

Educational Process Primary Learning Experiences

� Pulmonary Ambulatory Center (on page 31)� Cystic Fibrosis Clinic (on page 34)

Supplemental Learning Areas� Pulmonary/Critical Care Department Teaching Conferences (on page 47)

Fellows will learn pathophysiology and how to diagnose and manage patients with pulmonary neoplasms,including:

� Benign neoplasms of lung� Small cell cancer of lung� Non-small cell cancer of lung� Paraneoplastic syndromes of lung cancer� Malignancies metastatic to lung


� Pulmonary Ambulatory Center (on page 31)� Pulmonary Consult Service (on page 38)� Multidisciplinary Chest Tumor Conference (on page 54)

Supplemental Learning Areas� Pulmonary/Critical Care Department Teaching Conferences (on page 47)� Outpatient Pulmonary Conference (on page 49)

Fellows will learn pathophysiology and how to diagnose and manage patients with disorders of the pleura,including:

� Pleuritis� Pleural effusion� Empyema� Fibrothorax� Mesothelioma, benign and malignant

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Supplemental Learning Areas� Pulmonary/Critical Care Department Teaching Conferences (47)� Outpatient Pulmonary Conference (on page 49)

Fellows will learn pathophysiology and how to diagnose and manage patients with disorders of themediastinum, including:

� Mediastinitis� Mediastinal tumor



Supplemental Learning Areas� Pulmonary/Critical Care Department Teaching Conferences (on page 47)� Outpatient Pulmonary Conference (on page 49

Fellows will learn pathophysiology and how to diagnose and manage patients with chest trauma, including:� Rib fracture� Flail chest� Pneumothorax, simple and tension� Pulmonary contusion� Foreign body aspiration


� Medical Intensive Care (on page 39)� Surgical Intensive Care (on page 41)� Pulmonary/Critical Care Department Teaching Conferences (on page 47)

Supplemental Learning Areas� Pulmonary Medicine Consultation Service (on page 38)

Fellows will learn pathophysiology and how to diagnose and manage patients with acute lung injury due toinhalation and radiation, including:

� Chemical pneumonitis� Radiation pneumonitis



Supplemental Learning Areas� Pulmonary/Critical Care Department Teaching Conferences (on page 47)� Outpatient Pulmonary Conference (on page 49

Fellows will learn pathophysiology and how to diagnose and manage patients with developmentalabnormalities and congenital disorders, including:

� Azygous fissure

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� Pulmonary sequestration

Fellows will learn pathophysiology and how to diagnose and manage patients with genetic disorders, including:� Cystic fibrosis � Alpha-1-proteinase inhibitor deficiency


� Pulmonary Ambulatory Center (on page 31)� Cystic Fibrosis Clinic (on page 34)

Supplemental Learning Areas� Pulmonary/Critical Care Department Teaching Conferences (on page 47)� Pulmonary and Critical Care Journal Club (on page 55)� Outpatient Pulmonary Conference (on page 49)

Fellows will learn pathophysiology and how to diagnose and manage patients with respiratory failure, including:� Acute respiratory distress syndrome (ARDS)� Acute and chronic respiratory failure in obstructive or restrictive lung disease� Neuromuscular respiratory drive disorders


� Pulmonary Medicine Consultation Service (on page 38)� Medical Intensive Care (on page 39)� Surgical Intensive Care (on page 41)

Supplemental Learning Areas� Pulmonary/Critical Care Department Teaching Conferences (on page 47)� Critical Care Teaching Conferences (on page 51)� Pulmonary and Critical Care Journal Club (on page 55)

Fellows will learn pathophysiology and how to diagnose and manage patients with hypersomnia and sleepdisorders, including:

� Sleep disordered breathing� Obstructive sleep apnea syndrome� Nocturnal hypoxemia secondary to COPD� Nocturnal hypoxemia secondary to CHF

� Periodic leg movement syndrome (PLMS)� Narcolepsy� Insomnia


� Sleep Disorders Clinic (on page 36)Supplemental Learning Areas


Objective 2: (Critical Care Medicine knowledge areas)Fellows will learn pathophysiology and how to diagnose and manage patients with disorders which can causepatients to become critically ill, including:

� Cardiovascular disorders� Respiratory disorders� Renal disorders� Gastrointestinal disorders� Genitourinary disorders� Neurologic disorders

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� Endocrine disorders� Hematologic disorders� Musculoskeletal disorders� Disorders of the immune system� Infectious diseases� Obstetric and gynecological disorders� Anaphylaxis and acute allergic reactions� Trauma


� Medical Intensive Care (on page 39)� Surgical Intensive Care (on page 41)

Supplemental Learning Areas� Pulmonary/Critical Care Department Teaching Conferences (on page 47)� Critical Care Teaching Conferences (on page 51)� Pulmonary and Critical Care Journal Club (on page 55)

Fellows will learn pathophysiology and how to diagnose and manage patients with disorders secondary tocritical illness, including:

� Electrolyte and acid-base disorders secondary to critical illness� Metabolic, nutritional, and endocrine effects of critical illnesses� Hematologic and coagulation disorders secondary to critical illness� Pharmacokinetics, pharmacodynamics, drug metabolism, and drug excretion in critical illness



Supplemental Learning Areas� Anesthesia (on page 42)� Pulmonary/Critical Care Department Teaching Conferences (on page 47)� Critical Care Teaching Conferences (on page 51)� Pulmonary and Critical Care Journal Club (on page 55)

Fellows will learn pharmacology and clinical use of paralytic agents.


� Anesthesia (II. D)Supplemental Learning Areas


GOAL TWO:Fellows will demonstrate practice skills necessary to diagnose and manage problems pertinent to Pulmonaryand Critical Care Medicine.

Objective 1: (Pulmonary Medicine practice skills)Fellows will learn how to obtain a thorough and orderly history relevant to pulmonary problems, including:

� Dyspnea, on exertion and at rest� Cough and expectoration� Wheezing and stridor� History of known pulmonary diseases� Occupational history and history of exposures� History of past TB skin tests

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� History of past chest roentgenograms� History of previous surgical procedures


� Pulmonary Ambulatory Center (on page 31)� Northwestern Medical Center (on page 32)� Pulmonary Consult Service (on page 38)

Supplemental Learning Areas� Cystic Fibrosis Clinic (on page 34)� Allergy and Immunology Clinic (on page 35)� Outpatient Pulmonary Conference (on page 49)

Fellows will learn how to perform a thorough and systematic physical examination relevant to pulmonaryproblems, and will learn to recognize and understand the significance of pulmonary and extrapulmonary signsof pulmonary diseases, including:

� Abnormal patterns of breathing, including:� Kussmaul breathing� Cheyne-Stokes breathing� Thoracic-diaphragmatic dyscoordination� Abnormal chest and diaphragm movement� Use of accessory respiratory muscles

� Chest wall abnormalities, including:� Kyphosis� Scoliosis� Pectus excavatum� Pectus carniatum� Straight back� Barrel chest� Ankylosis

� Adventitious lung sounds


� Pulmonary Ambulatory Center (on page 31)� Northwestern Medical Center (on page 32)� Pulmonary Consult Service (on page 38)

Supplemental Learning Areas� Cystic Fibrosis Clinic (on page 34)� Allergy and Immunology Clinic (on page 35)� Outpatient Pulmonary Conference (on page 49)

Fellows will learn how to interpret laboratory data relevant to pulmonary problems, including:

� Sputum cultures and microscopic examination for bacteria, mycobacteria, fungi, and Legionella� Sputum cytology� Oxygen saturation (by pulse oximeter)� Arterial blood gas (ABG)� TB skin test� Skin test for delayed hypersensitivity� Sweat chloride test� Pleural fluid analysis, including cytology, chemistry, gram stain, and culture for bacteria, fungi, and

mycobacteria� Transthoracic needle aspirate and biopsy� Lung biopsy

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Supplemental Learning Areas� Pulmonary/Critical Care Department Teaching Conferences (on page 47)� Multidisciplinary Chest Tumor Conference (on page 54)� Outpatient Pulmonary Conference (on page 49)

Fellows will learn how to interpret physiologic data relevant to pulmonary problems, including:� Pulmonary function tests

� Simple spirometry� Spirometry before and after bronchodilator� Inhalation challenge studies� Lung volumes� Diffusing capacity

� Exercise tests� Sleep studies


� Pulmonary Ambulatory Center (on page 31)� Pulmonary Physiology and Pulmonary Function Testing (Error! Bookmark not defined.)

Supplemental Learning Areas� Allergy and Immunology Clinic (on page 35)� Sleep Disorders Clinic (on page 36)

Fellows will learn how to interpret radiologic imaging studies relevant to pulmonary problems including:� Chest roentgenogram� Fluoroscopy of the chest � Bronchogram� Computerized axial tomography (CAT) of chest� Radionuclide lung (V/Q) scan� Non-invasive leg studies

� Compression ultrasonography� Impedance plethysmography (IPG)

� Pulmonary arteriogram


� Pulmonary Ambulatory Center (on page 31)� Pulmonary/Critical Care Department Teaching Conferences (on page 47)� Radiology-Pathology Conference

Supplemental Learning Areas� Pulmonary Consult Service (on page 38)� Medical Intensive Care Unit (on page 39)� Multidisciplinary Chest Tumor Conference (on page 54)� Pulmonary and Critical Care Journal Club (on page 55)

Objective 2: (Critical Care Medicine practice skills)� Fellows will learn how to obtain a thorough and orderly history on critically ill patients in an efficient and

expedient manner.� Fellows will learn how to perform and thorough and systematic physical examination on critically ill patients

in an efficient and expedient manner. � Fellows will learn how to interpret laboratory data relevant to critically ill patients.� Fellows will learn how to interpret radiologic data relevant to critically ill patients.

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Supplemental Learning Areas� Critical Care Teaching Conferences (on page 51)

GOAL THREE:Fellows will demonstrate technical skill necessary to use specialized equipment and perform specializedprocedures used to diagnose and manage problems pertinent to Pulmonary and Critical Care Medicine.

Objective 1: (Technical skills with specialized equipment)Fellows will learn the indications, contraindications, complications, and proper use of specialized equipment formanaging patients with pulmonary and critical care problems, including:

� Management of airway� Establishment of airway� Maintenance of open airway in nonintubated, unconscious, paralyzed patients� Oral and nasotracheal intubation

� Management of breathing and ventilation� Ventilation by bag or mask� Mechanical ventilation using pressure-cycled, volume-cycled, and negative pressure mechanical

ventilators� Use of reservoir masks and CPAP masks for delivery of supplemental oxygen, humidifiers,

nebulizers, and incentive spirometry� Weaning from mechanical ventilation� Respiratory care techniques� Management of pneumothorax

� Maintenance of circulation� Oxygen saturation by pulse oximeter� Arterial blood gas analysis� Basic and advanced cardiopulmonary resuscitation� Cardioversion

� Pulmonary function tests� Simple spirometry� Spirometry before and after bronchodilators� Inhalation challenge studies� Lung volumes� Diffusing capacity� Exercise tests

� Calibration and operation of hemodynamic monitoring and recording systems, including utilization,zeroing, and calibration of transducers, and use of amplifiers and recorders.

� Parenteral nutrition


� Anesthesia (on page 42)� Pulmonary Physiology and Pulmonary Function Testing (Error! Bookmark not defined.)

Supplemental Learning Areas� Medical Intensive Care (on page 39)� Surgical Intensive Care (on page 41)� Critical Care Teaching Conferences (on page 51)� Pulmonary and Critical Care Journal Club (on page 55)

Fellows will learn to analyze specialized data pertaining to Pulmonary and Critical Care problems, including:� Cardiac output determinations by thermodilution and/or other techniques� Evaluation of all urine oliguria� Management of massive transfusions

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� Management of hemostatic defects� Interpretation of antibiotic levels and sensitivities� Monitoring and assessment of metabolism and nutrition� Calculation of oxygen content, intrapulmonary shunt, and alveolar-arterial gradients� Pharmacokinetics


� Anesthesia (on page 42)� Pulmonary Physiology and Pulmonary Function Testing (Error! Bookmark not defined.)

Supplemental Learning Areas� Medical Intensive Care (on page 39)� Surgical Intensive Care (on page 41)� Critical Care Teaching Conferences (on page 51)� Pulmonary and Critical Care Journal Club (on page 55)

Objective 2: (Technical skills performing specialized procedures)Fellows will learn the indications, contraindications, complications, and proper technique for performingprocedures relevant to pulmonary and critical care problems, including:

� Sputum induction� Sputum gram stain� TB skin tests� Skin tests for delayed hypersensitivity� Arterial puncture for arterial blood gas (ABG)� Insertion of arterial catheter� Insertion of central venous catheter� Insertion of pulmonary artery balloon floatation catheter� Thoracentesis� Pleural biopsy� Endotracheal intubation (oral and nasal)� Flexible fiberoptic bronchoscopy, including:

� Bronchial washing� Bronchial brushing� Collection of samples with protected bronchial brush� Bronchoalveolar lavage� Endobronchial biopsy� Transbronchial biopsy� Transbronchial needle aspiration

� Insertion of thoracostomy (chest) tube� Pleural sclerosis


� Pulmonary Medicine Consultation Service (on page 38)� Medical Intensive Care (on page 39)� Critical Care Teaching Conferences (on page 51)

Supplemental Learning Areas� Anesthesia (on page 42)� Critical Care Teaching Conferences (on page 51)

Fellows will learn the indications, contraindications, and complications of, and may gain practical experience inperforming, other procedures relevant to Pulmonary and Critical Care problems, including:

� Pericardiocentesis� Transvenous pacemaker insertion� Peritoneal dialysis� Peritoneal lavage� Aspiration of major joints

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� Percutaneous needle aspiration and/or cutting lung biopsy� Endobronchial laser therapy� Intracranial pressure monitoring


� Surgical Intensive Care (on page 41)� Critical Care Teaching Conferences (on page 51)

Supplemental Learning Areas� Medical Intensive Care (on page 39)� Pulmonary/Critical Care Departmental Teaching Conferences (on page 47)� Pulmonary and Critical Care Journal Club (on page 55)

GOAL FOUR:Fellows will demonstrate ability to apply knowledge, practice skills, and technical skills to diagnose and managepatients with problems pertinent to Pulmonary and Critical Care Medicine.

Objectives (Clinical application of knowledge and skill)Fellows will learn how to diagnose and manage patients with symptoms and signs of pulmonary disease,including:

� Dyspnea� Cough� Hemoptysis� Solitary pulmonary nodule� Lung mass� Localized pulmonary infiltrate� Diffuse pulmonary infiltrates� Atelectasis� Pleural effusion� Pneumothorax


� Pulmonary Ambulatory Center (on page 31)� Pulmonary Medicine Consultation Service (on page 38)

Supplemental Learning Areas� Medical Intensive Care (on page 39)� Pulmonary/Critical Care Department Teaching Conferences (on page 47)� Outpatient Pulmonary Case Conference (on page 49)

GOAL FIVE:Fellows will demonstrate ability to provide cognitive and technical advice and expertise as a consultingPulmonary and Critical Care Physician.

Objectives (Providing consultation, use of consultation)Fellows will learn the basic constructs of the referral-consultant relationship for managing or co-managing thecare of patients with pulmonary problems or patients who are critically ill.

Fellows will learn when to refer patients for procedures to be performed by a thoracic surgeon or otherspecialist, including:

� Thoracoscopy� Open lung biopsy� Scalene node biopsy� Mediastinoscopy� Mediastinotomy� Lung resection� Lung transplant

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� Pleural decortication� Rib resection and open pleural drainage� Tracheostomy� Radiation therapy of lung


� Pulmonary Ambulatory Center (on page 31)� Multidisciplinary Chest Tumor Conference (on page 54)

Supplemental Learning Areas� Pulmonary Consult Service (on page 38)� Medical Intensive Care Unit (on page 39)� Pulmonary/Critical Care Department Teaching Conferences (on page 47)� Critical Care Teaching Conferences (on page 51)� Outpatient Pulmonary Case Conference (on page 49)

GOAL SIX:Fellows will demonstrate knowledge of how the care of problems pertinent to Pulmonary and Critical CareMedicine fit into patients' overall health plan.

Objectives: (Attitudes, values, and habits about long-term care)Fellows will learn the importance of preventive medicine techniques in the long-term management of patientswith pulmonary problems, including:

� Smoking cessation� Influenza vaccine� Pneumococcal vaccine

Fellows will learn the long-term impact of treating patients who are severely and critically ill.


� Pulmonary Ambulatory Center (on page 31)� Pulmonary Rehabilitation Program (on page 33)

Supplemental Learning Areas� Northwestern Medical Center (on page 32)� Pulmonary/Critical Care Department Teaching Conferences (on page 47)� Outpatient Pulmonary Case Conference (on page 49)

GOAL SEVEN:Fellows will demonstrate attitudes, values, and habits of a dedicated academic subspecialist in Pulmonary andCritical Care Medicine.

Objectives: (Life-long attitudes, values, habits and contributions)� Teaching: Fellows will learn to take an active role in teaching common problems pertinent to Pulmonary

and Critical Care Medicine to medical students, residents, and practicing physicians in CME programs.� Management of resources and services: Fellows will learn to monitor and supervise special services

relevant to Pulmonary and Critical Care Medicine, including:� Pulmonary function laboratories� Respiratory care services� Respiratory physical therapy and rehabilitation services� Intensive Care Units

� Societal considerations: Fellows will learn the impact of pulmonary and critical care illnesses on society,including:� The ethical, economic, and legal aspects of pulmonary and critical illnesses, including:

� Smoking� Asthma� Chronic obstructive pulmonary disease (COPD)

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� Occupational lung diseases� Sleep disorders

� Occupational Safety and Health Administration (OSHA) regulations and universal precautions, andprotection of health care workers.

� Personal impact of pulmonary and critical illnesses on patients and patients' families.� Coping skills: Fellows will learn constructive coping skills for physicians and other health care

professionals who care for chronically ill pulmonary patients and for critically ill patients.


� Pulmonary Ambulatory Center (on page 31)� Medical Intensive Care Unit (on page 39)� Pulmonary/Critical Care Department Teaching Conferences (on page 47)

Supplemental Learning Areas� Northwestern Medical Center (on page 32)� Pulmonary Rehabilitation Program (on page 33)� Sleep Disorders Clinic (on page 36)� Department of Medicine – Fellows Lecture Series (on page 56)� Pulmonary Physiology and Pulmonary Function Testing (Error! Bookmark not defined.)

TABLE OF CONTENTS

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