Three-Year Fellowship Outlined
The clinical curriculum for trainees in the first, second and third year of fellowship training is outlined below. There is considerable overlap in the clinical experiences and education provided to the fellow in each year of training.
Year One: The first year of fellowship is divided into two components, the Inpatient Pulmonary Consult Service and the Critical Care/Respiratory Intensive Care Unit Service. The year is divided equally between these two rotations, in blocks of one-month duration. In addition, the trainee also evaluates outpatients in the emergency room throughout the year. Additional information regarding these rotations is also provided in the Pulmonary Disease/Critical Care Medicine Division Goals and Objectives Policy. During these rotations, the trainee acquires clinical experience with a spectrum of pulmonary and critical care diseases and procedures, including the following:
- Obstructive lung diseases, including asthma, chronic obstructive lung disease, bronchitis, emphysema, bronchiectasis and cystic fibrosis.
- Pulmonary malignancy, including primary lung tumors and metastatic disease
- Pulmonary infections, including tuberculosis, fungal lung disease and management of infection in the immunocompromised patient
- Interstitial lung disease, including sarcoid, idiopathic pulmonary fibrosis and disease related to vasculitis and collagen vascular disease
- Pulmonary hypertension and pulmonary hemorrhage syndromes
- Occupational lung diseases, including occupational asthma, COPD related to environmental exposures, interstitial lung diseases of occupations and hypersensitivity pneumonitis
- Iatrogenic and drug induced lung disease
- Acute lung injury and respiratory failure related to obstructive lung disease and neuromuscular disease
- Disorders of the pleura and mediastinum, including management of pleural effusions and empyema
- Genetic and developmental disorders
- Sleep disorders, including obstructive sleep apnea, narcolepsy and central hyperventilation syndromes
- Neruologic conditions, including intracranial hemorrhage, ischemic stroke, meningoencephalitis, and respiratory failure due to degenerative and neuromuscular diseases
- Complications of high risk obstetrical patients, such as pre-eclampsia, amniotic fluid embolism and pregnancy related cardiomyopathy
During the first year of clinical training, the fellow gains experience in the following procedures related to the care of pulmonary and critical care patients:
- Establishment and maintenance of an open airway in non-intubated, unconscious patients and intubation of the airway with an endotracheal tube
- Management of mechanical ventilation, including non-invasive mechanical ventilation and methods of ventilator weaning and liberation
- Use of masks and devices to deliver oxygen, nebulized medications and incentive spirometry
- Management of pneumothorax
- Arterial puncture and blood sampling, insertion of central venous, arterial and pulmonary artery balloon catheters
- Basic and advanced cardiopulmonary resuscitation and cardioversion
- Pulmonary function testing and interpretation, including spirometry, lung volumes, diffusion capacity, blood gas analysis, exercise testing and measurement of central respiratory drive
- Diagnostic and therapeutic procedures, including thoracentesis and fiber optic bronchoscopy
- Calibration of hemodynamic monitoring systems and the utilization, zeroing, and calibration of transducers
- Examination of samples of sputum, pleural fluid and tissue, and lung tissue for culture and histology
- Appropriate utilization and application of enteral and parenteral nutrition
Through didactics and clinical experience obtained during both the critical care and consult rotations the trainee also is exposed to and gains experience in the management of non-pulmonary critical care issues including electrolyte, acid base physiology, metabolic, nutritional and endocrine effects of critical illness. Critically ill patients with multi-organ diseases including hematology, oncology, immunodeficiency, allergy, and anaphylaxis are managed by the fellow, as are critical obstetrical and gynecologic disorders. Unique aspects of drug metabolism and effect plus the use of sedation and paralytic agents in pulmonary and critical care patients are encountered In addition, the ethical, economic and legal aspects of critical care including the administration of an intensive care unit, effective communication and the emotional and psychosocial effects of critical illness in patients with critical illness are also addressed.
Throughout the first year, the fellow also attends a one half day general pulmonary continuity clinic weekly. He or she will continue attending the same clinic over the three years, supervised by a faculty member.
Year Two: During the second year of training, the fellow spends the first half of the year gaining more experience with the management of similar pulmonary inpatients/outpatients and critical care patients as encountered in year one. In addition, the fellow rotates on the pulmonary procedure service, long term acute care unit and in a general surgical critical care unit. These rotations afford the trainee with additional experience in the areas of pulmonary function testing, inhalation challenge testing, cardiopulmonary exercise testing, management of pleural disease by pleural drainage procedures, complex airway management with rigid bronchoscopy, and fiberoptic bronchoscopy. During the pulmonary procedures rotation, the fellow is able to develop expertise in the monitoring and supervising of pulmonary function testing, respiratory physical therapy and pulmonary rehabilitation services, as well as respiratory care techniques and services. Procedures that the fellow will gain proficiency in performing include:
- Fiberoptic flexible bronchoscopy
- Endobronchial brush biopsy, protected brush technique
- Endobronchial biopsy
- Transbronchial biopsy
- Foreign body extraction technique
- Fine needle aspiration (FNA)
- Airway lesion balloon dilatation, stent placement
- Endobronchial ultrasound-directed biopsy (EBUS)
- Rigid bronchoscopy, airway tumor debridement techniques
- Percutaneous tracheostomy placement
- Chest drainage catheter placement under ultrasound guidance
- Cardiopulmonary exercise testing and interpretation
- Six-minute walking test
- Methacholine challenge testing, exercise bronchoprovocation tests
- Induction of sputum (hypertonic saline) for diagnosis
- Right heart catheterization
- Vasodilator trial (Flolan) infusion for PA Hypertension evaluation
The trainee is instructed in the use of amplifiers and records. All of these components are closely linked to the pulmonary physiology laboratory at St. Elizabeth’s Medical Center. While rotating at the St. Elizabeth’s Surgical Intensive Care Unit, the fellow also obtains additional exposure and practical experience with pericardiocentesis, transvenous pacemaker insertion, peritoneal dialysis and intracranial pressure monitoring with the supervision of a member of the surgical critical care division. General surgical, cardiothoracic, neurosurgical and complex urology patients are all managed in this unit. The trainee spends a one-month block rotating in this unit. The fellow also rotates at the Kindred Rehabilitation Hospital where he/she acquires skills required to manage chronically critically ill patients with multiple organ failure and comorbidities, including those on chronic mechanical ventilation and patients with complex airway problems. The second half of the year is spent in research and coverage rotations for the first year fellows vacation periods. This includes intensive instruction in research design, statistics and participation in journal club, where critical review of the literature is stressed.
Year Three: During the third year of training, the fellow continues their research activities in the first half of the year. This allows an uninterrupted period to focus on research project development, IRB submission, conduct of the research, analysis of data and manuscript preparation for publication. The second half of the year is devoted to clinical activities and electives. The fellow will again rotate coverage of the procedure service, and the cardiopulmonary and PFT lab. The fellow also rotates in a pulmonary rehabilitation facility providing extensive experience in the management of post-hospital patients including ventilator weaning, pulmonary rehabilitation and management of airway devices, including tracheotomy tubes. The third year fellow rotations include a one-month block at a Trauma Surgical Intensive Care Unit and at Kindred Rehabilitation Hospital. Elective rotations available for third year fellows include electives in lung transplantation and neonatal ICU medicine (NICU at St. Elizabeth’s Medical Center). There is also an elective in ICU telemedicine at the Steward Health Care eICU in Westwood, Massachusetts.
Fellows in all years of training actively manage patients under faculty supervision in a required continuity clinic consisting of a broad mix of patient problems in pulmonary medicine, conduced as half day sessions, weekly. Additional opportunities for outpatient exposure and management of specialty care patients are provided in the sleep medicine, interventional bronchology, and pulmonary hypertension clinics located at the Brighton Marine Health Center adjacent to the main hospital. All fellows are given opportunities in the interpretation of chest radiographs, computed axial tomograms, radionucliotide scans, pulmonary angiograms and PET scanning.
Through clinical experience and a comprehensive lecture series, the trainee is exposed to the basic sciences, including molecular biology and immunology, and the diagnosis of therapy of disorders of the cardiovascular, respiratory, renal, gastrointestinal, genitourinary, neurologic, endocrine, hematologic, musculoskeletal, immunologic systems, and infectious diseases. (A detailed overview of the clinical conferences of the division, including fellows’ role in these activities follows this document). Clinical data relating to the determination of cardiac output, oxygen content, intrapulmonary shunt and alveolar arterial gradients evaluation of oliguria, management of massive transfusions, hemostatic defects, drug levels and sensitivities, assessment and management of nutrition and metabolism, and drug pharmacokinetics are reviewed and analyzed. Fellows in pulmonary and critical care medicine also attend institutional lecture series, which include information regarding physician impairment and medical ethics. Fellows are also educated in the six core competencies, which include patients care skills, medical knowledge, interpersonal and communication skills, professionalism, practice-based learning and system based practice, and how they will be evaluated each of these areas.
Educational purpose, value and rationale
During the second and third year of fellowship training, trainees will spend 16 weeks each involved in clinical research. The rotation is under the direction of Peter LaCamera, MD, who works closely with Gerard Hayes, MD, to assure that the educational components of the rotation are being met. The pulmonary/clinical care research program is supported by a dedicated research office.
The goals of the research rotation are to expose the fellow to several aspects of clinical research. This includes initial design of a project, review of the literature, writing and submitting all necessary forms for the institutional review board (IRB), including protocol, initial research form, informed consent form, and annual review form. The fellow must also read the manual for investigative site entitled “Protecting Study Volunteers in Research, 2nd edition”. This manual will prepare the fellows to assume a critical role in clinical research. They will review different aspects of it, including ethics and federal regulations, roles and responsibilities of the Institution in Human Subject research, roles and responsibilities of the investigator, behavioral research issues, conflict of interest, and informed consent. To be allowed to participate in clinical research, the fellow must complete the Collaborative Institutional Training Initiative (CITI ) Program requirement at St. Elizabeth’s Medical Center. The CITI Program consists of two courses in the Protection of Human Research Subjects for Biomedical, as well as for Social/Behavioral Research. Modules required for the initial training requirement include:
- History and Ethical Principles
- Informed Consent
- Social and Behavioral Research for Biomedical Researchers
- Records-Based Research
- FDA-Regulated Research
- HIPAA and Human Subjects Research and
- Conflict of Interest in Human Subjects Research
This research rotation provides fellows with a unique opportunity during their career to participate in a guided clinical research in the area of pulmonary medicine. The studies the laboratory is involved could be divided in observational and interventional studies.
Observational studies: These studies involve a variety of topics in pulmonary and critical care medicine. Examples include airway epithelium expression in the diagnosis of lung cancer, evaluation of the STOP-BANG questionnaire in screening for sleep apnea in bariatric patients, and single-center experience in the diagnosis, classification and management of pneumothorax.
Interventional studies: Several interventional studies have been activated and are scheduled to start. The clinical areas include critical care medicine and pulmonary disease. Examples include randomized trial of pirfenidone versus placebo in IPF, a post-FDA approval trial of bronchial thermoplasty for asthma, and aggressive versus standard approach to drainage of pleural malignant effusion.
A partial listing of currently active research projects is listed below:
- Airway Epithelium Gene Expression in the Diagnosis of Lung Cancer
- To evaluate a new test for diagnosing lung cancer at an earlier stage
- American College of Chest Physicians (ACCP) AQUIRE Quality Improvement Registry
- To collect standardized multicenter data on various bronchoscopic interventional and diagnostic procedures
- Impact of Aggressive versus Standard Drainage Regimen Using a Long Term Indwelling Pleural Catheter on the Incidence of Auto-Pleurodesis in Patients with Malignant Pleural Effusions (The ASAP Study)
- To compare the incidence of auto-pleurodesis utilizing aggressive drainage versus standard drainage protocols with the PleurX® catheter
- A pilot prospective study evaluating the SPiN Drive™ Electromagnetic Tip Tracked devices used in Diagnostic Bronchoscopy
- To evaluate the ease of use and effectiveness of the SPiN Drive™ Electromagnetic Tip Tracked series of catheters and devices in locating and sampling sub-segmental peripheral lung lesions
- Intermune PIPF-016- A Randomized, Double-blind, Placebo-Controlled, Phase 3 Study of the Efficacy and Safety of Pirfenidone in Patients with Idiopathic Pulmonary Fibrosis
- To confirm the treatment effect and safety of pirfenidone 2403 mg/d compared with placebo on change in percent predicted forced vital capacity in patients with idiopathic pulmonary fibrosis (IPF)
- Post FDA Approval Clinical Trial Evaluating Bronchial Thermoplasty in Severe Persistent Asthma
- To assess the durability of the bronchial thermoplasty treatment effect, and short-term and longer-term safety of the Alair System in this post-approval study
- Biological Markers in Patients with Laryngopharyngeal Reflux
- To determine the presence of pepsin in the sputum and the laryngeal epithelial lining of patients being evaluated for laryngopharyngeal reflux
- Study of the AeriSeal® System for HyPerInflation Reduction in Emphysema (ASPIRE)
- To demonstrate the safety and efficacy of AeriSeal System treatment plus optimal medical therapy compared to optimal medical therapy alone in patients with advanced upper lobe predominant (ULP) heterogeneous emphysema
- Evaluation of the STOP-Bang questionnaire for screening of obstructive sleep apnea in the bariatric surgery patient
- To evaluate the feasibility and accuracy of STOP-Bang questionnaire as a pre-operative screening tool for obstructive sleep apnea versus conventional sleep studies in bariatric surgery population
Structure and function
First- and second-year fellows meet with Dr. Hayes before the start of their next curriculum year to discuss the different projects they will be involved with. The selection of the projects is based on several factors, including the estimated duration of the project, the basic knowledge required by the fellow to participate on it, and the fellow and attending preferences. The projects are assigned to a single fellow (responsible for the project) with other fellows as co-participants. This will assure that the fellows will be involved in more than one project but they will be responsible for the execution of at least one project.
The fellow will be responsible to perform the following duties during the rotation:
- Initial review of the literature: This activity will bring the fellow up to date to the current knowledge of the topic to be investigated. The fellow will present and discuss with the faculty mentoring him in the project, as well as with Dr. Hayes.
- Protocol writing: Based on the idea previously discussed, the fellow will write a protocol with the supervision and help of the staff in charge of the project. After completion, the protocol will be discussed in a research meeting (with staff and other fellows) to be criticized and modified accordingly.
- Institutional Review Board (IRB) requirements: Each fellow is responsible to complete the forms required by the IRB with the input from the staff involved in the protocol. The forms are an initial research form, consent form, HIPAA form and annual review form. The fellow is also responsible for reading the preparation book for clinical research, take and approve the exam. The fellow will participate in the initial IRB meeting that will discuss the protocol he/she is responsible for. This is a unique experience since the fellow will be exposed to the discussion, point of view of people with different background of the IRB panel. The fellow will also be responsible to make the changes in any of the documents required by the IRB.
- Protocol implementation: The trainee and attending are responsible for the implementation of the protocol. Initially, the fellow will be accompanied by the attending to assure the correct patient selection and protocol execution. After the attending confirms the trainee expertise to carry the project on, the fellow will continue the project with a lower level of supervision. This supervision will follow as the trainee and staff meet on a regular basis to analyze the patient selection and partial results.
- Protocol management: The fellow will be responsible for completing all the forms required by the protocol as well as any queries generated by a clinical research organization (CRO) or monitor of the study, as required by the IRB.
- Protocol completion: Based on a pre-determined estimation and/or interim results, the protocol will be concluded. The fellow will inform the IRB about this action.