Pulmonary/Critical Care Fellowship Curriculum

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 mainly 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 2-week blocks. There is also a month dedicated to sleep medicine. 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
• Neurologic 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 management, acid base physiology, as well as metabolic effects of critical illness. Critically ill patients with multi-organ diseases including hematologic, oncologic, immunologic, and anaphylactic disorders are managed by the fellow. Unique aspects of drug metabolism and effect plus the use of sedation and paralytic agents in pulmonary and critical care patients are encountered. 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, the fellow’s responsibilities increase by rotating on the pulmonary procedure service 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, and fiberoptic bronchoscopy. During the pulmonary procedure 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)
• Endobronchial ultrasound-directed biopsy (EBUS)
• Navigational bronchoscopy
• Chest drainage catheter placement under ultrasound guidance
• Thoracentesis
• Cardiopulmonary exercise testing and interpretation
• Six-minute walking test
• Methacholine challenge testing, exercise bronchoprovocation tests
• Induction of sputum (hypertonic saline) for diagnosis

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 second half of the year is spent in research. The goals of the rotation are to expose the fellow to several aspects of clinical research. Fellows begin their efforts by enrolling in Tufts Clinical and Translational Science Institute (CTSI) Graduate Program Summer Institute at the beginning of their second year of training (syllabus included below). This four week course, specific to professionals with advanced biomedical degrees, teaches fellows to formulate and develop a clinical research hypothesis and clinical research project. The course includes an introduction to the fundamentals of clinical epidemiology and biostatistics and also surveys topics in the other core concentrations, including health services research, bench-to-bedside translational research, systematic review and decision analysis.

Fellows are required to develop a research proposal and present this proposal in class to the other class participants and faculty preceptors for scientific review. These proposals and presentations serve as the framework from which their actual research projects are based. Fellows will be able to summarize basic and advanced principles of study design and challenges commonly faced when conducting biomedical research involving human subjects. By the end of the course, fellows are expected to achieve the following:

• Describe and assess basic study designs used in clinical research including case-control, cross-sectional, observational cohort, and experimental studies.
• Discuss the strengths, limitations, and use of different study designs and their applications. Apply research methods across the spectrum of clinical studies including early phase, genetic association, and stakeholder-engaged studies.
• Define the role of outcome research, health economics, systematic reviews and clinical decision making in clinical and translational research.
• Interpret statistical results including p-values, confidence intervals, and formal statistical test results.
• Develop a research protocol.

The development of a research protocol during the Tufts CTSI Graduate Program Summer Institute will perpetuate the fellows’ learning to execute their project for institutional review board (IRB) approval and implementation. All projects are mentored by one or more attending physicians within the division and the expectation is for the completed project to be submitted and presented at an international pulmonary/critical care conference [American Thoracic Society (ATS) International Conference, American College of Chest Physicians (CHEST), etc.].

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, conducting 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 third-year fellow rotations include a one-month block at a lung transplantation center as well as a one-month block focusing on pulmonary hypertension, including interpretation of right heart catheterization and level 3 cardiopulmonary exercise testing. Opportunities exist to participate in the electronic ICU in Westwood, Massachusetts, for those who have an interest in learning about telemedicine. Lastly, senior fellows return to the medical ICU for a one-month block of “pre-attending” time. This gives the fellow a chance to hone their own style in running rounds under the supervision of faculty.

In addition to introductory didactic lectures on a variety of pulmonary and critical care topics, educational conferences are provided as follows:

• Thoracic Oncology conference: weekly
• Thoracic Radiology conference: monthly
• Pulmonary/CC Journal Club: monthly
• ICU M&M: monthly: Sept – June w/ resident
• Clinical case conference: monthly, Sept – June
• Physiology conference: every other month
• Sleep conference: every other month
• Research work-in-progress: monthly
• Board preparation conference: monthly
• Pathology conference: every 3 months
• Clinical Conundrums: monthly