• Rotation Director: Russell Miller, M.D.
• Rotation Location: Naval Medical Center San Diego
• Rotation Duration: Ongoing throughout Training
• Trainees/month: Number varies.

Educational Purpose and Rotation Description:

The pulmonary outpatient continuity clinic offers fellows an opportunity to assess, diagnose, and treat a wide range of pulmonary diseases. In this clinic, fellows take charge of a panel of adult male and female patients, managing all aspects of their care under the guidance of attending pulmonary specialists. Unless on a rotation outside the San Diego area (e.g. at the Intermountain Health or National Jewish rotations), fellows are expected to attend 1-2 half-day clinics each week. Each clinic sees the handling of 1-2 new consultations and 4-6 returning patients. New patient consultations are screened to maximize the fellow’s educational experience and exposure to various pulmonary diseases. Each clinic is proctored by an assigned, dedicated staff physician who is readily available for consultations. Fellows are tasked with answering phone calls, refilling prescriptions, and following up on all lab/radiology studies for their panel of patients. Any scheduled procedures should be coordinated outside clinic hours with a staff member to ensure proper supervision. If the fellow is unable to provide ongoing care due to absence from the hospital, their patients will be cared for by the designated “duty doc” or assigned to another physician.

Rotation Objectives:

1. Obtain knowledge and clinical experience in the following clinical areas:
   • Obstructive lung diseases, such as asthma, bronchitis, emphysema, bronchiectasis, and cystic fibrosis
   • Primary and metastatic pulmonary malignancies
   • Pulmonary infections, including tuberculosis, fungal infections, and those innate to the immunocompromised host
   • Diffuse interstitial lung diseases
   • Pulmonary vascular diseases, including primary and secondary pulmonary hypertension, vasculitis, and pulmonary hemorrhage syndromes
   • Occupational and environmental lung diseases
   • Iatrogenic respiratory diseases, including drug-induced illnesses
   • Acute lung injuries from radiation, inhalation, or trauma
   • Pulmonary manifestations of systemic diseases, including collagen vascular diseases primarily affecting other organs
   • Respiratory failures, including the adult respiratory distress syndrome, acute and chronic respiratory failures in obstructive lung diseases, and neuromuscular respiratory drive disorders
   • Pleura and mediastinum disorders
   • Genetic and developmental disorders of the respiratory system
   • Sleep disorders
   • Pulmonary issues during pregnancy
   • Preoperative pulmonary evaluations
2. Develop knowledge (indications, contraindications, complications, and limitations) and skills in performing the following procedures:
   • Pulmonary function tests to evaluate respiratory mechanics, gas exchange, and respiratory drive, encompassing spirometry, flow volume studies, lung volumes, diffusing capacity, arterial blood gas analysis, and exercise studies
   • Diagnostic and therapeutic procedures, including thoracentesis, pleural biopsy, flexible fiberoptic bronchoscopy, and related procedures.
   • Examination and interpretation of sputum, bronchopulmonary secretions, pleural fluid or tissue, and lung tissue for infectious agents; cytology; and histopathology
   • Inhalation challenge studies
   • Percutaneous needle aspiration and/or cutting lung biopsy.
3. Acquire knowledge and proficiency in interpreting the following diagnostic studies and data, including:
   • Chest X-rays
   • Computed axial tomography scans
   • Radionuclide scans
   • Pulmonary angiograms
   • Other radiological procedures
   • Sleep studies
4. Enhance knowledge, skills, attitudes, and educational experience in the core competency areas of patient care, medical knowledge, practice-based learning, interpersonal and communication skills, professionalism, and systems-based practice by:
   • Participating in quality improvement activities such as chart review
   • Promptly responding to phone messages
   • Timely notification of patients regarding test results
   • Avoiding discussing patients in public places
   • Obtaining informed consent for all invasive procedures
   • Making necessary arrangements for patient follow-ups during periods of unavailability (e.g., leave or TAD)
   • Using the internet and computer search strategies to access the latest diagnostic and treatment recommendations for patients
   • Clearly documenting and communicating consultation recommendations to requesting physicians, both in writing and in person, as appropriate
   • Understanding and complying with hospital and national regulations regarding patient privacy (HIPAA)
   • Promptly completing clinic notes/consultations (on the same day) and returning them to medical records for the benefit of other physicians
   • Adhering to hospital guidelines on interactions with pharmaceutical representatives and medical equipment vendors, thus avoiding any appearance of impropriety
   • Learning and implementing hospital and national clinical guidelines/pathways for common pulmonary diseases
   • Identifying and acknowledging socioeconomic and language barriers to medical care
   • Proactively inquiring about tobacco use (including smokeless tobacco), promoting cessation, and enrolling patients in effective cessation programs
   • Staying updated on current literature, including active participation in journal clubs.

ACGME COMPETENCY-BASED GOALS AND OBJECTIVE BY YEAR OF TRAINING:

Patient care

With the fellowship involving direct patient contact during continuity clinic rotations, fellows are expected to accurately gather all relevant data. They will be tasked with devising diagnostic and treatment plans informed by their clinical judgment and the latest scientific evidence. Fellows should ensure effective communication with patients and their families regarding their care, working in coordination with other healthcare professionals to guarantee the best patient care and outcomes.

1st year fellow:

• Independently evaluate (using history and physical exam) all assigned patients, then discuss findings and evaluations with the attending staff.
• Aim to correctly interpret laboratory and radiology results, presenting organized data.
• Provide continuous follow-up care until resolution of pulmonary issues.
• Formulate a basic differential diagnosis for common pulmonary complaints.
• Outpatient diagnosis of common pulmonary problems.
• Ensure the care plan is implemented by coordinating with patients, referring providers, and other consultants.
• Begin gaining expertise in diagnostic bronchoscopy.
• Review selected radiology and histopathology materials with staff, and with radiologists or pathologists as needed.
• Fulfill the responsibilities associated with the continuity clinic.

2nd year fellow:

• Continue fulfilling the 1st year goals and, in addition:
• Develop understanding of the pathophysiology, clinical findings, diagnostic tools, and management principles of common pulmonary disorders.
• Accurately evaluate (via history and physical exam) all patient consults, and independently devise a diagnostic and therapeutic management plan. Use primary literature as required and present a comprehensive plan to the attending for review.
• Perform diagnostic flexible bronchoscopy (if suitable for the fellow’s endoscopic supervision level) with minimal staff intervention.
• Gain experience in therapeutic bronchoscopy.
• Assist in organizing program academic conferences.
• By the end of the second year, fellows should be capable of practicing Pulmonary Medicine independently and competently.

3rd year fellow:

• Meet all the above goals and, furthermore:
• Formulate a comprehensive differential diagnosis for both common and complex pulmonary complaints.
• Independently perform diagnostic flexible bronchoscopy (if suitable for fellow’s endoscopic supervision level) with staff on standby.
• Gain expertise in therapeutic bronchoscopy.

Medical knowledge

Fellows will demonstrate an analytical approach to clinical situations and should consider and discuss aspects of biomedical, clinical, and cognate sciences relevant to patient care. Fellows should also actively participate in all pulmonary conferences and stimulate discussions about scientific studies, including the review of pertinent, up-to-date medical literature on disease processes and patient care.

1st year fellow:

• Progress from a basic internist level understanding of pulmonary disorders diagnosis and management to a more in-depth understanding of subtle diagnostic and therapeutic management issues related to various pulmonary disorders.
  • Generate an expansive differential diagnosis list for patient symptoms indicative of a potential pulmonary disorder.
  • Develop a basic diagnostic and management plan using general pulmonary references and input from faculty.
  • Develop progressive ability to create well-thought-out diagnostic and therapeutic plans prior to case discussions with staff.
  • Understand and explain the basics of evidence-based medicine.
  • Perform patient directed learning by reading appropriate textbook chapters, review articles, and performing literature searches.
  • Attend and present at all Pulmonary Conferences.
  • Fellows demonstrate clinical knowledge in their understanding of diversity, health literacy, and healthcare disparity.

2nd year fellow:

• Meet all the above goals and, in addition:
  • Perform patient directed learning by conducting literature searches to locate the latest medical literature and apply evidence-based critiques of the literature.
  • Fellows demonstrate advanced knowledge in their understanding of cultural/gender diversity, health literacy, and healthcare disparity.

3rd year fellow:

• In addition to meeting the goals listed above, the fellow should also be able to:
• Advance patient-directed learning by criticizing up-to-date medical literature and applying that knowledge directly in patient care.

Practice-Based Learning and Improvement

Fellows will improve patient care practices by critically evaluating scientific evidence and applying it to their patients’ care. This involves the application of evidence-based medicine (which includes knowledge of study design and statistical methods) in determining how medical literature applies to individual or population-based care. Unusual cases should be considered for presentation at morning conferences.

1st Year Fellow:

• Improve patient care practices by critically evaluating scientific evidence and applying it to patient care.
• Apply evidence-based medicine (incorporating knowledge of study design and statistical methods) in determining the application of medical literature to individual or population-based care.
• Develop the ability to ask answerable questions.
• Understand the limits of personal knowledge.
• Develop the ability to perform literature searches. Fellows will begin a Performance Improvement Project during the second half of their first year, discuss it with the program director or their designee, start collecting data about their performance, and implement an improvement program.

2nd Year Fellow:

In addition to the above goals, the following should be achieved.

• Develop the ability to perform literature searches quickly and efficiently and apply knowledge to specific patient care and overall patient care practices.
• Fellows will reassess their performance based on their Performance Improvement Project, analyze data, and present the data during the last quarter of their second year to the staff.

3rd Year Fellow:

• The objectives outlined above continue to apply at this level of training.

Interpersonal and Communication Skills

Fellows will communicate directly with patients, families, and professional associates. The development and maintenance of therapeutic and ethically sound relationships, which involve both listening and communication (verbal and non-verbal), will be emphasized.

1st Year Fellow:

• Develop the ability to interact effectively with patients and families during initial consultation and throughout the entire course of care.
• Learn to interact respectfully with residents and interns at the time of initial consultation.
• Develop the ability to convey diagnostic plans and treatment recommendations to the appropriate resident team, nurses, and support staff.
• Document initial consult notes, follow-up notes, telephone consults, and other procedural notes that are complete, accurate, and clearly outline the plan of care.
• Present data to the attending staff in a clear, organized format, focusing on the important or critical issues.
• Engage in teaching with medical students or residents rotating on the service.

2nd Year Fellow:

In addition to the above goals, the following should be achieved:

• Learn to negotiate with other consultative services when there are differences of opinion.
• Develop the ability to present cases to staff effectively and efficiently, communicating important information with an emphasis on assessment and plan.

3rd Year Fellow:

In addition to the above goals, the following should be achieved:

• Develop the ability to lead teaching rounds to demonstrate time management, control of presentation and discussion, and the ability to prioritize.

Professionalism

Fellows are required to display a commitment to fulfilling their professional responsibilities. Interactions with and care for patients must be conducted in a respectful, compassionate, and ethical manner, with a responsiveness to the needs of patients and their families. This implies an understanding and consideration of a patient’s culture, age, gender, and disabilities. The objectives listed below apply to all stages of training.

1st, 2nd, and 3rd year fellows:

• Fellows should exhibit a dedication to ethical principles concerning the provision and withholding of care, the confidentiality of patient information, and informed consent.
• Patient interactions and care should always be conducted in a compassionate, respectful, and ethical manner. This also includes a focus on responsiveness to the patients’ culture, age, gender, and disabilities.
• Fellows must display an unwavering commitment to fulfilling their professional responsibilities.
• Entries in MHS Genesis should be completed within 48 hours to allow for timely co-signature by the staff.
• Appearance should always be appropriate, adhering to the duty uniform protocol, and maintaining a professional military bearing.
• Fellows are expected to report for all assigned duties, and make suitable arrangements for coverage if needed.
• Interactions with all members of the healthcare team should always be respectful and ethical, with patient care as the central concern.

System-based practice

Fellows are expected to demonstrate an understanding and cognizance of patient care, as it exists within the context of the military health care system. They should be able to discuss how patient care and professional practices impact other health care professionals and navigate the constraints of the military medical system. As and when required, fellows should facilitate and coordinate patient care to other facilities within the military medical system or the civilian community.

1st year fellow:

• Fellows should display an understanding and awareness of patient care within the military health care system.
• Fellows should be able to discuss how patient care and professional practices affect other healthcare professionals, considering the constraints of the military medical system.
• If necessary, fellows should facilitate and coordinate patient care to other facilities within the military medical system or within the civilian community.
• Fellows should be confident navigating multiple clinical data systems.
• Fellows should understand the limitations of referring facilities to assess the specific needs of patients by hospitals.
• Fellows should cooperate with the pharmacy to procure special order medications.
• Fellows should work effectively with pulmonary support staff and head nurses to streamline the scheduling of procedures.
• Fellows should be able to identify sources of medical errors and the process of reporting these errors.

2nd year fellow:

In addition to the above objectives, a second-year fellow should be able to:

• Discuss the balance between cost and quality of care.

3rd year fellow:

Third-year fellows should aim to fulfill all objectives outlined for the 2nd year.

Learning Venues and Teaching Methods:

Direct Patient Care:

• Pulmonary Clinic, 3rd Floor, Building 3
• Procedures Suite, 3rd Floor, Building 3
• PFT Lab, 3rd Floor, Building 3

Reading Material

1. Fishman’s Pulmonary Diseases and Disorders, Third Edition, McGraw-Hill
2. Textbook of Respiratory Medicine, Murray and Nadel, W.B. Saunders
3. Pleural Diseases, Fourth Edition, Light
4. Principles and Practice of Sleep Medicine, Third Edition, Kryger, W.B. Saunders
5. Principles of Exercise Testing, Third Edition, Wasserman, Lippincott

Evaluations:

Trainees will be evaluated continuously by the responsible staff members. At the end of each quarter, the collective staff will provide a written evaluation of each fellow, particularly regarding their overall effectiveness in the continuity clinic. This includes the development and expansion of differential diagnostic skills and the use of evidence-based medicine to enhance and refine practice parameters.