• Rotation Director: Russell Miller, M.D.
• Rotation Location: Naval Medical Center San Diego
• Rotation Duration: One to Four 4-week block rotations during each year of Fellowship
• Trainees/month: One

Educational Purpose and Rotation Description:

The inpatient consult service provides the fellow with the opportunity to evaluate, diagnose, and treat hospitalized adult patients, both male and female, with a wide variety of pulmonary diseases. The service typically includes a medical resident and/or intern and/or student, in addition to the fellow and attending pulmonologist. Consultations are usually requested via phone or e-mail.  Upon receiving the consultation request, the fellow reviews it, sees the patient, makes initial recommendations in a brief progress note on the chart, and then discusses the patient with the inpatient attending before completing the full written consultation. The fellow may ask the resident/intern/student to see consults first, but in all cases, the fellow will personally evaluate the patient promptly, write initial recommendations in the medical record, and discuss the case with the attending physician before completing the consultation.

Consults from the ICU/CCU will generally be handled by the ICU fellow and staff. The fellow or resident/intern/student on the service should write notes daily on all patients with active pulmonary issues, and the fellow should cosign all resident/intern/student notes. The inpatient consult attending sees all new patients, supervises invasive pulmonary procedures, and conducts daily rounds. Stable inpatients requiring bronchoscopy will generally be brought to the pulmonary procedure’s suite. The fellow is responsible for scheduling the procedure, obtaining written informed consent, writing pre-procedure orders, and coordinating with the primary service.

While patients remain under the care of their primary service throughout hospitalization, it may be appropriate for patients to return to the fellow’s continuity clinic for follow-up of unresolved pulmonary issues. This should be arranged with the primary service before discharge. The consult fellow will present at the morning Pulmonary Clinical Conference (M,F) and will coordinate the Wednesday journal clubs, and radiology conferences.  Lastly, the fellow assumes primary responsibility for teaching residents/interns/students assigned to the pulmonary inpatient consultation service.

Rotation Objectives:

1. Acquire knowledge of and gain clinical experience in the following clinical areas: complications, and limitations) of and competence in performing the following procedures:
   • Obstructive lung diseases, including asthma, bronchitis, emphysema, bronchiectasis, and cystic fibrosis
   • Pulmonary malignancy – primary and metastatic
   • Pulmonary infections, including tuberculosis, fungal and those in the immunocompromised host
   • Diffuse interstitial lung disease
   • Pulmonary vascular disease, including primary and secondary pulmonary hypertension and the vasculitis and pulmonary hemorrhage syndromes
   • Occupational and environmental lung disease
   • Iatrogenic respiratory disease, including drug-induced disease
   • Acute lung injury, including radiation, inhalation, and trauma
   • Pulmonary manifestations of systemic disease, including collagen vascular diseases that are primary in other organs
   • Respiratory failure, including adult respiratory distress syndrome, acute and chronic respiratory failure in obstructive lung diseases, and neuromuscular respiratory drive disorders.
   • Disorders of the pleura and the mediastinum
   • Genetic and developmental disorders of the respiratory system
   • Postoperative pulmonary complications
   • Pulmonary problems in pregnancy
2. Acquire knowledge (indications, contraindications, complications, and limitations) of and competence in performing the following procedures:
   • Management of pneumothorax (needle insertion and drainage systems)
   • Pulmonary function tests to assess respiratory mechanics, gas exchange, and respiratory drive, including 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/tissue, and lung tissue for infectious agents; cytology; and histopathology
   • Thoracostomy tube insertion and drainage
3. Acquire knowledge of and ability to interpret the following diagnostic studies and data pertaining to:
   • Chest roentgenograms
   • Computed axial tomograms
   • Radionuclide scans
   • Pulmonary angiograms
   • Other radiologic procedures       
   • Interpretation of antibiotic levels and sensitivities
4. Gain additional 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 doing the following:
   • Discussing end of life care issues, pain management, and advanced care directives with patients and their families when appropriate
   • Communicating effectively with the primary care team and consultants from other services to ensure the optimal care of patients on whom the fellow is consulting
   • Participating in morbidity and mortality conferences
   • Participating in quality improvement activities including chart reviews
   • Avoiding discussion of patients in public areas
   • Obtaining informed consent for all invasive procedures
   • Utilizing the internet and computer search strategies to obtain the latest diagnostic and treatment recommendations for patients
   • Clearly communicating consultative recommendations in writing (and in person when appropriate) to requesting physicians
   • Ensuring adequate sedation/pain control for all procedures and treatments where physical or emotional stress is anticipated
   • Keeping the attending physician informed of significant changes in patient status and recognizing potentially serious findings or trends.
   • Communicating patient orders to nurses, therapists, and other personnel in a professional manner and according to hospital guidelines
   • Supervising junior house staff physicians during all procedures until competency has been documented.
   • Learning and applying hospital and national regulations regarding patient privacy (HIPAA)
   • Learning and applying hospital and national clinical guidelines/pathways for common pulmonary diseases
   • Looking for and identifying socioeconomic and language barriers to medical care
   • Asking about tobacco use (including smokeless), encouraging cessation, and enrolling patients in effective cessation courses
   • Keeping abreast of current literature including selection of 2 articles for journal club
   • Coordinating the monthly pathology conference

Competency-Based Goals and Objectives by Year of Training:

Patient Care

Since fellows are involved in direct patient contact during this rotation, accurate gathering of data is imperative. Fellows will develop informed diagnostic and treatment plans based on the use of clinical judgment and current scientific evidence. Additionally, fellows will continue to ensure effective communication with patients and their families during discussions about aspects of the patient’s care. Fellows will work with other healthcare professionals to ensure appropriate patient care and outcome.

1st year fellow

• Fully evaluate (with history and physical exam) all patient consults independently and discuss with attending staff.
• Strive to interpret relevant laboratory and radiology results and present the data in an organized fashion.
• Provide continuing follow-up until sign-off or discharge.
• Follow patients in continuity clinic after discharge if they require follow-up and do not already have an assigned pulmonologist.
• Formulate basic differential diagnosis for common pulmonary complaints.
• Diagnose common pulmonary problems in inpatients.
• Ensure plan of care is implemented by discussing with inpatient medical teams.
• Begin to acquire expertise in diagnostic bronchoscopy.
• Review selected radiology and histopathology material with staff and radiologist or pathologist, respectively.
• Fulfill continuity clinic responsibilities.

2nd year fellow

All above goals and, in addition, the following:

• Develop understanding of the pathophysiology, clinical findings, diagnostic tools, and management principles of common pulmonary disorders.
• Accurately evaluate (with history and physical exam) all patient consults and display the ability to independently devise a diagnostic and therapeutic management plan utilizing primary literature as required and then present a cohesive plan to the attending for input and review.
• Independently perform diagnostic flexible bronchoscopy (if appropriate for fellow’s endoscopic level of supervision).
• Gain experience in therapeutic bronchoscopy.
• Assist in coordination of program academic conferences.
• By the end of this year fellows should exhibit the ability to practice Pulmonary Medicine in a competent and independent fashion.

3rd year fellow

All above and, in addition, the following:

• Formulate extensive differential diagnosis for common and complex pulmonary complaints.
• Independently perform diagnostic flexible bronchoscopy (if appropriate for fellow’s endoscopic level of supervision).
• Gain expertise in therapeutic bronchoscopy.
• By the end of this year fellows should exhibit the ability to practice Critical Care Medicine in a competent and independent fashion.

Medical Knowledge:

Fellows will demonstrate an analytical thinking approach to clinical situations. This will be demonstrated by considering and discussing pertinent aspects of biomedical, clinical, and cognate sciences when developing approaches to patient care.

Additionally, fellow presentation and participation in the weekly management conference and facilitate discussions of scientific studies (including reviewing pertinent up-to-date medical literature) regarding disease processes and patient care.

1st year fellow

• Progress from a more basic internist-level understanding of the diagnosis and management of endocrine disorders to a more in-depth appreciation of subtle diagnostic and therapeutic management issues involved with various pulmonary disorders.
• Generate an increasing differential diagnosis list for patient symptoms with a possible pulmonary disorder.
• Using general pulmonary references and input from faculty.  Fellow should be able to develop a basic diagnostic and management plan.
• Fellows should exhibit a progressive ability to develop well-thought-out diagnostic and therapeutic plans prior to discussion of the case with staff.
• Understand and explain the basics of evidence-based medicine.
• Perform patient-directed learning by reading appropriate textbook chapters and reviewing articles and performing literature searches.
• Attend and present at the weekly management conference (schedule determined by PD on a monthly basis).
• Attend the weekly Monday and Tuesday morning conferences, as well as city-wide conferences.

2nd year fellow

All above goals and, in addition, the following:

• Perform patient directed learning by conducting literature searches to locate up-to-date medical literature and applying evidence-based critiques of the literature.

3rd year fellow

All above and, in addition, the following:

• Perform patient directed learning by critiquing up to date medical literature and applying knowledge to patient care.

Practice-Based Learning and Improvement

Fellows will enhance patient care practices by critically appraising scientific evidence and relating it to their patients’ care. Important aspects of this are the application of evidence based medicine (incorporating knowledge of study design and statistical methods) in determining the application of medical literature to individual or population based care. Additionally, fellows will work with assigned students and residents to facilitate their learning and will meet regularly with the residents on the consulting services to discuss appropriate topics regarding patient care.

1st year fellow

• Enhance patient care practices by means of critically appraising scientific evidence and relating patients’ care practices.
• Application of evidence based medicine (incorporating knowledge of study design and statistical methods) in determining the application of medical literature to individual or population based care.
• Be able to ask an answerable question.
• Understand limits of own knowledge.
• Able to perform literature search.

2nd year fellow

All above goals and, in addition, the following:

• Able to perform literature searches quickly and efficiently and apply knowledge to specific patient care and overall patient care practices.

3rd year fellow

The objectives outlined above apply to 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 involving both listening and communication (verbal and non-verbal) will be stressed.

1st year fellow

• Able to interact effectively with patients and families at time of initial consultation and throughout entire course of care.
• Able to interact with residents and interns in a respectful manner at time of initial consultation.
• Able to convey diagnostic plan and treatment recommendations to appropriate resident team, nurses, and support staff.
• Write a daily consult note that is complete, accurate, and has plan of care clearly outlined. Initial written consultation documented within 24 hours of consultation.
• Present data to the attending staff in a clear, organized format on rounds with the ability to focus on the important or the critical issues.
• Engage in teaching with medical students or residents rotating on the service.
• Effectively sign out active patient issues to the on-call fellow for weekend and holiday coverage.

2nd year fellow

All above goals and, in addition, the following:

• Able to negotiate with other consultative services when there are differences of opinion.
• Able to present cases to staff quickly and efficiently while communicating important information with an emphasis on assessment and plan.

3rd year fellow

All above and, in addition, the following:

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

Professionalism

Fellows must demonstrate a commitment to carrying out professional responsibilities. Patient care and interaction will be carried out in a respectful, compassionate, and ethical manner and demonstrate responsiveness to the needs of patients and families. This will include responsiveness to patients’ culture, age, gender, and disabilities. The fellow will demonstrate a commitment to ethical principles pertaining to the provision or withholding of care, confidentiality of patient information, and informed consent.

Systems-Based Practice

Fellows will demonstrate an understanding and awareness patient care in the context of the military health care system. The fellow will discuss how patient care and professional practices affect other health care professionals and the constraints of the military medical system. When necessary, fellows will facilitate and coordinate patient care to other facilities within the military medical system or in the civilian community.

1st year fellow

• Fellows will demonstrate an understanding and awareness of patient care in the context of the military health care system.
• The fellow will be able to discuss how patient care and professional practices affect other healthcare professionals and the constraints of the military medical system.
• When necessary, fellows will facilitate and coordinate patient care to other facilities within the military medical system or in the civilian community.
• Able to navigate multiple clinical data systems.
• Understand the limitations of referring facilities in order to determine hospital-specific needs of patients.
• Able to work with the pharmacy to obtain special order medications.
• Able to work with pulmonary support staff and head nurse to facilitate the scheduling of procedures.
• Identify sources of medical errors and methods of reporting those errors.

2nd year fellow

All above goals and, in addition, the following:

• Able to discuss the balance of cost and quality of care.

3rd year fellow

Objectives as outlined for 2nd year fellow

Learning Venues and Teaching Methods:

Conferences (refer to schedule)

• Pulmonary Clinical Conference 0730 (M,Th)
• Pulmonary Multidisciplinary Tumor Board 0700 (Tuesday)
• Pulmonary Staff Teaching Session 0700 (W)
• PCCM Journal Club 2nd and 4th Friday 0700
• PCCM Radiology Conference Friday 1300
• Pulmonary-Clin-Path Conference 4th Friday at 1300
• PCCM Core Conference Series: Fridays 1100

Direct Patient Care:

• Hospital Wards
• Pulmonary Clinic, 3rd floor, building 3
• Procedures Suite, 3rd floor, building 3
• PFT Lab, 3rd floor, building 3

Suggested Reading:

1. Fishman’s Pulmonary Diseases and Disorders,  McGraw-Hill
2. Textbook of Respiratory Medicine, Murray and Nadel, W.B. Saunders
3. Pleural Diseases, fifth edition, Light

Evaluation:

The trainee will receive a written evaluation at the end of their rotation based on cognitive, patient management, procedural and humanistic skills.  This evaluation, including areas for improvement, will be discussed personally with the trainee at the end of the rotation and then forwarded to the Program Director for inclusion in the trainee’s permanent file.