Pulmonology

I. GOALS AND OBJECTIVES

A. Overview: GOALS

The consult rotation in Pulmonary Medicine is designed to equip the house officer with the knowledge and skills needed to diagnose and treat pulmonary diseases, including acute and chronic respiratory failure, pulmonary infections, pulmonary neoplasms, obstructive and restrictive diseases, pulmonary vascular diseases, and immunologic diseases affecting the respiratory system. The house officer will learn to manage a wide variety of commonly encountered respiratory problems, in many cases, without the need for pulmonary consultation.

The Pulmonary elective is of 1 block duration (either 2 or 4 weeks) and involves participation in the in-patient pulmonary consultation service, the in- and out-patient bronchoscopy services, weekly out-patient pulmonary clinic sessions, and weekly conferences.

The Pulmonary elective is available to all Internal Medicine PGY-1, 2s and 3s.

B. Level-based Rotation Objectives:

PGY1:

Patient Care: Recognize the daily patient workload and prioritize; recognize the significance of a patient’s pulmonary conditions; differentiate the acuity level of illness, to establish patient-focused care

Medical Knowledge: Use discussions during daily rounds, literature and reference sources to increase knowledge base; apply guidelines for patient management; acquire basic knowledge in the areas of underlying pathophysiology and the clinical aspects of pulmonary disease states

Professionalism: Establish trust with patients and family; participate as part of team; exhibit honesty, reliability, and responsibility in patient care; demonstrate respect for patients and staff; attend conferences

Interpersonal and Communication (ICS) Skills: Write understandable and organized notes; listen to patients and staff; communicate and work effectively as a member of the health care team

Practice Based Learning and Improvement: Recognize limitations of knowledge; use literature to improve practice patterns; accept feedback and change behavior; ask for help when needed; recall outcomes of prior pulmonary patients to improve outcomes in the future

System Based Practice: Apply necessary devised guidelines; develop understanding about the health care systems/structure and how it relates to patients requiring pulmonary treatments and procedures

PGY2:

Patient Care: Prioritize the daily “work”; recognize the relative significance of a given pulmonary patient’s list of conditions; recognize the acuity levels of illness; list the indications, contraindications and risks of pulmonary procedures; work with all providers to provide patient-focused care

Medical Knowledge: Use literature and reference sources to increase knowledge base in Pulmonary Medicine; demonstrate basic knowledge in the areas of underlying pathophysiology and the clinical aspects of pulmonary disease states; apply knowledge in the treatment of patients

Professionalism: Establish trust with patients and staff; exhibit honesty, reliability and responsibility in patient care; demonstrate respect for patients and staff; work to fulfill the needs of patients; accept assignments graciously; attend conferences

Interpersonal and Communication Skills: Write understandable notes and consultation reports; improve ability to listen to patients; staff and communicate verbally and nonverbally in a productive manner; work effectively as a member of the health care team.

Practice Based Learning and Improvement: Understand limitations of knowledge; use references and literature to improve practice patterns; accept feedback and change behavior; ask for help when needed; recognize limits of responsibilities.

System Based Practice: Apply necessary devised guidelines; develop understanding about the health care systems/structure and how it relates to patients requiring pulmonary treatments and procedures

PGY3:

Patient Care: Prioritize the daily work load for pulmonary patients and supervise the junior house staff appropriately; recognize the relative significance of a given patients list of pulmonary and other conditions; recognize the acuity levels of illness; recite the indications, contraindications and risks of common and uncommon procedures; discuss risks/benefits native of patient’s with specialists.

Medical Knowledge: Use literature and reference sources to increase knowledge base and share knowledge with junior house staff; demonstrate sophisticated knowledge in the areas of underlying pathophysiology and the clinical aspects of simple and complicated disease states; apply knowledge in the treatment of patients

Professionalism: Establish trust with patients and staff; exhibit honesty, reliability and responsibility in patient care; demonstrate respect for patients and staff and junior house staff whom you are supervising; work with team to fulfill the needs of patients; lead health care team in patient care; recognize limitations and ask supervisors for help when indicated; accept assignments graciously; attend conferences

Interpersonal and Communication Skills: Write understandable notes and consultation reports; improve ability to listen to patients and staff and communicate verbally and nonverbally in a productive manner; work effectively as a member of the health care team, and be an example for junior house officers

Practice Based Learning and Improvement: recognize limitations of knowledge; use references and literature to improve practice patterns; accept feedback and change behavior; ask for help when needed; learn from the outcomes of pulmonary patients under your care and alter practice patterns to improve outcomes in the future; aid junior house staff in evaluating their practice patterns

System Based Practice: Develop a sophisticated understanding about the health care system/structure and develop mechanisms to utilize ancillary services to benefit patients

II. CONTENT AREAS COVERED DURING ROTATION

1. Principles, Physiology and Basic Sciences: Develop an understanding of:

a) Ventilation

b) Pulmonary circulation

c) gas exchange

d) Acid-base physiology

e) Respiratory system anatomy

2. Practice skills unique to Pulmonary Medicine:

a) Medical History with attention to chest pain, cough and dyspnea, differentiating types of each.

b) Chest physical examination

c) Specific tests and procedures: use and interpretation: Chest x-ray and CT, PFTS, Bronchoscopy, thoracentesis and pleural biopsy, Mechanical ventilation, invasive and noninvasive.

d) Preventive care: smoking cessation, DVT prophylaxis

e) Patient education: smoking cessation, diet, bronchodilator therapy

f) Attitudes/values: understand the psychosocial issues surrounding chronic respiratory illness

3. Approach to presenting complaints/problems in Pulmonary Medicine

a) Acute and chronic respiratory failure

b) Dyspnea

c) Wheeze

d) Cough

e) Hemoptysis

f) Chest pain

g) Hypoxia

h) Cyanosis

i) Hypercapnia

j) Somnolence/sleep disturbance

k) Lung nodule

l) Pleural effusion

m) Wheezing

n) Anticoagulation therapy

o) Thoracentesis/Chest tube insertion

p) Medications

4. Specific diagnoses in Pulmonary:

a) Lung cancer

b) Pneumonias and other infections

c) Interstitial lung diseases

d) Pneumoconioses

e) Sarcoidosis

f) Drug toxicity

g) ARDS

h) Pneumothorax

i) Pleural effusion and Empyema

j) COPD and alpha-1 antitrypsin deficiency

k) Bronchiectasis and Cystic fibrosis

l) Asthma

m) AIDS related pulmonary diseases

5. Emergencies/Therapeutic Interventions:

a. Acute respiratory failure

b. Tension pneumothorax

c. Lung collapse

d. Hemoptysis

e. Upper airway obstruction

f. Acute pulmonary embolus

g. Oxygen therapy

h. Bronchodilator therapy

i. Antibiotic therapy

j. Adrenocorticosteroid therapy

k. Mechanical ventilation, invasive and noninvasive

l. Respiratory physical therapy

m. Anticoagulation/ IVC filter/thrombolysis

n. Cancer radiotherapy/chemotherapy

o. Surgical referrals

6) Technical Skills:

a) ABG

b) Thoracentesis

c) Intubation (familiarity)

d) Bronchoscopy, diagnostic and therapeutic (familiarity)

e) Mechanical ventilation, invasive and noninvasive

III. SCHEDULE OF ACTIVITIES

1) Team Rounds:

a) Participants: PGY 1-3, Pulmonary fellow, sometimes MS III, IV

b) Objectives: direct patient care and learning

c) Time: M-F Variable times

2) Attending Rounds:

a) Participants: PGY 1-3 on team, sometimes MSIII, IV, Pulmonary fellow, attending

b) Objective: direct patient management, direct didactic and interactive learning

Time: M-F Variable times

3) Pulmonary core and curriculum conferences:

a) Participants: PGY1-3, MS III, IV, fellows, attending staff

b) Objective: didactic learning

c) Time: Tu 8:00AM- 9:00AM, videoconferenced both sides.

4) Medical Grand Rounds:

a) Participants: PGY1-3, MS III, IV, fellows, attending staff

b) Objective: didactic learning

c) Time: Th 12:15PM- 1:15PM

5) Pathology conference:

a) Participants: PGY1-3, MS III, IV, fellows, attending staff

b) Objective: case review, didactic learning

c) Time: Last Monday of the month 9:00-10:00 AM

6) Thoracic Tumor Board

a) Participants: Fellows and Attendings from Pulmonary Medicine, Medical Oncology, Radiation Oncology, Pathology, Nuclear Medicine, Radiology

b) Objective: patient evaluation and management planning, interactive learning

c) Time: Fridays 8:00-9:00 AM

7) Radiology Rounds:

a) Participants: PGY1-3 on team and on Pulmonary consultation service, MSIII, IV, Pulmonary fellows, attendings, Radiology attendings

b) Objective: patient evaluation and management planning, interactive learning

c) Time: Thursdays 9:00-10 AM

IV. METHODS OF TEACHING COMPETENCIES AND COMPETENCY ASSESSMENT

The house officers are evaluated continuously during their Pulmonary Medicine elective. Importantly, there is continuous feedback to the house officers. The final evaluation is done through www.new-innov.com and the results are discussed in a meeting with the house officers. They are evaluated in terms of their overall clinical competence with the following categories: