Program Curriculum

Overview of Curriculum

A sample block schedule is available here.

Major components 

The major components for a one-year standard training curriculum in transplant ID include: 

(1) Inpatient clinical training (~24 weeks)

(2) Research training for the remaining time

(3) 1/2 day of clinic per week

Additional training components 

Standard training competencies in practice-based learning, professionalism, ethics, and systems development related to transplant ID should be demonstrated.

  Practice-based learning: 

• Develop knowledge of fundamental resources including, but not limited to, the AST Transplant ID guidelines, evidence-based medicine databases, and additional guidelines from other critical sources. 

•  Utilize these resources to participate in case-based learning with transplant ID faculty. 

• There is also a transplant SOT ID manual specific to our institution. 

Professionalism / Communication

• • Develop skills to interact appropriately with patients and families while respecting patient confidentiality.   

  • Demonstrate cooperative team building with all members of the transplant team including nurses, coordinators, data managers, and physicians/surgeons.   

  • Interact professionally with the multi-disciplinary transplant team including trainees and advanced practice providers. 

  • Demonstrate that transplant ID forms an integral component of the transplant program and transplant-related care. 

 Ethics 

• Demonstrate a working understanding of the processes of consent, donor, and recipient selection (including issues of brain death and donation after cardiac death), allocation systems, and considerations regarding re-transplantation and limited resource utilization.

 Systems Development 

• •  Demonstrate a working understanding of the structure and function of OPTN/UNOS, OPOs, and the National Marrow Donor Program (in Canada, the Stem Cell and Marrow Network). Develop an understanding for the need and methods to increase donation at large and in minority groups.

Detailed description of core components 

Clinical training

The clinical component of training will include both inpatient and outpatient care. Clinical time will include rotations on the solid organ transplant (SOT) and hematopoietic stem cell transplant (HSCT) ID service lines, a weekly outpatient continuity clinic, and the option for up to 4 weeks of elective rotations with other transplant service lines. Our SOT program includes exposure to patients undergoing heart, lung, liver, kidney, and kidney-pancreas transplants. Care of other immunocompromised hosts, such as patients with human immunodeficiency virus will not be a significant focus of training unless transplant-related. The trainee will work 1 weekend per month.

Inpatient clinical service 

Inpatient clinical service is the core of the transplant ID training program. The duration of inpatient service commitments will range between 20-24 weeks. Inpatient clinical encounters will occur on inpatient wards, intensive care units, and the emergency department. Each case should be reviewed by the attending physician on service, and learning points highlighted and discussed on a case-by-case basis. Fellows should be expected to provide longitudinal follow-up of patients along with the attending physicians. Independent decision making and problem solving should be encouraged. Medical decision making should take into account relevant clinical, microbiologic, and radiographic findings. Inpatient rotations will typically be 2-4 week blocks with 1 weekend per month. 

Outpatient clinic

The fellow will have 1/2 day of clinic per week which will still occur while on the inpatient rotations or elective rotations . The clinic will be staffed by an transplant ID attending for the trainee to discuss cases. Interested fellows can also participate in our ventricular assist device (VAD) clinic which occurs twice per month on Fridays. When you have clinic scheduled a general ID rotation and acting as a supervising attending your clinic will be scheduled (see independent practice). Amy Kaiser is clinic manager (email amy.kaiser@fairview.org) who helps with clinic cancellations. 42 day cancellation is required to cancel a clinic (otherwise requires medical director approval). 

Independent Practice Option

This is a non - transplant ID experience that will give you experience as an attending in a supportive and collegial environment. This additional knowledge will help make you a well-rounded clinician as you prepare for independent practice in the management of the immunocompromised host. The TID fellow will be the attending of record for patients staffed on a general ID team and will be responsible for supervising advanced practice providers and/or trainees if they are part of the team. Approximately 4 weeks M-F and 4 weekends will be spent on the general ID service. Meetings will be scheduled with the billing and coding team to review coding/billing responsibilities as an attending physician and to provide feedback on notes. Your clinic will be canceled during these weeks. 

Supervision for J1 or H1B Visa Holders:

• The TID fellowship program has obtained Non-Standard Training (NST) recognition through the ACGME which is a requirement for a program to accept trainees who have a J1 visa. With this recognition there are specific trainee supervision requirements. 

  • A supervising TID faculty member will be available to supervise the NST trainee with all patients 24/7.  Once the TID fellow starts rotations in the inpatient and outpatient settings supervision will include direct supervision of patient care until the fellow has demonstrated the knowledge and skills necessary to perform consultations and medical decision making under indirect supervision with direct supervision available, either by phone or in person as deemed appropriate for clinical care. 

  • Direct supervision will be the priority within the first 3 months of the program. 

  • Progressive responsibility and levels of supervision will vary based on the clinical needs and the fellow’s demonstrated skill and competence. All patients (new consults, follow ups, and curbside calls )are reviewed by the attending.

Learning Goals, Objectives, Expectations (adopted from the AST guidelines for a TID fellowship):

Core Rotations

Major goals 

1. Demonstrate how transplant ID fits into the global context of transplant care, from pre-transplant workup and transplant selection committees, to donor evaluation and peri-operative care, to post-transplant management. 

2. Demonstrate an understanding of immunosuppression, and how specific immunosuppressive agents contribute to the net state immunosuppression. This includes knowledge of immunosuppressive mechanisms of action, drug interactions with anti-infectives including enhanced toxicity with some combinations of antimicrobials and immunosuppressives, evolving assays to assess immune function, and infectious risk with enhanced immunosuppression related to induction therapy or treatment of rejection. 

3. Identify the major pathogens of opportunistic and other common infections as well as the major clinical syndromes that occur in SOT and HSCT recipients. 

4. Demonstrate an understanding of the principal diagnostic modalities including radiology, microbiology (including molecular and immunologic diagnostic assays), and histopathology, along with the most effective application and limitations of each in this patient population. 

5. Demonstrate an understanding of strategies for prevention of infection in these patients including the use of prophylactic and preemptive strategies. 

6. Demonstrate an understanding of the principles of treatment of infections in these patients, and how these patients differ from non immunocompromised hosts in terms of therapeutic response and therapeutic urgency. 

7. Become comfortable in dealing with life-threatening infections and critically ill transplant patients and their families.

Specific Objectives: SOT ID Rotation

• Describe the approach and treatment of common infections observed in patients with end-stage organ failure prior to transplant. Specifically, this includes, but is not limited to: 

  • infections related to dialysis access in patients with end-stage renal disease, 

  • spontaneous bacterial peritonitis and hepatitis B and C in patients with liver failure, 

  • exacerbations of cystic fibrosis in patients awaiting lung transplantation, 

  • infections related to mechanical circulatory support including extracorporeal membrane oxygenation 

  • infectious related to ventricular assist devices in cardiac transplant candidates. 

• Perform complete pre-transplantation evaluations. The fellow should understand the risks for infection after transplant based on epidemiology and personal his tory, and communicate these risks to potential recipients. This workup should include an evaluation of the need for immunization using medical history and/or laboratory data.

• Have a clear approach to common donor-related ID and current laboratory evaluation techniques for potentially transmissible infections in donors. In the United States, understand the reporting requirements of do nor-transmitted infections. 

• Describe technical complications and infectious sequelae that may occur as a result of such complications. The trainee should have a fluent understanding of the anatomy related to the transplant procedure. The trainee should have a clear understanding of the incidence, risk factors, timing, and presentations of vascular and non-vascular technical complications related to each transplant procedure. 

• Appreciate the risks associated with hospitalization at transplant, including but not limited to infection control and prevention policies, hand hygiene, surgical site infections, and nosocomial infections related to instrumentation. 

• Understand the approach to the transplant patient with fever and no localizing signs. This approach includes use of appropriate imaging and laboratory diagnostics

• For disease-specific presentations, understand the appropriate medical history including potential exposures, physical examination, imaging, and laboratory diagnostics. Commonly encountered diseases that should be covered include viral infections (cytome-galovirus [CMV], Epstein-Barr virus [EBV], varicella zoster virus [VZV], other herpesviruses, BK virus, hepatitis viruses, and community-acquired respiratory viruses), mycobacterial infections (tuberculosis, non-tuberculous mycobacteria), fungal infections (Candida, Aspergillus, and rare molds), and bacterial infections (including emerging multi-drug resistant bacteria: Pseudomonas, carbapenem-resistant Klebsiella pneumoniae, Acinetobacter baumannii, methicillin resistant Staphylococcus aureus, and vancomycin-resistant Enterococcus). 

• Perform comprehensive follow-up for infectious episodes in the outpatient setting. 

• Understand outpatient evaluation for transplant recipients planning travel and the need for continued review of immunization status after transplantation. 

Specific Objectives: HSCT ID Rotation

• Demonstrate understanding of the pre-transplantation clinical assessment, including risk based on HSCT modality (myeloablative vs. reduced-intensity, allogeneic vs. autologous, related, unrelated, and cord blood donors), and donor assessment including vaccination and disqualification. 

• Exhibit understanding of peri-transplant prophylaxis strategies in the induction, neutropenic, and early engraftment phases. 

• Appreciate the risks associated with hospitalization at transplant, including but not limited to infection control and prevention policies, hand hygiene, surgical site infections, and infection related to instrumentation. 

• Discuss the diagnosis and management of early post transplant infectious complications including viral infections (CMV, EBV, VZV, other herpesviruses, BK virus, adenovirus, and community-acquired respiratory viruses), fungal infections (Candida, Aspergillus, and rare molds), and bacterial infections (including emerging multi-drug-resistant bacteria). 

• Demonstrate understanding of late post-transplant complications including graft-versus-host disease and autoimmune diseases. 

• Appreciate the difficulty in discerning graft-versus host disease from infection in this population.   Describe the recommendations and rationale for revaccination after HSCT. 

Specific Objectives: Research training (translational, basic, and clinical research-individualized)

• Research training is focused on the individual goals of the fellow and, depending on the goals. It may be basic, translational, or clinical in nature.

• At least 1 abstract should be submitted for presentation at a national/international transplant ID-related meeting prior to completion of the 1 year. A summary manuscript should be drafted and, ideally, submitted for publication. Attendance at a transplant ID-related meeting is strongly encouraged.

Specific Objectives: Independent Practice

Expectations:

• 4 weeks M-F and 4 weekends will be spent on the general ID service

• Will be the attending of the record for patients on your team and will be responsible for supervising advanced practice providers and/or trainees if they are part of the team. 

• 2 meetings will be scheduled with the billing and coders to review coding/billing responsibilities as well as provide feedback on notes

• You will have an assigned faculty member that will serve as a resource during this rotation to discuss cases

Learning objectives:

• Learning about coding and billing in preparation for independent practice

• Develop time management and supervision skills on a team with multiple members

• Develop teaching skills and topic talks in real time scenarios of seeing patients

Electives (optional): 

Inpatient Transplant Pulmonology Expectations and Specific Objectives

Expectations: 

• Join the inpatient transplant pulmonology consult team for a 2-week rotation M-F.

• Weekly Transplant ID clinic (1/2 day of clinic) will still occur while on this elective.

• The transplant pulmonologist attending will be your supervising physician while on this elective

• The TID fellow will be expected to be an integral part of the team and will be responsible to see an equitable number of patients as decided by the transplant pulmonology team. 

• Although antimicrobial discussions will be part of this elective rotation it is expected that you respect the antimicrobial treatment decisions made by the transplant team.

• Present a case at a Lung Transplant Case Conference? 

• Join selection committee meetings

Learning objectives:

• Learn absolute and relative contraindications of lung transplant especially with regards to infectious diseases

• Effect of infection history on donor selection 

• Comprehend conditions that qualify for a need for single or bilateral lung transplant

• Learn and understand the differences between various immunosuppressive induction and maintenance regimens

• Learn about common non-infectious complications post-transplant

• Learning about the significance, interpretation, and treatment of donor and recipient bronchoscopies and BAL results at the time of transplant. 

• Understand the indications for a post-transplant bronchoscopy. 

• Learn what is being assessed for in a post-transplant bronchoscopy, features concerning for anastomosis dehiscence, and the frequency of post-transplant bronchoscopies.

• Learn about long term complications and common side effects of immunosuppression (i.e. skin cancers, HTN)

• Understand factors that influence increasing or decreasing immunosuppression

• Learn a basic understanding of the interpretation of spirometry results as it relates to infection

• Learn about infectious diseases and the factors that influence treatment of infections from the perspective of a transplant pulmonologist. 

Resources: 

•  Introduction to Solid Organ Transplant

• Immunosuppressive pharmacology

• Aspergillus 

• CMV

Inpatient Bone Marrow Transplant Team Specific Expectations and Learning Objectives

Expectations: 

• Join the inpatient BMT team for a 2-week rotation M-F from 8-5pm 

• Weekly transplant ID clinic (½ day of clinic) will still occur while on this elective

• The BMT attending will be your supervising physician while on this elective

• The TID fellow will be expected to be an integral part of the BMT team and will be responsible for the patients assigned to them

• Although antimicrobial discussions may occur, it is expected that you respect the antimicrobial treatment decision made by the BMT team

• Join BMT CME conference (Mondays, 2 pm, MCRB 450 or Zoom) and Patient Care Conference (Mondays, 3:15 pm, MCRB 450 or Zoom)

Learning Objectives:

• Learn about different types of transplants available and why each type of transplant is indicated

• Understand how conditioning regimens are determined and the duration of immunosuppression that occurs in the posttransplant period

• Learn about what HLA matching means and how it impacts conditioning regimens and the post transplant course

• Understand what degree of neutropenia is expected with different types of malignancies and transplants

• Understand the indications for transplantation for a variety of non-malignant and malignant conditions, and the risks and potential benefits to the patient

• Understand antimicrobial prophylactic protocols from a BMT provider’s perspective

• Learn about vaccine schedules post transplant

• Understand the nonmalignant early and late effects that can occur following transplantation and treatment 

• Learn about the risk of viral and fungal from a BMT clinician’s perspective

• Understand the diagnostic criteria for acute and chronic GVHD, and how to treat the disease

• Understand indications for and risks of donor lymphocyte infusions

Resources: 

• BMT/CT Clinical Care Guidelines (high yield for board review!): https://sites.google.com/umn.edu/cgi-isc-team-hub/interdisciplinary-teams/supportive-care

• Bone Marrow Harvest Procedure: https://www.youtube.com/watch?time_continue=3&v=-gGpwivNPmo&feature=emb_title

• BeTheMatch® Didactic Curriculum: https://bethematchclinical.org/resources-and-education/education-courses-and-events/curriulum/curriculum-modules-and-videos/

• For additional resources visit: https://sites.google.com/umn.edu/cgi-isc-team-hub/hospital-and-clinic-info/5c-rotations?pli=1

Evaluation

Clinical Rotations

At the end of each clinical rotation, the fellow will be evaluated electronically by transplant faculty. The faculty member should include an assessment of all standard training competencies (knowledge, practice based learning, professionalism, ethics, and systems development) as related to Transplant ID.

Optimally, multi-source feedback on inter-professional, collaborator, and communication skills should be sought from transplant ID staff as well as all members of the multi-disciplinary transplant team.

The transplant fellowship program directors also encourages in the moment feedback with faculty members and program leadership.

Scholarly Oversight Committee

The program has established a Scholarship Oversight Committee (SOC) which will systematically review the progress of the fellow at least twice during the program. The fellow is expected to identify the SOC members and present to the SOC their research plan at its inception and to review with the committee their progress and productivity, according to a checklist that addresses research activity, publications, presentations, coursework, grant applications, etc. Discussion of career goals is an integral component of the SOC. There will be approximately 2-3 meetings per year to review scholarly progress throughout the year. 

Education:

• Lectures/talks to attend:

  • Monthly TID lectures as part of the general ID fellowship lecture series

  • Monthly TID journal club - 3rd Thursday of the month

  • Monthly: Multicenter TID conference - 4th Friday of the month

  • Bimonthly TID meetings on Thursday afternoons with TID faculty at 2 pm (2nd and 4th Thursday of the month)

  • Weekly: join organ specific selection committees as able

  • Weekly: Thursday afternoon at 4 pm system wide transplant conferences

  • Yearly: Mayo and UMN Fellows Forum: combined conference for Mayo and UMN fellows. 

• Lectures to present at: 

  • General ID TID fellowship lectures: 2 presentations 

  • TID journal club: discuss  3-4 journal articles in 1 year

  • Multicenter TID conference - 1 presentation about a case during the year

  • Citywide: 3 patient cases during the year (no hosting)

  • Mayo and UMN Fellows forum: Apply to present research and QI work 

• Conferences: 

  • Funds of $2500 for education including conference fees, lodging, etc

  • Attend 1 conference per year