UMKC School of Medicine - Pulmonary Medicine Fellowship ...

UMKC School of Medicine - Pulmonary Medicine Fellowship • Program Training Guide

UMKC – School of Medicine 1 of 23 12/29/04

TABLE OF CONTENTS I. Introduction Page 2 II. Faculty Page 2 III. Fellows Pages 3-6 A. Applicants Page 3 B. Medical Education Fund Page 3 C. Travel Fund Policy Pages 3-4 D. Leaves of Absence Page 4 E. Delinquent Medical Records Page 4 F. Dress Code Page 5 G. Moonlighting Activities Page 5 H. Permanent Licensure Page 5 I. Liability Insurance Page 5 J. Health and Disability Insurance Page 5 K. Counseling and Support Services Page 6 IV. Facilities Page 6 V. Educational Program Pages 6-12 A. Schedule Pages 6-7 B. Rotation Pages 7-9 C. Policy for Non-Teaching Patients Page 9 D. Policy on Order Writing Page 9 E. Vacations Page 9 F. Medical Meetings Page 9 G. Conferences 0 H. Procedures Page 10 I. OSHA/HIPPA Regulations Page 10 J. Continuous Quality Improvement and Management Page 10 K. Psychosocial, Economic, and Ethical Issues Page 10 L. Educational and Counseling Skills Page 11 M. Research Page 11 N. Other Scholarly Activities Page 11 VI. Evaluation Pages 11-12 VII. Supervisory Lines of Responsibility Page 12 VIII. Goals and Objectives Pages 12-19 IX. Curriculum Pages 19-22 Appendix



I. INTRODUCTION The three-year combined training program in pulmonary disease and critical care medicine at the University of Missouri-Kansas City School of Medicine provides the training, appropriate experiences and feedback for fellows to acquire the knowledge, skills, attitudes, and professional behavior expected of specialists in Pulmonary and Critical Care Medicine. II. FACULTY Truman Medical Center-Hospital Hill Pulmonary/ Critical Care Medicine George Reisz. M.D. (Chairman, Department of Medicine) Gary Salzman, M.D. (Director of Pulmonary/ Critical Care Training Program) Dennis R. Pyszcynski, M.D. Yuji Oba, M.D. Diana Dark, M.D. Rebecca Shriver, M.D. Surgical Critical Care Doug Geehan, M.D. Part Time Lee Forsythe, M.D. (Pulmonary Clinic) Betty Herndon, Ph.D. (Research Laboratory) Mercedes Amado, M.D. (Allergy Clinic Staff) Saint Luke’s Hospital Pulmonary/Critical Care Medicine Vincent M. Lem M.D. Mark Yagan, M.D. Bruce Schwartz, M.D. Ann M. Romaker, M.D. David Hof, M.D. Cardiology Critical Care John Spertus, M.D. Cardiothoracic Surgery Critical Care Randy Hudson, M.D. A. Michael Borkon, M.D. Nephrology Critical Care Barry C. Wood, M.D. Jim I. Mertz, M.D. Thomas T. Crouch, M.D.



III. FELLOWS A. APPLICANTS Applicants must be ABIM eligible prior to starting the fellowship. The candidate must be eligible for a permanent Missouri Medical License. In addition, curriculum vitae, personal statement, and three (3) letters of recommendation (including one from the Chief of Medicine at the applicant’s residency program) are required. The program selection committee reviews applicants and qualified applicants are invited for interviews. The Selection Committee for the program will choose two qualified applicants. B. MEDICAL EDUCATION FUND Each full time fellow is allotted a $1,000 annual allowance. These funds are time limited and will not roll over to the upcoming academic year. The funds can be used to cover the following expenses:

• Medical meetings and related travel expenses as authorized by the Chairperson or Program Director. Receipts must be submitted. A reasonable expense includes, but is not limited to hotel, airfare, and meal expenses for the individual applying for reimbursement. Reimbursement will only cover registration for local meeting.

• Continuing medical education correspondence course if authorized or approved by Chairperson or

Program Director in advance.

• Review courses as authorized by Chairperson or Program Director.

• Medical books, equipment and journals.

• PDAs to be used for business, if purchased in the first quarter of the contract year.

• Surgical loupes, stethoscopes, and indirect ophthalmoscopes and lenses.

• ACLS, BCLS training if approved by Program Director. Appropriate documentation of expenses include:

• Original receipts or statements from company showing balance due of zero. • Copies of cancelled checks. • Copies of credit card statements detailing purchases.

See Appendix C. GUIDELINES FOR RESEARCH ACTIVITY RELATED SUPPORT/TRAVEL FUND POLICY When a fellow has a paper accepted for presentation at a national meeting, a special fund has been set up to off set the cost of attending the meeting. Any fellow from the University of Missouri-Kansas City School of Medicine sponsored training program is eligible to receive said funding. Prior approval from the Chairperson or Program Director must be obtained.



• In general five hundred dollars ($500.00) has been set aside for each fellow.

In addition, the Division may supplement reimbursement of expenses not covered by the initial $500.

• An application form can be obtained from the Medical Staff Office at Truman Medical Center or the Education Department at Saint Luke’s Hospital. The forms must be completed and returned to one of the locations mentioned above.

• Once the form is complete and the appropriate signatures have been obtained, it will be forwarded to

University of Missouri. The University will reimburse the fellow from the travel fund. Receipts must be turned into the Program Director. D. LEAVES OF ABSENCE Sick Leave: Fellows accrue sick leave at the rate of one (1) day per month. This is accruable from year to year. In the event that a fellow cannot report for his/her duties, s/he should contact the attending physician and/or clinic staff as soon as possible. Jury Duty: Fellows required to serve on a jury shall be paid the difference of their regular salary and the jury duty pay. Interview Leave: Fellows shall receive five (5) days during their training to use for the purpose of interviewing for job positions. Approval must be obtained in writing from the attending, Program Director and/or the Section Chief of the rotation in which the interview days will be taken. General: All time and rotations missed as a result of any authorized leave must be made up. The fellow’s health insurance shall remain in effect. The fellow’s malpractice insurance and pay shall be suspended for the duration of the leave. If the fellow obtains employment during leave, or fails to report for duty at the end of an approved leave, the fellow’s participation in the program shall automatically be terminated. E. DELINQUENT MEDICAL RECORDS The timely completion of medical records is an important professional and educational responsibility of each fellow. Therefore, it is expected that each fellow complete all medical records in a timely fashion. The standards, in which each fellow shall adhere to, shall be those established by the institution in connection with the fellowship-training program. The Pulmonary/Critical Care Medicine Program will inform each fellow of the standards set by each hospital. It shall be the responsibility of the fellow to stay informed of the standards and to adhere to them strictly. In the event a fellow is consistently delinquent in the completion of medical records, the Program Director shall take the following action: 1. Three (3) weeks delinquent: written notification to the fellow regarding the status of the records. 2. Four (4) weeks delinquent: written notification and paycheck will be withheld immediately upon notification. 3. Six (6) weeks delinquent: suspension from service without pay until the fellow has updated all delinquent records. The delinquency will be noted in the fellow’s personnel file.



F. DRESS CODE It is expected that each fellow will dress in a professional manner. Men are to be attired in a shirt and tie. Women should be dressed appropriately. Both men and women are expected to wear white coats when seeing patients. All individuals should dress in their work clothing no later than Morning Report. Scrubs are only acceptable in the evening and after patient management rounds on the weekend. Jeans, sneakers, shorts, mini-skirts, or sandals are not allowed. Individuals not following the dress code will be asked to relinquish their patient care activities until such time as they are dressed appropriately. Repeated episodes of inappropriate dress will not be allowed. G. MOONLIGHTING ACTIVITIES Employment of fellows by employers other than University of Missouri beyond those relating to the UMKC School of Medicine Pulmonary/Critical Care Medicine Training Program is strongly discouraged for all fellows. With the exception of Emergency Room coverage and/or participation in the Department of Medicine Non-Teaching House Physician program at Saint Luke’s Hospitals, fellows are not permitted to moonlight at any affiliated hospital. If a fellow decides to participate in moonlighting activities, the following guidelines must be abide by:

• The activity may NOT take place until after 5:00 p.m. or at the end of the workday. • The program director or his/her designee, and the chief administrative officer of the Department of

Medicine must be informed of any moonlighting activities. If the above provisions are violated, the fellow may be subject to loss of credit for the rotation(s) affected, and may also be subject to suspension, termination, or other disciplinary action pursuant to the established disciplinary procedures of the Department of Medicine. Any fellow choosing to moonlight will be responsible for obtaining (at his/her own expense) professional liability insurance. A copy of this coverage must be provided to the Program Director for inclusion to the fellow’s permanent file. H. PERMANENT LICENSE Each fellow shall be required to provide to the University of Missouri a copy of his/her permanent Missouri license. It is the fellow’s responsibility to annually report to the Program Director, the status of his/her licensure at the time of application or renewal. I. LIABILITY INSURANCE Professional liability coverage for the duration of training will be provided for each fellow. Coverage includes legal defense, and protection against awards from claims reported or filed after the completion of graduation if the alleged acts or omissions are within the scope of the educational program. This coverage is consistent with the institution's coverage for other medical practitioners. J. HEALTH AND DISABILITY INSURANCE Health and disability insurance is available through the University of Missouri. An employee benefit guide is located on the University website at www.umkc.edu/hres.



K. COUNSELING AND SUPPORT SERVICES Confidential counseling services are available at the UMKC Counseling Service Center. The office is located at 4825 Troost, Room 206, Kansas City, Missouri. The center is open Monday through Friday from 8 to 5 by appointment only. Emergency hours are from 10-2. IV. FACILITIES The University of Missouri Kansas City School of Medicine has accredited residencies in Internal Medicine, Surgery, OB/GYN, Pediatrics, Family Medicine (Geriatrics), Psychiatry, Emergency Medicine, Ophthalmology, Orthopedic Surgery, Thoracic Surgery, Pathology, Radiology, and Anesthesiology. There are accredited internal medicine subspecialty training programs in Pulmonary/Critical Care Medicine, Cardiology, Hematology/Oncology, Gastroenterology, and Infectious Diseases. Truman Medical Center Hospital Hill Truman Medical Center is a 250-bed level-one trauma center. It is one of the five primary teaching hospitals of the University of Missouri-Kansas City School of Medicine. TMC has an average of 16,000 hospital admissions per year to primary services of internal medicine, general surgery, obstetric-gynecology, orthopedics, and neurosurgery. The hospital also offers thoracic, urological and otorhinolaryngologic surgery services. Annually, approximately 280,000 outpatient visits are made. There is a 12-bed medical intensive care unit and a 10-bed surgical intensive care unit. Services in radiology, laboratory, and respiratory therapy are available 24 hours a day, 7 days per week. The pulmonary function lab and extensive pathology services are readily available. A clinical microbiologist is actively involved in patient care activities with the fellows. All fellows work with the metabolic support team. Saint Luke’s Hospital of Kansas City This 686-bed hospital system is a referral center encompassing eight hospitals in a six-state area. Saint Luke’s hospital is a level one-trauma center. The hospital offers many specialized centers including a dialysis/transplantation program and cancer center. The Mid-America Heart Institute is internationally known for its diagnostic and treatment programs. There is a very active open-heart surgery program and cardiac transplantation program. Saint Luke’s Hospital admits more than 21,000 patients and has over 90,000 outpatient visits per year. There are 50 intensive care unit beds in medical, surgical, cardiac, and cardiothoracic surgery critical care units. Services are available 24 hours a day from the clinical laboratory, radiology, and respiratory therapy. In addition, a complete pulmonary rehabilitation program is available as well as extensive pathology services. V. EDUCATIONAL PROGRAM A. SCHEDULE Year 1: 4 months Pulmonary Consult Service/TMC 4 months Pulmonary/ Critical Care Medicine Inpatient/SLH 1 month Pulmonary Function Lab/TMC



1 month Exercise and Sleep Lab/ SLH 2 months Research* 1/2 day per week Pulmonary Clinic Year 2: 2 months Pulmonary Consult Service/TMC 2 months Medical Intensive Care Unit/SLH 6 months Research 2 months Medical Intensive Care Unit/TMC 1/2 day per week Pulmonary Clinic Year 3: 2 months Research 4 months Medical Intensive Care Unit/TMC 1 month Surgical Intensive Care Unit/TMC 1 month Metabolic Support/TMC 2 months Coronary Care Unit/SLH 2 months Cardiothoracic Surgery Unit/SLH 1/2 day per week Pulmonary Clinic B. ROTATION Pulmonary Consult Service-TMC A fellow who is in their first or second year will work under the direct supervision of a full-time faculty member from the respiratory and critical care medicine division. The fellow will provide direct supervision to an internal medicine resident and a senior medical student. The consult service provides initial consultations and daily recommendations for continuing care. The fellow performs specialized procedures and provides follow up after the patient is discharged from the pulmonary clinic. The fellow will assist with the care of patients in all areas of the hospital except the medical intensive care unit. The fellow has approximately 15 new consults per week and follows 10-15 inpatients at any given time. No in-house call is required; however, the fellow will take pager calls from home. Weekend coverage at the hospital including critical care units is divided between the fellow assigned to the MICU and the fellow on the pulmonary consult service. Pulmonary and Critical Care Medicine Inpatient Service- Saint Luke’s Hospital The first or second year fellow works under the direct supervision of a clinical pulmonary critical care faculty member at Saint Luke’s Hospital. The fellow supervises approximately three (3) internal medicine residents. The fellow must take an active role in patient management in this busy private practice setting. The fellow will provide initial and ongoing consultative service and work with internal medicine residents and clinical faculty members. Fellows direct patient care for those patients admitted to the pulmonary and critical care group practice. The fellow manages approximately 20 new consults or admits per week and follows 20-25 inpatients at any given time. The fellow takes pager calls from home and is responsible for no more than 2 weekends a month. Pulmonary Function, Sleep Exercise Laboratory – Saint Luke's Hospital The fellow is assigned to a faculty member in the laboratories. An extensive bibliography is given to the fellow to guide reading and studying. While observing and performing these studies, practical experience in the technical aspects are provided. The faculty member provides one-on-one instruction and feedback on



interpreting the studies. The fellow is not required to be on call. Fellows will receive Level I sleep training at the American Sleep Disorder Association (ASDA) certified lab at Saint Luke’s Hospital under the direction of two (1) ABSM certified faculty. The fellow takes pager calls from home and is responsible for no more than 2 weekends a month. Research Fellows work with a faculty member of their choice. It is the fellow’s responsibility to identify a faculty member to collaborate with. Please report this information to the Program Director as soon as possible. Minimum expectation for fellows are to complete one clinical research project and one laboratory project at the end of the 3 years. At least one of these projects must be the primary idea and work of the fellow. The faculty member provides assistance and guidance. Internal funds are available to fellows for research projects. No call is required during research months. Medical Intensive Care Unit-TMC During the second or third year, the fellow works under the direct supervision of a full time faculty member in the respiratory/critical care division. Usually, the fellow supervises an internal medicine resident, emergency medicine resident, and 1 or 2 medical students. The fellow will evaluate all patients admitted to the unit with a mandatory consult and provide daily recommendations for ongoing management in the 12-bed unit. When the patient is transferred out of the unit, the fellow on pulmonary consult service provides recommendations for ongoing management after discussion of the case with the MICU fellow. There are approximately 25 new consults per week. The fellow takes pager calls from home and shares weekend calls with the pulmonary consult fellow. The fellow takes pager calls from home and is responsible for no more than 2 weekends a month. Surgical Intensive Care Unit/Metabolic Support- TMC A full time faculty member in surgical critical care directly supervises the third-year fellow. The fellow rounds daily (Monday through Friday) in the surgical intensive care unit working with surgical residents and attending in patient care activities. One month of the rotation is devoted to the metabolic support team. The fellow actively participates in the clinical consultative hospital activities of the metabolic support team. A reading list is provided. The fellow shall participate in surgical and nutritional support conferences. No call or weekend coverage is required. During the third year the fellow must complete the Advanced Trauma Life Support Course. Coronary Care Unit-Saint Luke’s Hospital Third year fellows will work under the supervision of a cardiology faculty member and a second or third year cardiology fellow. The fellow will participate in direct patient care activities and procedures. Limited supervisory responsibilities over internal medicine residents and medical students will be required. No call or weekend coverage is required. Cardiothoracic Surgery Unit- Saint Luke’s Hospital The third year fellow will spend 2 months directly supervised by cardiothoracic surgeons and anesthesiologist in direct patient care in the cardiothoracic surgery unit. The fellow will gain experience in the post operative care of thoracic, vascular, and open-heart surgery patients. The fellow observes in the operation room and



actively participates in postoperative care. The fellow will attend cardiothoracic surgery conferences and give a presentation. No call or weekend coverage is required. Ambulatory Care-TMC and Saint Luke’s Hospital All fellows have clinic 1/2 day per week throughout all 3 years of the program. Consultative, and continuing care activities, and communication with the referring physician is emphasized. At each clinic, the fellow will see 2-3 new patients and 3-6 returning patients. The fellows are supervised and evaluated by a full time faculty member in the respiratory/critical care medicine division for 6 months at a time. Six different attending will supervise a fellow’s ambulatory care experience over the 3-year period. The fellow who cared for the patient in the MICU may follow up with said patient upon discharge. C. NON-TEACHING PATIENTS TMC AND SLH At Truman Medical Center, it is rare and unusual for a fellow to encounter a non-teaching patient. If the patient requires immediate medical intervention, the fellow will stabilize the patient until the responsible attending physician is available to assume care for the patient. If the patient is clinically stable and does not require immediate medical intervention, the fellow will request the nursing staff contact the responsible attending physician. At Saint Luke’s, during the night and weekends, there are in house physicians who are paid to care for all non-teaching patients. During the day, the attending physicians are responsible for their non-teaching patients. If a fellow encounters a medically unstable non-teaching patient, the fellow will stabilize the patient until the responsible physician is available to assume care for the patient. If the patient is clinically stable and does not require immediate medical intervention, the fellow will request the nursing staff contact the responsible attending physician. D. ORDER WRITING TMC AND SLH Internal Medicine residents, under the direct supervision of the Pulmonary/Critical Care Medicine fellows and attending physicians, should write the majority of orders. If the clinical condition of an individual patient requires a timely order and an Internal Medicine resident is not immediately available, the fellow or attending physician will write the order. Verbal orders will only be given in circumstances where the physician is unable to be physically present to write the order. Registered Nurses may only take verbal orders if the nurse knows the physician. Verbal orders are to be signed and dated within 24 hours. E. VACATIONS Fellows are allowed three (3) weeks each year for vacation. It is preferred that any vacation time be taken during research months. If a fellow takes a vacation during clinical rotation months, it is the fellow’s responsibility to arrange for a suitable replacement. Fellows are expected to notify the clinic staff and attending physician at least 1 month in advance. Priority will be given to requests that are received thirty (30) days in advance. F. MEDICAL MEETING Fellows are allowed one (1) week for approved continuing medical education (CME) meetings each year. The leave must be taken during the respective year of training and is not accruable. If the fellow is scheduled for a clinical rotation, it is their responsibility to find any needed coverage.



G. CONFERENCES Monthly Conferences Clinical Conferences – weekly (assigned to fellow) Basic Science Conferences –weekly (given by faculty) Journal Club–weekly Research Conference–weekly Pulmonary/Thoracic Surgery Conference – bi-monthly H. PROCEDURES Fellows must demonstrate knowledge and skills in educating patients about the technique, rationale, ramifications of procedures, and in obtaining procedure-specific informed consent. Faculty will directly supervise fellows in all procedures until the fellow is judged competent in the procedure. Each fellow will be assessed individually for competency. Fellows must maintain records, and turn them in semi-annually documenting the indications, complications, and the name of the supervising physician. These records will be used for obtaining credentials. The fellow must develop a comprehensive understanding of the indications, contraindications, limitations, complications, and techniques and interpretation of results for the following technical procedures. The minimum numbers of procedures in parenthesis are published recommendations for the development of competency. 1 Endotracheal intubation (25) Fiberoptic bronchoscopy and accompanying procedures (75) Ventilator management (50) Thoracentesis (5) Arterial puncture (5) Arterial catheter placement (15) Pulmonary artery balloon flotation catheter placement (15) Calibration and operation of hemodynamic recording systems (10) Supervision of technical aspects of pulmonary function testing (10) Supervision of technical aspects of exercise testing (10) Chest tubes, insertion and management (5) Central venous catheter placement (15) Perform advance cardiac life support (10) I. OSHA /HIPPA REGULATIONS Every year, each fellow will receive formal documented instructions in universal precautions and protection of heath care workers. J. CONTINUOUS PERFORMANCE IMPROVEMENT AND MANAGEMENT Third year fellows are active members of the Medical Intensive Care Unit Committee and participate in performance improvement activities, risk management, and the unit management decisions. K. PSYCHOSOCIAL, ECONOMIC, AND ETHICAL ISSUES Fellows and attendings from all internal medicine subspecialties are encouraged to attend the Ethics Committee meetings to discuss ethical, psychosocial, and economic issues in a formal case based conference. Many opportunities for discussion on these topics arise during clinical rotation.



L. EDUCATIONAL AND COUNSELING SKILLS Patient education is emphasized in ambulatory and inpatient clinical experiences. Faculty members give feedback and reinforcement to fellows on patient counseling and education skills in clinical inpatient rotations and in the ambulatory care setting. M. RESEARCH Each fellow is required to be the principal investigator of one project and co-investigator of another project. At least one project must be clinical and the other laboratory. During the 3-year period, the fellow has 10 months of protected research time available for these projects. Fellows are supervised and evaluated during each month of research by a faculty member. Fellows are encouraged to present abstracts, posters, and cases at national, state, and local meetings. N. OTHER SCHOLARLY ACTIVITIES Each fellow must present 1 or 2 clinical case based conferences per year to the internal medicine faculty, residents, and students. Fellows are assigned articles to review and discuss at a monthly meeting. VI. EVALUATION A. FORMATIVE EVALUATION Fellows are evaluated each month of their 36-month fellowship. Forms for inpatient clinical rotation, research and ambulatory care are in the appendix. The following areas are evaluated: clinical judgment clinical skills medical knowledge humanistic qualities commitment to scholarship medical care professional attitudes behavior clinical competence Fellows are evaluated in these areas each month and their performance reviewed and discussed with a faculty member. Semi-annually the fellow receives structured feedback from the program director. Their performance is reviewed with appropriate counseling and any necessary remedial actions. B. SUMMATIVE EVALUATION Semi-annually the program director completes a written evaluation of each fellow based upon review of monthly evaluations by the fellowship evaluation committee. These evaluations stipulate the degree to which the fellow has mastered each component of clinical competence and has acquired proficiency in each of the required procedural skills. Fellows may appeal judgments of academic deficiencies or misconduct before the professional standards committee at TMC appeal. See Disciplinary Action Policy located on the UMKC website at http://www.med.umkc.edu/residency/graduate/links.html. C. EVALUATION OF FACULTY AND PROGRAM The fellow evaluates each rotation monthly and provides confidential feedback to the program director on the performance of the faculty and merits and deficiencies in the training program. The teaching staff meets with



the fellow semi-annually to evaluate the utilization of the resources available to the program, the contribution of SLH and TMC to the program, financial and administrative support, volume and variety of patients available to the program for educational purposes, the performance of members of the teaching staff, the quality of supervision of fellows, and review the effectiveness of the program in achieving the stated goals and objectives. VII. SUPERVISORY LINES OF RESPONSIBILITY First Year Fellows Fellows supervise the patient care activities of medical students and internal medicine residents working under their direction at Saint Luke’s or Truman Medical Center. First year fellows may consult with second or third year fellows when covering the critical care units at Truman Medical Center on the weekends. Faculty members are available by pager at all times for phone consultation or to personally evaluate the patient and directly supervise the fellow. Faculty members personally evaluate all new patients seen in consultation and feedback is given to the fellow. Fellows are closely supervised while developing procedural skills. Second Year Fellows Fellows supervise the patient care activities of medical students, internal medicine residents, and first year fellows. Faculty members are available at all times for phone consultation or to personally evaluate the patient and supervise the fellow as needed. When the fellow is judged to be competent in specific procedures, personal supervision by faculty members in that procedure is optional. A faculty member personally evaluates all new patients seen in consultation and feedback is given to the fellow. Third Year Fellows Fellows supervise medical students, internal medicine residents, and first year fellows in patient care activities. Third year fellows will supervise first and second year fellows in procedures the third year fellow has been judged competent to teach. Third year fellows are usually competent to perform many procedures independently. Teaching faculty are available by pager at all times for phone consultation and to directly observe the fellow if needed. The faculty member personally evaluates all new patients seen in consultation. VIII. GOALS AND OBJECTIVES-TRAINING FIRST YEAR TRAINING 1. Demonstrates integrity, respect, compassion, and empathy for patients. 2. Provides effective communication to patients, families, nurses, respiratory therapists, students, residents, teaching faculty, and referring physicians. 3. Demonstrates ethical behavior in dealing with clinical and non-clinical issues. 4. Develops expertise as a consultant dealing with common pulmonary disease problems. 5. Demonstrates knowledge and competency in the technical aspects and interpretations of pulmonary function testing, progressive exercise testing, and sleep studies. 6. Demonstrates knowledge and competency in fiberoptic bronchoscopy and accompanying procedures. 7. Demonstrates knowledge and competency in thoracentesis. 8. Demonstrates knowledge and competency in arterial puncture.



SECOND YEAR TRAINING 1. Demonstrates integrity, respect, compassion, and empathy for patients. 2. Provides effective communication to patients, families, nurses, respiratory therapists, students, residents, teaching faculty, and referring physicians. 3. Demonstrates ethical behavior in dealing with clinical and non-clinical issues. 4. Develops expertise as a consultant dealing with common pulmonary disease problems. 5. Maintains competency in procedural skills mastered in the first year and develops knowledge and competency in: Endotracheal intubation and airway maintenance Ventilator management Percutaneous pleural biopsy Arterial and pulmonary artery balloon flotation catheters and central venous catheters placement Calibration and operation of hemodynamic recording systems Insertion and management of chest tubes ACLS THIRD YEAR TRAINING 1. Demonstrates integrity, respect, compassion, and empathy for patients. 2. Provides effective communication to patients, families, nurses, respiratory therapists, students, residents, teaching faculty, and referring physicians. 3. Demonstrates ethical behavior in dealing with clinical and non-clinical issues. 4. Maintains expertise as a consultant dealing with common and uncommon pulmonary disease problems. 5. Develops expertise in managing adult patients with a wide variety of serious illnesses and injuries requiring treatment in a critical care unit. 6. Maintains competency in the procedural skills mastered in the first and second year. The fellow has the opportunity to learn the indications, contraindications, limitations, and complications of the following procedures: Advance Trauma Life Support (ATLS) Pericardiocentesis Transvenous pacemaker insertion Peritoneal dialysis Hemodialysis Peritoneal lavage Aspiration of major joints Percutaneous needle aspiration of the lung Endobronchial laser therapy Intracranial pressure monitoring ROTATIONS Pulmonary Consult Service-Truman Medical Center-Hospital Hill 1. Demonstrates integrity, respect, compassion, and empathy for patients.



2. Provides effective communication to patients, families, nurses, respiratory therapists, students, residents, teaching faculty, and referring physicians. 3. Demonstrates ethical behavior in dealing with clinical and non-clinical issues. 4. Acquires knowledge, skills and professional attitudes to provide expert consultations dealing with a variety of pulmonary problems. 5. Acquires the knowledge, and skills to interpret the following diagnostic studies: Pulmonary function tests Arterial blood gas Pulse oximetry Sleep studies Overnight desaturation studies Pleural fluid studies and cytology Pleural, bronchial, transbronchial biopsies, and needle aspirate cytology Chest radiography Computed tomography of the chest Pulmonary angiogram Ventilation-perfusion lung scan 6. Acquires knowledge and competence in performing the following: Fiberoptic brochosopy and accompanying procedures Thoracentesis Arterial Puncture Chest tube placement 7. Acquires knowledge, skills, and professional attitudes in bedside teaching and presentation of clinical conferences. Pulmonary and Critical Care Medicine Inpatient Services-Saint Luke’s Hospital 1. Demonstrates integrity, respect, compassion, and empathy for patients. 2. Provides effective communication to patients, families, nurses, respiratory therapists, students, residents, teaching faculty, and referring physicians. 3. Demonstrates ethical behavior in dealing with patient care, research, and economic issues. 4. Acquires knowledge, skills and professional attitudes to provide expert consultations and inpatient management of variety of pulmonary and caracal care problems. 5. Acquires the knowledge, and skills to interpret the following diagnostic studies: Pulmonary function tests Arterial blood gas Pulse oximetry Sleep studies Overnight desaturation studies Pleural fluid studies and cytology Pleural, bronchial, transbronchial biopsies, and needle aspirate cytology. Chest radiography Computed tomography of the chest Pulmonary angiogram



Ventilation-perfusion lung scan 6. Acquires knowledge and competence in performing the following: Fiberoptic brochosopy and accompanying procedures Thoracentesis Arterial Puncture Chest tube placement Endotracheal intubation 7. Acquires knowledge, skills, and professional attitudes in bedside teaching and presentation of clinical conferences. Pulmonary Function and Exercise Laboratory 1. To become skilled in the supervision of technical aspects of pulmonary function testing. 2. To become skilled in the performance and interpretation of progressive exercise testing. Sleep Studies Laboratory 1. To become skilled in the supervision of technical aspects of sleep testing. 2. To become skilled in the performance and interpretation of nocturnal desaturation and sleep studies. 3. Develop knowledge in basic sleep mechanisms and physiology. 4. Develop knowledge in sleep apnea diagnosis and treatment. 5. Develop knowledge in sleep disorders symptomatology. 6. Develop knowledge in differential diagnosis of excessive daytime sleepiness. 7. Develop knowledge in clinical utilization and basic interpretation of reports of overnight polysomnography. 8. Develop knowledge in the interaction of respiratory disease and drugs with sleep. 9. Develop knowledge in clinical utilization of the multiple sleep latency test Research 1. Develop knowledge and expertise in the design and interpretation of research studies, responsible use of informed consent, and research methodology and interpretation of data. 2. Develop knowledge and expertise in specific laboratory skills related to a research project in the Gold Pulmonary Laboratory. 3. Prepare and present a clinical research proposal with informed consent form to the institutional review board. 4. Present a poster, abstract, or case at a national meeting. 5. Prepare and submit at least one article to a peer review journal. 6. Prepare and submit at least one case report annually.



Medical Intensive Care Unit-Truman Medical Center-Hospital Hill 1. Acquire knowledge of the physiology, pathophysiology, diagnosis and therapy of disorders of the cardiovascular, respiratory, renal gastrointestinal, genitourinary, neurological, endocrine, hematologic, musculoskeletal, immune systems, and infectious diseases. 2. Acquire knowledge and experience in the following content areas: Electrolyte and acid–base physiology, pathophysiology, diagnosis and therapy. Metabolic, nutritional, and endocrine effects of critical illnesses. Hematological and coagulation disorders secondary to critical illness. Critical obstetric and gynecological disorders. Management of the immunosuppressed patient. Management of anaphylaxis and acute allergic reactions. Monitoring and medical instrumentation. Pharmacokinetics and dynamics; drug metabolism and excretion in critical illness. Biostatistics and experimental design. Principles and techniques of administration and management. Ethical, economic, and legal aspects of critical illness. Psychosocial and emotional effects of critical illnesses. Iatrogenic and nosocomial problems in critical care medicine. Personal development, attitudes and coping skills of physicians and other health care professional who care for critically ill patients. Specific Objectives 1. Coordinate all admissions and discharge in the MICU. 2. Evaluate all patients admitted to the MICU and provide daily recommendations for ongoing management. 3. Supervise, assist, and/or perform all invasive procedures in the MICU. 4. Learn the indications, contraindication, complications, and limitation of the following critical care procedures and the technical skills necessary to perform them. Maintenance of open airway in non-intubated, unconscious, paralyzed patients Intubations Ventilation by bag and mask Mechanical ventilation using pressure-cycled, volume cycled, and negative pressure ventilators Use of reservoir masks and positive end expiratory mask for delivery of supplemental oxygen, humidifiers nebulizers, and incentive spiro meter Management of pneumothorax Basic and advance cardiopulmonary resuscitation Arterial puncture and blood sampling Insertion of central venous, arterial, and pulmonary artery catheters Cardioversion Parenteral and enteral nutrition



Utilization, zeroing, calibration of transducers Use of amplifiers and recorders Pericardiocentesis Transvenous pacemaker insertion Peritoneal dialysis Peritoneal lavage Insertion of chest tubes 5. Gain experience in the analysis of data pertaining to the following: Cardiac output determinations by thermo dilution. Evaluation of oliguria. Management of massive transfusions. Management of hemostatic defects. Interpretation of antibiotic levels and sensitivities. Monitoring and assessment of metabolism and nutrition. Calculation of oxygen content, intrapulmonary shunt and alveolar arterial gradients Pharmacokinetics 6. Work closely with all consultants evaluating patients in the MICU. 7. Coordinate efforts to provide optimal care for the patients and provide a teaching environment for the medical residents and students. 8. Attend the monthly MICU committee. 9. Devise and conduct quality assurance studies in the MICU. 10. Participate in original research projects. 11. Will be involved with ethical issues that arise in the MICU and take part in discussions with patients, family, nurses, attending physicians, the hospital ethics consultant, chaplain and the hospital’s attorney. Surgical Intensive Care Unit-Truman Medical Center 1. The fellow will be exposed to a wide variety of critically ill surgical patients under the supervision of the surgery faculty. The fellow will develop an appreciation of the surgical approach in the management of clinical problems in critically ill surgical patients. 2. Will be exposed to the trauma team and be introduced to a multidisciplinary approach to trauma care.Will be exposed to the critically ill neurosurgery patient and other surgical subspecialties. Specific Objectives 1. Will learn to recognize and develop a plan for prevention and management of common post-operative complications seen in the SICU. 2. Will learn the rationale for commonly used drainage tubes and to recognize malfunction and complications. 3. Will learn to recognize some of the common acute problems requiring urgent surgical intervention. 4. Under the supervision of the neurosurgical faculty, the fellow will learn to recognize and manage increased intracranial pressure and become familiar with intracranial pressure monitoring. 5. Will be introduced to the management strategy for spinal cord injuries. 6. Will be introduced to the concepts behind the appropriate timing and type of specific surgical interventions in critically ill patients.



7. Will enhance skills in hemodynamic monitoring and managing patients on mechanical ventilation. 8. Will acquire knowledge and skills in providing nutritional support. Goals and Objectives of Metabolic Support Service 1. Understand the management of nutrition support in hospitalized patients. 2. Appreciate the varieties of nutritional support products and be able to discuss risks, benefits, and alternatives in order to select the most appropriate product. 3. Understand basic nutritional principles. 4. Understand the differences, advantages, and disadvantages of different feeding tubes and parenteral catheters. 5. Manage hospitalized patients within a team environment. 6. Function within a team environment. 7. Communicate clearly with consultants and primary care providers. 8. Make appropriate and timely consultations while providing appropriate follow-up care. 9. Base nutrition support therapy on sound pathophysiologic, pharmacologic, and behavioral principles. 10. Define patient problems and do literature searches to answer specific questions related to nutritional support. Cardiothoracic Surgery Unit- Saint Luke’s Hospital 1. Learn to recognize and manage some of the common problems encountered in post-operative cardiac and thoracic surgery under the supervision of the Cardiac and Thoracic Surgeons. 2. Learn to appreciate the cardiac anesthesiologist and cardiac surgeons approach to critical care. Thus enabling the trainee to develop a multi-disciplinary approach to critical care. Specific Objective 1. Develop skills in the utilization, zeroing, and calibration of transducers and enhance skills in the use of amplifiers and recorders. 2. Gain experience in the analysis of data obtained by hemodynamic monitoring. 3. Gain experience in the use of cardiac pharmacologic agents to manage critically ill post-operative cardiac patients. 4. Learn to recognize and develop a plan for management of common surgical complications in patients. 5. Recognize and treat common arrhythmias encountered in patients. 6. Manage fluid and electrolyte problems. 7. Recognize the common problems with hemostasis and blood loss and develop a rational approach to transfusion therapy. 8. Enhance skills in managing patients on mechanical ventilation. 9. Will be introduced to the concepts and mechanisms behind the intra-aortic balloon pump and the ventricular assist devices. 10. Will be introduced to the concepts of early post-operative care of cardiac transplant patients, including immunosuppression and management of rejection. 11. Learn to recognize and treat post-operative problems developing in patients following lung resection, particularly those related to chest tubes.



Coronary Care Unit-Saint Luke’s Hospital 1. Acquire knowledge of the physiology, pathophysiology, diagnosis and therapy of disorders of the cardiovascular system commonly encountered in the Coronary Care Unit (CCU). Objectives: 1. Develop skills in the use of thrombolytic therapy for acute myocardial infarction. 2. Develop an understanding of the role of angioplasty and coronary artery bypass surgery in the management of patients with myocardial ischemia and infarction. 3. Develop a rational approach to the recognition and treatment of commonly encountered arrhythmias. 4. Gain experience in hemodynamic monitoring. 5. Gain experience in the use of cardiac pharmacologic agents such as vasopressors, inotropes, vasodilators, and antiarrhythmic agents. 6. Will have the opportunity to learn the indications, contra-indication, complications, and limitation of the following: Basic and advanced cardiopulmonary resuscitation. Insertion of central venous, arterial and pulmonary artery catheters Cardioversion Pericardiocentesis Transvenous pacemaker insertion 7. Will learn to develop a rational approach to the management of the patient with an acute myocardial infarction and the patient presented with acute myocardial ischemia. 8. Develop a rational approach to the management of the patient with congestive heart failure. Ambulatory Care Experience: Pulmonary/Critical Care 1. Develop the knowledge, skills, and professional attitudes to provide ambulatory care and consultation for patients with pulmonary diseases and patients recovering from serious medical problems after they are discharged from the hospital. 2. Maintain knowledge, skills, and professional attitudes in general internal medicine. 3. Demonstrate effective communication skills when dealing with patients, families, nurses, respiratory therapists, residents, and students in the ambulatory care setting. 4. Develop the knowledge, skills and professional attitudes to perform the following procedures in an outpatient setting: Fiberoptic bronchoscopy and accompanying procedures Thoracentesis Supervision of technical aspects and interpretations of pulmonary function tests, exercise testing, and sleep studies. 5. Develop the professional judgment in determining which patients require hospitalization and which can be safely managed in an outpatient setting. 6. Develop the knowledge, skills and attitudes in working with community resources. For example home health agencies, government agencies, public health departments, psychiatric hospitals, and health care delivery organizations. IX. CURRICULUM There are four (4) methods in which fellows acquire medical knowledge, concepts, and skills.



1. Clinical experience with bedside teaching and supervision of clinical activities and procedures by teaching faculty. 2. Participation in lectures, conferences, and journal clubs. 3. Independent reading. 4. Clinical and basic research activities including presentations at national meetings. A. The program provides the environment and resources for fellows to acquire knowledge of and have clinical experience with a broad spectrum of pulmonary disease, including but not limited to the following: 1. Obstructive lung disease, including asthma, bronchitis, emphysema, bronchiectasis, and cystic fibrosis. 2. Pulmonary malignancy-primary and metastatic. 3. Pulmonary infections, including tuberculosis, fungal and those in the immunocompromised host 4. Diffuse interstitial lung disease. 5. Pulmonary vascular disease, including primary and secondary pulmonary hypertension and the vasculitis and pulmonary hemorrhage syndromes. 6. Occupational and environmental lung diseases. 7. Iatrogenic respiratory diseases, including drug-induced disease. 8. Acute lung injury, including radiation, inhalation, and trauma. 9. Pulmonary manifestations of systemic diseases, including collagen vascular diseases that are primary in other organs. 10. Respiratory failure, including the adult respiratory distress syndrome, acute and chronic respiratory failure in obstructive lung disease, and neuromuscular respiratory drive. 11. Disorders of the pleura and the mediastinum. 12. Genetic and developmental disorders of the respiratory system. 13. Sleep disorders. B. The program provides the environment and resources for the fellow to acquire knowledge of and competence in performing the following: 1. Establishment of airway. 2. Maintenance of open airway in non-intubated, unconscious, paralyzed patients. 3. Oral and nasotracheal intubation. 4. Breathing, ventilation. Ventilation by bag or mask

Mechanical ventilation using pressure-cycled, volume-cycled, and negative pressure mechanical ventilators. Use of reservoir masks and continuous positive airway pressure masks for delivery of supplemental oxygen, humidifiers, n nebulizers, and incentive spirometry.

Weaning and respiratory care techniques. Management of pneumothorax (needle insertion and drainage systems) 5. Maintenance of circulation. Arterial puncture and blood sampling. Insertion of central venous, arterial, and pulmonary artery balloon flotation catheters.



Basic and advance cardiopulmonary resuscitation. Cardioversion. 6. 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. 7. Diagnostic and therapeutic procedures, including thoracentesis, pleural biopsy, flexible fiberoptic bronchoscopy, and related procedures. 8. Calibration and operation of hemodynamic recording systems. 9. Ventilator support, weaning, and respiratory care techniques. 10. Examination and interpretation of sputum, bronchopulmonary secretions, pleural fluid/tissue, and lung tissue for infectious agents; cytology and histopathology. C. The program provides the environment and resources for the fellow to acquire knowledge of and ability to interpret the following: 1. Imaging procedures including: Chest roentgenograms. Radionuclide scans Other radiologic procedures 2. Sleep Studies D. The program provides the environment and resources for fellows to develop expertise in monitoring and supervising special services including: 1. Critical Care Units 2. Pulmonary function laboratories 3. Respiratory physical therapy and rehabilitation services. 4. Respiratory care techniques and services. E. The program provides the environment and resources for the fellow to develop clinical competence in performing the following: 1. Inhalation challenge studies. 2. Thoracostomy tube insertion and drainage. F. The program provides opportunities for fellows to acquire knowledge and develop clinical competence in the following critical care content areas: 1. Physiology, pathophysiology, molecular biology, diagnosis, and therapy of disorders of the cardiovascular, respiratory, renal, gastrointestinal, genitourinary, neurologic, endocrine, hematologic, musculoskeletal, and immune systems as well as of infectious diseases. 2. Electrolyte and acid-base physiology, pathophysiology, diagnosis, and therapy. 3. Hematologic and coagulation disorders secondary to critical illnesses. 4. Metabolic, nutritional, and endocrine effects of critical illnesses. 5. Critical obstetric and gynecological disorders. 6. Management of immunosuppressed patient. 7. Management of anaphylaxis and acute allergic 8. Trauma 9. Pharmacokinetics, pharmacodynamics, drug metabolism and excretion in critical illness.



10. Use of paralytic agents. 11. Ethical, economic, and legal aspects of critical illness. 12. Psychosocial and emotional effects of critical illnesses. 13. Iatrogenic and nosocomial problems in critical care medicine. 14. Personal development, attitudes, and coping skills of physicians and other heath-care professionals who care for critically ill patients. 15. Biostatistics and experimental design. 16. Occupational Safety and Health Administration (OSHA) regulations and universal precautions and protections of health care workers. G. The program provides opportunities for fellows to learn the indication, contraindications, limitations, and complications of the following critical care procedures and the technical skills necessary to perform them: 1. Parenteral nutrition. 2. Monitoring/bioengineering. H. The program also provides opportunity to learn the indication, contraindications, limitations, and complications of the following procedures. Practical experience is recommended but not required. 1. Percardiocentesis 2. Transvenous pacemaker insertion 3. Peritoneal dialysis. 4. Peritoneal lavage 5. Aspiration of major joints. 6. Percutaneous needle aspiration and/or cutting lung biopsy. 7. Endobronchial laser therapy. 8. Intracranial pressure monitoring. I. Experience is provided in the analysis of data pertaining to the following: 1. Cardiac output determinations by thermodilution and/or other techniques. 2. Evaluation of oliguria. 3. Management of massive transfusions. 4. Management of hemostatic defects. 5. Interpretation of antibiotic levels of sensitivities. 6. Monitoring and assessment of metabolism and nutrition. 7. Calculation of oxygen content. Intrapulmonary shunt, and alveolar arterial gradients. 8. Pharmacokinetics.



Appendix 1 Reference-Guideline Committee; Society of Critical Care Medicine. Guidelines for program content for fellowship training in Critical Care Medicine. Crit Care Med 1992; 20(6): 875-882

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