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LSUHSC-New Orleans Pulmonary/Critical Care Medicine Fellowship Training: LSU Interim Hospital

The LSU Interim Hospital is an inner city hospital serving a predominantly indigent patient population. The institution is jointly staffed by both LSU and Tulane Medical School faculty, housestaff, and students on most services. The hospital has undergone a major renovation and has reopened as a Level 1 trauma center serving the Greater New Orleans area with ~180 beds. The Medical ICU is an 8 bed unit with a high acuity of illness. The patient population is predominantly African-Americans, with Caucasian, Hispanic,and Asian populations also represented. The majority of LSU Interim Hospital patients are uninsured or covered by Medicaid. Common admission diagnoses for the ICU patients include sepsis, pneumonia , asthma/COPD exacerbation, drug overdose, congestive heart failure, and diabetic ketoacidosis.

 

Curriculum in Clinical Pulmonary Medicine

Educational Goals & Objectives

Training in Inpatient Care and Management

Fellows are expected to develop the skills necessary to obtain a history and perform a complete respiratory physical examination. Subspecialty trainees are also expected to gain experience adequate to fulfill the roles of primary physician and consultant to other physicians in the management of patients with pulmonary disorders. Fellows have direct responsibility for performing these functions under the supervision of the faculty in the Pulmonary / Critical Care Medicine Section in proportion to the experience and qualifications of trainees.

Training in Ambulatory, Outpatient, and Follow-up Care

Responsibility for management of outpatients with respiratory illnesses, as well as outpatient consultation, is sustained for at least 30 months of the 36-month fellowship program. All Pulmonary / Critical Care Medicine fellows attend a ½ day per week ambulatory Pulmonary clinic throughout training with as little disruption as possible. Continuity clinic sites include the Chest Clinic at LSU Interim Hospital. Under faculty supervision, subspecialty trainees provide continuity care for a panel of outpatients and perform consultations. Fellows also attend TB Clinic, currently located in Marrero, LA, to direct the outpatient diagnosis/management of tuberculosis infection. The combination of these ambulatory experiences exposes fellows to a broad spectrum of adult respiratory disorders spanning all ages, ethnic groups, and both genders. Trainees develop particular expertise in the continuity of care for outpatients with pulmonary diseases, post-hospital and post-ICU patient care, consultation, pre-operative evaluation, and in the efficient use of laboratory and radiology resources in diagnosis and treatment.

Training in Understanding, Diagnosis, Prevention, and Treatment

Subspecialty trainees are expected to develop expertise in pathogenesis, pathology, risk factors, natural history, differential diagnosis, diagnostic work-up, medical/surgical management, complications, and prevention of pulmonary diseases. Areas of study include: acute lung injury; airway diseases; congenital lung diseases; infections of the respiratory tract; interstitial lung diseases; neoplastic pulmonary diseases; occupational lung diseases; pleural diseases; respiratory disease during pregnancy; pre-operative pulmonary risk assessment and peri-operative management of lung disease; pulmonary manifestations of systemic disorders; pulmonary vascular diseases; respiratory failure; and sleep-disordered breathing. Fellows also become competent in the diagnosis and management of common presentations of pulmonary signs and symptoms such as chest pain, cough, daytime somnolence, dyspnea, fevers with radiographic infiltrates, hemoptysis, lung mass by chest radiograph, pleural effusions, stridor, and wheezing. Under faculty guidance, subspecialty trainees are expected to develop competence in procedures essential to the diagnosis and management of pulmonary disorders including indications, contraindications, complications, performance, and interpretation of results. Fundamental procedural competence includes: arterial blood gas sampling and interpretation; bronchoscopy; chest tube thoracostomy; endotracheal intubation and ventilatory management; advanced airway management including percutaneous tracheostomy; oximetry monitoring; management of supplemental oxygen including O2 conserving techniques and placement of SCOOP catheters; pathology; peak flow monitoring; vascular access placement (arterial and venous); pulmonary artery catheterization; pulmonary function testing including cardiopulmonary exercise and bronchoprovocation testing; radiology including plain films, computed tomography, nuclear medicine, magnetic resonance and PET; skin testing for tuberculosis; thoracentesis; and pleural biopsy.

Principal Teaching Methods

During clinical rotations in Pulmonary Medicine, trainees are trained by supervising attendings. All attending staff are faculty members of Louisiana State University Health Sciences Center at New Orleans. Supervising faculty on the inpatient Pulmonary consultation rotation are Board-certified in Internal Medicine and Pulmonary Diseases. The style of teaching is unique to each attending but is typically “hands on” and “patient-directed” based upon topics suggested by clinical consultations.

Additional teaching occurs through the didactic series of lectures including a weekly Chest Conference, Pulmonary Fellows Journal Club, and weekly didactic core lectures. These conferences include a broad array of subject matter and speakers from within and without the Division. Conferences are considered an integral component of the educational process for fellowship training and attendance is mandatory for these seminars. Additional conferences include Internal Medicine Grand Rounds at LSU, a departmental Practice Management lecture series, and Research conferences.

Fellows are expected to augment the above by independent reading. Along with complementing the more organized components of the program, this commitment to self-study and acquisition of new knowledge is considered integral to achievement and maintenance of lifelong expertise in Pulmonary Medicine.

Educational Content

Pulmonary Consults at LSU Interim Hospital
(~4 months)

During this rotation, the fellow functions as a consultant in Pulmonary Medicine at LSU Interim Hospital. The subspecialty trainee is expected to develop expertise in the diagnosis and management of pulmonary diseases. Skills should include: interpretation of radiographic and nuclear medicine imaging studies, competence in pulmonary procedures, examination and interpretation of pathologic and cytopathologic specimens, and supervision/management of the Pulmonary Function Laboratory. With faculty guidance, the fellow on the Consult service is responsible for overseeing and interpreting pulmonary function testing including spirometry, lung volumes, diffusion capacity, arterial blood gas, bronchoprovocation studies, and cardiopulmonary exercise testing. The Consult fellow should develop competence in diagnostic procedures of Pulmonary Medicine such as bronchoscopy (including indications/contraindications/complications of endoscopic techniques such as bronchoalveolar lavage, endobronchial/transbronchial biopsy, and transbronchial/transtracheal needle aspiration) and pleural biopsy. In addition to assessment of general pulmonary diseases, the fellow is exposed to peri-operative pulmonary management of patients, infectious diseases in normal and immunocompromised hosts (including HIV and transplant populations), pulmonary vascular diseases, pleural diseases, interstitial lung diseases, and immunologic disorders affecting the respiratory system. Fellows perform consultations in the critical care environment, as well as on medical and non-medical wards. As such, trainees are required to interact with physicians from Anesthesia, Surgery, Obstetrics-Gynecology, Family Medicine, and Internal Medicine during the rotation.

Coverage of the Consult service after-hours and on weekends is provided by the on-call fellow as determined by the monthly call schedule. In addition to consultation responsibilities, fellows provide weekend and evening coverage of the Medical Intensive Care Unit at LSU Interim Hospital 2-3 nights per week.

The fellow functions as a member of a team consisting of an attending, 1-3 Internal Medicine residents, and 1-2 third or fourth year medical students. Under the guidance of supervising faculty, trainees are responsible for evaluating all patients referred to the Consult service during initial and follow-up care over the course of hospitalization. In addition to their participation in teaching activities, fellows provide direct supervision of residents and are expected to assess each new consultation independently from the resident. There are no absolute limits to the number of patients followed by the service, but the average daily census is typically 4-8 patients with 1-4 new consults each weekday. The Consult fellow is responsible for arranging and performing outpatient work-ups scheduled by the Chest Clinic. While fellows may provide consultation for patients of non-university physicians, trainees in Pulmonary and Critical Care Medicine are not responsible for the primary patient care needs of non-teaching patients.

Method of Evaluation of Fellows

Fellows are evaluated by supervising faculty at the conclusion of each rotation. Employing the standard 9-point ABIM evaluation form, written assessments are completed in a timely manner prior to submission to the Fellowship Program Director. To provide feedback to trainees, faculty members are encouraged to verbally review performance during and at the conclusion of each rotation. In addition, fellows undergo periodic performance reviews with the Program Director and Section Chief to assure continued communication.

Method for Evaluation of Faculty and Rotations

Fellows are expected to complete an evaluation form at the conclusion of each rotation for both supervising faculty and the rotation itself. In addition, the Program Director solicits input from the fellows regarding the quality of training rotations and means of improving the academic character of the Pulmonary fellowship program.

 

Curriculum in Clinical Critical Care Medicine

Educational Goals and Objectives

Training in Inpatient Care and Management

Fellows are expected to develop the needed skills to obtain a history and perform a complete physical examination as necessary to care for the critically ill patient. Subspecialty trainees are also expected to gain experience adequate to fulfill the roles of primary critical care physician and consultant to other physicians in the management of ICU patients. Fellows have direct responsibility for performing these functions under the supervision of the faculty in the Pulmonary and Critical Care Medicine Section in proportion to the experience and qualifications of trainees. In addition to expertise in patient management, trainees participate in ICU administrative functions such as infection control, quality improvement, cost containment, technology assessment, and other multidisciplinary activities in the ICU. Fellows participate in care of trauma and surgical patients in a consultative role during this rotation.

Training in Ambulatory, Outpatient, and Follow-up Care

Despite the rigors of hospital-based Critical Care Medicine, the Pulmonary and Critical Care Medicine Section firmly believes that trainees should maintain continued responsibility for management of outpatients with respiratory illnesses even during ICU rotations. All Pulmonary and Critical Care Medicine fellows attend their assigned ½ day per week continuity clinic throughout training with as little disruption as possible. In addition to outpatient consultation, the ambulatory clinic experience allows fellows to see patients in post-hospital follow-up, including those patients recovering from critical illness. Post-ICU follow-up is also provided by Pulmonary Consult Services during the hospital stay for some critically ill MICU patients.

Training in Understanding, Diagnosis, Prevention, and Treatment

Subspecialty trainees are expected to develop expertise in pathogenesis, pathology, risk factors, natural history, differential diagnosis, diagnostic work-up, medical/surgical management, complications, and prevention of critical illness. By its nature, Critical Care Medicine encompasses many disciplines and pathophysiologic derangements of multiple organ systems. Fellows are expected to gain experience in the diagnosis and management of the following: cardiac diseases, endocrine disorders, environmental exposures, ethical issues such as end of life and advanced directives, gastrointestinal diseases, hematologic disorders, infectious diseases, neurologic disorders, enteral and parenteral nutrition, pulmonary diseases, renal diseases, rheumatologic disorders, and substance abuse including drug withdrawal and overdose syndromes. Trainees should also become competent in the diagnosis and management of common presentations of many other critical illnesses. Under direct supervision of Section faculty, subspecialty trainees are expected to develop competence in procedures essential to the diagnosis and management of ICU patients including indications, contraindications, complications, performance, and interpretation of results. Fundamental technical competence should include the following procedures: advanced cardiac life support, arterial blood gas sampling and interpretation; bronchoscopy; chest tube thoracostomy; endotracheal intubation and emergency airway management; oximetry monitoring; pulmonary artery catheterization; radiology including plain films, computed tomography, nuclear medicine, magnetic resonance, and interventional radiographic techniques; vascular (arterial and venous) access placement, ventilator management, transvenous cardiac pacing, and percutaneous tracheostomy.

Principal Teaching Methods

During clinical rotations in the ICU setting, trainees are principally taught by their supervising attending. All attending staff are faculty members of the Louisiana State University Health Sciences Center at New Orleans. Faculty supervising on ICU rotations are Board-certified in Internal Medicine and Pulmonary Diseases with additional certification in Critical Care Medicine. The style of teaching is unique to each attending but is typically “hands on” and “patient-directed” based upon topics suggested by the patient population. Each month the staff and fellows conduct a lecture series to cover important topics in critical care for students, residents, and fellows assigned to the rotation. Usual discussions cover principles of acid-base derangements, hemodynamic monitoring, vasoactive drugs, respiratory failure, and ventilator management/weaning.

Additional teaching occurs through the didactic series of lectures including weekly Chest Conference, Pulmonary Fellows Journal Club, and weekly didactic core lectures. These conferences include a broad array of subject matter and speakers from within and without the Division. Conferences are considered an integral component of the educational process for fellowship training and attendance is mandatory for these seminars.

Finally, fellows are expected to augment the above by independent reading. In addition to complementing the more organized components of the program, this commitment to self-study and acquisition of new knowledge is considered integral to achievement and maintenance of expertise in Critical Care Medicine.

Educational Content

Medical Intensive Care Units at University Hospital (~4-6 months)

During these ½ month rotations, fellows supervise the primary critical care delivery for patients admitted to the Medical Intensive Care Unit at the LSU Interim Hospital under the direction of Section faculty. The subspecialty trainee is expected to develop competence and expertise in the diagnosis and management of critically ill patients. In addition to capable patient care and procedural performance, this expertise includes: administrative management of an intensive care unit, coordination of patient care with input from consultative experts from many disciplines in medicine and paramedical services (including Nursing, Pharmacy, Respiratory Therapy, Nutrition, and Physical Therapy/Rehabilitation), interpretation of radiographic imaging studies, and understanding ethical issues, as well as the psychosocial impact of critical illness on patients and families. Trainees should recognize the contributions of medical subspecialists to differential diagnosis and management of critically ill patients. Critical Care fellows should learn indications, contraindications, and limitations fundamental to specialized invasive procedures in the ICU setting including EEG monitoring, dialysis, endoscopic, radiographic, surgical, and vascular procedures. The Critical Care Service manages many patients admitted with cardiovascular illnesses including acute myocardial infarction, congestive heart failure, cardiac arrhythmias, and hypertensive crisis. In addition to Internal Medicine subspecialties, the fellow is expected to interact with specialists in other fields including Anesthesiology, Trauma, Surgery, Cardiovascular Surgery, and Radiology to provide expanded pulmonary and critical care expertise.

Coverage of the ICU service after-hours and on weekends is provided by the on-call fellow as determined by the monthly call schedule. In addition to daytime responsibility for management of the MICU, subspecialty fellows share alternate weekend and evening coverage.

The MICU fellow functions as a member of a team consisting of an attending from the Section, 2-3 upper level Internal Medicine residents, 2-3 interns from Internal Medicine and other disciplines, and fourth year medical students. Under the guidance of supervising faculty, trainees are responsible for evaluating all patients on the service during initial and follow-up care over the course of their ICU hospitalization. Fellows provide direct supervision of residents and are expected to assess each new admission independently from the resident. As the primary leader of the ICU team, fellows are integral to the teaching and monthly evaluation of residents and students on the MICU service with assistance from supervising faculty. While there are no absolute limits to the number of patients followed on the service, the average daily census is typically 6-12 patients with 2-4 new admissions daily. There are no non-teaching patients on the ICU inpatient service at LSU Interim Hospital.

Method of Evaluation of Fellows

Fellows are evaluated by supervising faculty at the conclusion of each rotation. Employing the standard 9-point ABIM evaluation form, written assessments are completed in a timely manner prior to submission to the Fellowship Program Director. To provide feedback to trainees, faculty members are encouraged to verbally review performance during and at the conclusion of each rotation. In addition, fellows undergo periodic performance reviews with the Program Director and Section Chief to assure continued communication.

Method for Evaluation of Faculty and Rotations

Fellows are expected to complete an evaluation form at the conclusion of each rotation for both supervising faculty and the rotation itself. In addition, the Program Director solicits input from the fellows regarding the quality of training rotations and means of improving the academic character of the Critical Care Medicine fellowship program.

 

Curriculum in Pulmonary and Critical Care Medicine Basic Science and Clinical Research

Educational Goals & Objectives

Subspecialty trainees usually spend 3-6 months during the second and third years of fellowship participating in research activities of the Section. Under the guidance of Pulmonary faculty, both clinical and bench research opportunities are available at the LSUHSC-New Orleans campus. At the discretion of the Section Head, an additional year for research may be possible for selected trainees. The goal of the Section is to provide fellows experience in the fundamentals of basic science and clinical research within critical care units, inpatient services, pulmonary function laboratory, and the basic science laboratory. All clinical investigation is carried out under the supervision of an experienced investigator and according to approved principles of biomedical ethics and institutional rules for patient safety.

Principal Teaching Methods and Educational Content

During research rotations, mentors from the Section are primarily responsible for directing the education of fellows. The style of teaching is unique to each attending but typically focuses on problem-solving specific to the research project.

Additionally, education occurs in more formal settings such as weekly Research conference, weekly Pulmonary Fellows Journal Club and a Clinical Research Design Course conducted annually by the University. These seminars focus on design and interpretation of research, informed consent issues, research methodology, and interpretation of data. In addition to reviewing principles of basic pulmonary and cardiovascular physiology, Journal Club provides the setting for critical analysis of the literature, including new therapies.

Through their exposure to research, fellows are expected to develop skills in these basic components of research: 

1. Critical analysis of the literature to assess currently available knowledge that allows an investigator to place the planned research in the appropriate scientific context prior to, during, and at the conclusion of any study. 
2. Formulation of a hypothesis and specific goals in research planning to assure that the hypothesis is indeed testable and that the study design will allow appropriate and relevant conclusions. 
3. Development of a research plan to include study design, formulation of a protocol, obtaining approval from appropriate animal care or institutional review boards, subject recruitment, informed consent and respect for subject privacy, data collection, and intended statistical analysis. 
4. Collection of data 
5. Establishment of procedural skills and proficiency as necessary to obtain valid results. 
6. Presentation of data and results both in oral and written form. Findings are reviewed periodically with faculty mentors prior to public reporting of results. Under the direction of supervising Section faculty, fellows are encouraged to present their findings at regional, national, and international scientific meetings as abstracts and poster/slide presentations. The goal of any research project is publication of the study in the peer-reviewed literature. Fellows are expected to collaborate extensively with faculty mentors in manuscript preparation and submission for publication.