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LSUHSC-New Orleans Pulmonary/Critical Care Medicine Fellowship

Ochsner Medical Center

Ochsner Medical Center has more than 500 beds to serve a large referral base in Southeastern Louisiana and the Gulf Coast. Ochsner receives more than 30,000 Emergency Room visits annually. More than 18,000 patients are admitted to Ochsner Medical Center each year by a multispecialty practice of about 375 physicians who provide over 600,000 clinic visits annually. The institution serves as a primary site for organ transplantation in the Arkansas, Louisiana, and Mississippi area for patients suffering from heart, kidney, liver, or lung diseases. The ICU is a state of the art combined medical-surgical unit with 30 beds, admitting more than 1300 patients each year. Medical patients account for about 30-40% of ICU admissions. The patient population is ~70% Caucasian, ~20% African-American, ~2% Hispanic, and ~6% other. The majority of Ochsner patients are insured: 67% commercial insurance, 26% Medicare, and 5% Medicaid. In addition to critical care services, Ochsner has a busy outpatient pulmonary clinic (>3000 visits per year) and serves as a wide referral area with the Ochsner Lung Specialty Center and Transplantation Clinic. Ochsner Medical Center sponsors its own ACGME-accredited residency training program in many disciplines including Internal Medicine, and has affiliations with the LSU Health Sciences Center in several departments (including Pulmonary/Critical Care Medicine).

Fellowship Rotations at the Ochsner Medical Center

• Pulmonary Consultations
• Lung Transplantation / Inpatient Pulmonary
• Pulmonary Physiology
• Mentored Scholarly Activity (Basic Science and Clinical Research)
• Medical Intensive Care Unit
• Surgical Intensive Care Unit

Curriculum in Clinical Pulmonary Medicine

Educational Goals and 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 Pulmonary Clinic at Ochsner Medical Center. Under faculty supervision, subspecialty trainees provide continuity care for a panel of outpatients and perform consultations. Additional outpatient experience includes two half-days per week in Lung Transplantation Clinic at Ochsner Medical Center during rotations on Lung Transplant / Inpatient Pulmonary (typically 4-6 months during the three years). 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; sleep-disordered breathing; lung transplantation; and pulmonary complications of organ transplantation. 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; 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, interventional radiographic techniques including percutaneous needle biopsy, and newer modalities such as 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 affiliated with Louisiana State University Health Sciences Center at New Orleans. Supervising faculty on the three inpatient Pulmonary consultation rotations 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. In addition, fellows participating in Ochsner-based rotations are expected to attend the Ochsner Clinicopathologic Pulmonary Conference. 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.

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 Ochsner Medical Center (~4 months)

During this rotation, the fellow functions as a consultant in Pulmonary Medicine at Ochsner Medical Center. The subspecialty trainee is expected to develop expertise in the diagnosis and management of pulmonary diseases. Because of the referral patterns to Ochsner Medical Center, fellows are specifically expected to attain competence in the diagnosis and management of pleuropulmonary manifestations of neoplastic diseases during this rotation. This expertise should include: interpretation of radiographic and nuclear medicine imaging studies, competence in pulmonary diagnostic procedures, and examination/interpretation of pathologic and cytopathologic specimens. With faculty guidance, the fellow on the Consult service is responsible for overseeing and interpretation of pulmonary function testing including spirometry, lung volumes, diffusion capacity, and bronchodilator response studies. In addition, the Consult fellow develops competence in diagnostic bronchoscopy including indications / contraindications / complications of endoscopic techniques such as bronchoalveolar lavage, endobronchial / transbronchial biopsy, and transbronchial / transtracheal needle aspiration. Along with assessment of general pulmonary diseases, the fellow is expected to evaluate malignant diseases of the chest including lung cancer, mediastinal masses, metastatic lesions of the lungs, malignant pleural disease, and solitary pulmonary nodules. In addition, trainees are expected to develop expertise in the diagnosis and management of immunocompromised patients and indications / contraindications / complications of radiotherapy and chemotherapy in the treatment of neoplastic diseases. The fellow is also expected to master peri-operative pulmonary management of patients, infectious diseases in normal and immunocompromised hosts (especially the transplant population), pulmonary vascular diseases, pleural diseases, interstitial lung diseases, and immunologic disorders affecting the respiratory system. Fellows perform consultations in the outpatient environment, as well as on medical and non-medical inpatient wards. As such, trainees are required to interact with physicians from all medical disciplines.

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 daytime consultation responsibilities, subspecialty fellows share evening call and alternate weekend coverage.

Working directly with Ochsner Pulmonary specialists, the fellow functions in a one to one fashion. Under the guidance of supervising adjunct faculty, trainees are responsible for evaluating all patients on the Consult service during initial and follow-up care over the course of hospitalization. Internal Medicine residents are occasionally assigned to the Pulmonary Consult service, and there are no non-teaching patients on the inpatient services at Ochsner Medical Center. There are no absolute limits to the number of patients followed on the service, but the average daily census is typically 6-10 patients with 2-4 new consults each weekday.

Lung Transplantation / Inpatient Pulmonary at Ochsner Medical Center (~2-4 months)

During this rotation, the fellow gains expertise in lung transplantation under the direction of LSU and Ochsner pulmonary faculty at Ochsner Medical Center. The subspecialty trainee is exposed to important aspects of pulmonary transplantation, including pre-operative clinic evaluation and long-term post-transplant outpatient follow-up. In the pre-transplant setting, the Transplant fellow learns the essentials of the screening process. Trainees manage end stage lung diseases of all varieties, such as emphysema, interstitial lung disease, and bronchiectasis, including cystic fibrosis. Fellows gain familiarity with immunosuppression regimens including drug-drug interactions and infectious/non-infectious complications of long-term immune suppression. The lung transplant rotation is combined with the inpatient pulmonary rotation, which additionally provides a supervised clinical experience in the management of complex pulmonary disease, including pulmonary hypertension, advanced interstitial lung disease, and obstructive lung disease, and patients recovering from critical illness.

Fellows routinely participate in two morning Transplant clinics each week and manage hospitalized patients. Subspecialty fellows provide weeknight and alternate weekend "on call" coverage of the Ochsner Medical Center Pulmonary Consult, MICU and SICU services. On call responsibilities are shared with fellows assigned to the Ochsner ICU with coverage of the Lung Transplant / Inpatient Pulmonary service on weekends as determined by the monthly call schedule.

The fellow is responsible for supervising and teaching junior trainees (internal medicine residents and medical students) under the direct supervision of LSU faculty based at Ochsner. Patients include lung transplant recipients and patients with complex pulmonary disease. Staff trained in lung transplantation coordinate this rotation and supervise the outpatient portion of the transplant experience. This rotation also provides opportunities for performance and supervision of procedures, including central venous access and thoracentesis. The Lung Transplant / Inpatient Pulmonary rotation is a teaching service, and there are no non-teaching patients under the care of the fellow.

Pulmonary Physiology at Ochsner Medical Center (~ 1-2 months)

During this rotation, the fellow independently reads pulmonary function studies and reviews these studies with supervising Ochsner staff with additional training and expertise in pulmonary function testing. This educational experience is expected to be combined with progress in Mentored Scholarly Activity.

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 Objective

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's of both institutions.

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. In addition, Section faculty and fellows primarily manage patients referred from regional ICU's for long-term acute care, ventilator weaning, and rehabilitation.

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 affiliated with 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 Unit at Ochsner Foundation Hospital (~4-6 months)

During this rotation, the fellow supervises the primary critical care delivery for patients admitted to the Medical Intensive Care Unit at Ochsner Foundation Hospital under the direction of Division faculty. The subspecialty trainee is expected to develop expertise in the diagnosis and management of critical illness. In addition to competence in patient care and procedural performance, this expertise should include: administrative management of an intensive care unit, coordination of patient care with input from consultative experts from many disciplines in medicine and paramedical services, interpretation of radiographic imaging studies, and understanding ethical issues, as well as the psychosocial impact of critical illness on patients and families. Under faculty guidance, the fellow on the MICU service is responsible for overseeing the care of all medical patients admitted to the OFH MICU. 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 intracranial pressure/EEG monitoring, dialysis, and endoscopic, radiographic, surgical, and vascular procedures. As a combined Medical/Surgical intensive care unit, the Ochsner ICU encourages close interaction between the Medical ICU team and surgical services. Many subspecialty surgical patients (Orthopedics, Otolaryngology, Obstetrics/Gynecology, Urology) admitted to the ICU are managed jointly by the surgical team and the MICU team directed by the Critical Care fellow. In addition, in the absence of a specialized Neurology ICU at OFH, the MICU team coordinates care for most patients suffering from neurologic disorders such as seizures, cerebrovascular accidents, intracerebral hemorrhage, and coma. The Critical Care Service also manages many patients admitted with cardiovascular illnesses including acute myocardial infarction, congestive heart failure, cardiac arrhythmias, and hypertensive crisis.

Call responsibility for the Ochsner ICU is shared between fellows assigned to the Ochsner Medical Center as determined by the monthly call schedule. Along with daytime responsibility for management of the ICU, subspecialty fellows provide alternate weekend and evening coverage of the OMC Intensive Care Unit.

The fellow functions as a member of a team consisting of an attending from the Section, 4 upper level Internal Medicine residents, 4 interns from Internal Medicine and other disciplines, and occasional fourth year medical students performing ICU electives. 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 stay. Fellows provide direct supervision of residents and are expected to assess each new admission independently. Trainees also participate in the teaching and monthly evaluation of residents and students on the MICU service with assistance from the faculty staff. There are no absolute limits to the number of patients followed on the service, but the average daily census is typically 10-15 patients with 2-4 new admissions daily. There are no non-teaching patients on the ICU inpatient service at Ochsner Medical Center.

Surgical Intensive Care Unit at Ochsner Medical Center (2 - 4 months)

The fellow rotating with the SICU team serves as a consultative resource for patients on other services including Cardiology, Colorectal Surgery, Heart Transplant, General Surgery, and Thoracic-Cardiovascular Surgery. Educational content on this rotation includes management of complex post-operative critically ill patients, surgical sepsis, acute lung injury and neurosurgical disease. The team is composed of 1-3 specialty trainees in surgery and anesthesia, and is supervised by pulmonary faculty and anesthesia staff with demonstrated commitment to graduate medical education in critical care. The average daily census is 4 to 8 patients, with 1-3 new consultations per day.

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.

 

Mentored Scholarly Activity (Basic and Clinical Research)

Educational Goals and Objectives

Subspecialty trainees usually spend 3-6 months during the second and third years of fellowship participating in research activities of the Section. Clinical research occurs at Ochsner Medical Center and other clinical training sites within the fellowship. Under the guidance of Pulmonary faculty, 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