Pulmonary

Pulmonary

INTERNAL MEDICINE RESIDENCY PROGRAM

Faculty: Ismail A. Bobat, MD

Sites: Provena Covenant Medical Center, Carle Foundation Hospital

Duration: 4 week Block Rotation PGY II __________________________________________________________________________________________________________

DESCRIPTION

This is a four week block rotation under the supervision of Ismail A. Bobat, MD and Division of Pulmonary Medicine faculty. Residents gain experience in the evaluation and care of common out-patient and in-patient pulmonary problems.

Additionally, pulmonary training takes place longitudinally throughout all 3 years, e.g. block rotations in Ambulatory Medicine, Adult Medicine, Cardiology, Critical Care. Other pulmonary education occurs during Continuity Clinic, weekly conferences, and Grand Rounds, Quality Review, and Journal Club.

I. GOALS

Develop the attitudes, knowledge, and skills for competent care of patients with pulmonary problems, including disease prevention, recognition of disease presentation and promotion of optimal functional independence.

II. OBJECTIVES

A. PATIENT CARE

Objective 1: Demonstrate the ability to obtain accurate and detailed histories, and perform comprehensive chest and cardiac oriented pulmonary examination of patients with common outpatient and in-patient pulmonary problems, including:

a. Allergic disorders

b. Infectious disorders

c. Obstructive pulmonary disease

d. Interstitial lung disease

e. ARDS

f. Malignant disorders of the lung and mediastinum

g. Pneumothorax

h. Pleural effusion

i. Vasculitic and granulomatous chest disorders

j. Common genetic lung disorders

k. Sleep disorders

l. Pulmonary hypertension

m.Disorders of respiratory control and sleep disorders

n. Occupational lung disorders

o. Pulmonary consequences of congestive heart failure

p. P ulmonary thromboembolism

q. Common traumatic lung disorder, including

• Contusion

• Flail chest

• Hemothorax and pneumothorax

• Major vascular problems of the chest

B. MEDICAL KNOWLEDGE

Objective 1: Demonstrate an understanding of the pathophysiology, clinical presentations, differential diagnosis and management of the above disorders, with the common respiratory presenting problems.

a. Dyspnea

b. Hemopysis

c. Chest pain

d. Cough

e. Wheezing

f. Positive tuberculin test

Objective 2: Recognize chest wall deformities on physical exam.

a. Perform meticulous chest physical examination including inspection, palpation, percussion and auscultation.

b. Recognize crackles, rhonchi, wheezing, bronchial breathing, stridor, friction rubs, alterations in the intensity of breath sounds, and normal and abnormal diaphragmatic motion.

c. Identify disorders of neuromuscular respiratory control; Kussmaul breathing, Cheyne-Stokes ventilation, use of accessory muscles of respiration, and paradoxical abdominal thoracic muscle function.

d. Demonstrate familiarity with the physical findings of the common pulmonary problems.

Objective 3: Demonstrate ability to perform basic interpretation of pulmonary function tests and use in diagnosis and assessment of pulmonary complaints including spirometry, compartments, DLCO, and Pulmonary exercise testing, and the appropriate ordering of sleep laboratory testing.

Objective 4: Demonstrate of knowledge of the pharmacology, indications, contraindications, and use of the following classes of medications:

a. Expectorants

b. Cough Suppressants

c. Bronchodilators

d. Antibiotics

e. Antifungal agents

f. Antiviral agents

g. Corticosteroids

h. Immunosuppressant drugs

i. Oxygen therapy

Objective 5: Understand the use and indications for pulmonary rehabilitation, postural drainage, incentive spirometry, and CPAP.

a. Demonstrate understanding of the major modes of ventilation, including:

• Nasal cannula

• Ventimask oxygen

• Non rebreather osygen masks

• CPAP masks

• Nasal CPAP

• Non-invasive positive pressure ventilation, and

• Mechanical ventilation, i.e.modes of volume control, SIMV, pressure support

Objective 5: Demonstrate knowledge of the indications and risks of bfiberoptic bronchoscopy, transbronchial lung biopsy, and transbronchial needle aspiration, and fine needle aspiration of the lungs.

Objective 6: Demonstrate of ability to interpret arterial blood gases. Demonstrate basic ability to interpret the chest x-ray and the chest CT.

Objective 7: Demonstrate of knowledge of indications and contraindications for arterial puncture for blood gas analysis, thoracentesis, and ability to perform thoracentesis, and appropriate ordering of tests, and the interpretations of test results on pleural fluid.

Objective 8: Demonstrate understanding of the appropriate utilization of high resolution CT, bronchoscopy, fluoroscopy, bronchial lavage, lung biopsy by fine needle or thoracoscopic techniques, radio-isotype lung scans, pulmonary antiography, spiral CT for pulmonary thromboembolism, tracheotomy, chest tube drainage, and mediastinoscopy.

C. PRACTICE-BASED LEARNING AND IMPROVEMENT

Objective 1: Demonstrate ability to use computerized records as a tool of medical management and care.

Objective 2: Demonstrate ability to utilize the Internet, Med-Line, Pub-Med, medical web sites, the medical library, and standard medical texts in patient care.

Objective 3: Understand application of the principles of evidence-based medicine to the care of the pulmonary patient.

Objective 4: Present review of short pulmonary text or selected current medical bibliography on topic pertinent to care of pulmonary patient

a. Pneumonia

b. Asthma

c. COPD

d. Interstitial lung diseases

e. Granulomatous lung disorders

f. ARDS

g. Ventilator management

h. Cough

i. Chest pain

j. Typical and atypical mycobacterial infections

k. Fungal pulmonary diseases

l. Pulmonary thromboembolism

m. Ventilator acquired infections

n. Pulmonary infections in the immunosuppressed patients

o. Pulmonary problems in HIV

D. INTERPERSONAL AND COMMUNICATION SKILLS

Objective 1: Demonstrate the ability to relate well to patients in the in-patient and out-patient arena in order to obtain appropriate medical historical information, to explain issues to patients, to discuss indications and contraindications for procedures with patients, and to provide patients with appropriate information about their condition and management.

Objective 2: Demonstrate the ability to work well in the team setting with the physicians, nurses, and pulmonary technicians of the pulmonary division.

Objective 3: Contribute to the education of self and the pulmonary staff during the rotation.

E. PROFESSIONALISM

Objective 1: Demonstrate a high degree of professional appearance, demeanor, and behavior.

Objective 2: Demonstrate compassion for patients; considers the needs of patients, families, and colleagues.

Objective 3: Display honesty and integrity in all interactions with patients and staff; admits errors.

Objective 4: Helps patients understand the nature and prognosis of their conditions.

Objective 5: Appear regularly and on time for all duties of the rotation.

F. SYSTEM-BASED LEARNING

Objective 1: Exhibits individual initiative in accessing the most up-to-date information on patient's care and management.

Objective 2: Interact with Public Health departments, other physicians and hospitals to obtain needed patient information, when indicated.

Objective 3: Review clinic records and imaging studies of the patient.

Objective 4: Assist in appropriate referral for respiratory care equipment, CPAP equipment, oxygen equipment, and rehabilitation programs.

Objective 5: Evaluate patient insurance resources and their role in determining the most appropriate care for a patient.

Objective 6: Learn the principals of Social Security disability determination.

Objective 7: Model effective teaching skills to house staff and students when doing in-patient consultations.

III. METHODS

The pulmonary rotation is a four-week experience supervised by pulmonologists, faculty members of the University Of Illinois College Of Medicine at Urbana-Champaign, Department of Internal Medicine. All pulmonary faculty members are certified by the American Board of Internal Medicine.

The rotation includes four weeks of meaningful patient responsibility in ambulatory and hospital settings. Residents work in the Carle Clinic Association Department of Pulmonary Medicine, and Carle Foundation Hospital .

Patient care responsibilities extend from Monday through Friday, 0730 to 1700. A sample ambulatory schedule is attached. Hospital consults are assigned, when appropriate, when requests are received in the ambulatory offices. Weekend, holiday, and on-call responsibilities are not scheduled.

Residents work under the direct supervision of an assigned attending pulmonologist. The rotation is designed primarily as an out-patient experience, with a tutorial or mentoring approach in which the resident associates with a designated physician for a half or whole day. During the first two weeks, the resident sees patients with the attending. The cases are discussed with the resident during the patient interview, between patient visits, and at the end of the clinical half day. On days when there is a light patient load, the resident spends time in the pulmonary function laboratory, to observe testing and receive instruction from an experienced pulmonary function instructor.

During the second two weeks, the resident performs the initial history and physical examination, and present findings and available laboratory data to the attending pulmonologist. After reviewing patient data and pertinent teaching points, the resident and attending pulmonologist complete the patient encounter together. Selected components of the examination may be repeated and demonstrated to the resident. Residents are responsible for documenting the patient encounter with a written or dictated note.

Sample Schedule

	Mon	Tue	Wed	Thu	Fri
0730	Teaching Rounds	Teaching Rounds	Teaching Rounds	Teaching Rounds	Teaching Rounds
0900	Ambulatory Cons	Ambulatory Cons	Ambulatory Cons	Ambulatory Cons	Ambulatory Cons
1215	Department Conf	Department Conf	Department Conf	Multidisciplinary Chest Conf	Department Conf
1330	Ambulatory Cons	Continuity Clinic*	Ambulatory Cons	Core Conference	Ambulatory Cons
1630	Pulmonary Function Lab	Pulmonary Function Lab	Pulmonary Function Lab	Pulmonary Function Lab	Pulmonary Function Lab

*Day of week varies by rotation

IV. EVALUATION

ACGME Competencies

According to Accreditation Council of Graduate Medical Education (ACGME), training and evaluation must include the following competencies: Patient Care, Medical Knowledge, Practice – Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, and System-Based Practice.

Patient Care will be evaluated by assessment of the attending physician. Procedures performed will be documented.

Medical Knowledge will be evaluated by assessment of the attending physician.

Practice-Based Learning and Improvement will be evaluated by assessment of the attending physician.

Interpersonal and Communication Skills will be evaluated by assessment of attending physician and additional information from nursing staff, patients and families.

Professionalism will be evaluated by assessment of attending physician and additional information from nursing staff, patients and families.

System-Based Practice will be evaluated by assessment of the attending physician.

The evaluation method is primarily accomplished electronically. Residents' performance is evaluated by the attending physician. Evaluations are reviewed with the residents for formal feedback. Face to face interaction between the attending physician and the resident is the required method. At the midway point of the rotation, the resident is encouraged to approach the attending to assess and discuss performance. In addition, ongoing feedback is provided related to residents' patient care responsibilities and activities.

Residents will document the Pulmonary rotation in portfolios, e.g. patient care responsibilities. This tool will provide individual learning, reflection and assessment. Additionally, residents will evaluate the rotation experience.

Residents provide input on the Pulmonary Medicine core lecture series, which is used in scheduling future topics and speakers. Conference lectures include: Asthma: Diagnosis, Physiology and Management, COPD, Fiberoptic Bronchoscopy, Grand Rounds, Interstitial Lung Disease, Lung Cancer, Pulmonary Function Testing and Metabolic Stress, Pneumonia, Pneumonia Imaging, Pulmonary Disorders, Pulmonary Embolism, Sleep, Tuberculosis, and Vasculitis Involving the Lungs. Periodically, residents are surveyed to evaluate the curriculum and teaching faculty.

V. REFERENCES

"Diagnosis of Interstitial Lung diseases" Ryu, Jay, et.al. Mayo Clinic Proceedings, August 2007: 82: 939-943.

"Update in Chronic Obstructive Pulmonary Disease 2006" Rabe, Laus, Beghe, Bianca, Luppi, Fabrizio, and Fbabbri, Leonardo. Am. J. respir. Crit care med; vol 175: 1222-1232, 2007.

Rev 8/11/05, 7/1/06,7/1/07, 8/31/07