PULMONARY, CRITICAL CARE & SLEEP MEDICINE FELLOWSHIP MOUNT SINAI SCHOOL OF MEDICINE OVERALL EDUCATIONAL GOALS, OBJECTIVES AND CORE COMPETENCIES

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1 Revised 6/15 PULMONARY, CRITICAL CARE & SLEEP MEDICINE FELLOWSHIP MOUNT SINAI SCHOOL OF MEDICINE OVERALL EDUCATIONAL GOALS, OBJECTIVES AND CORE COMPETENCIES 1. OVERALL EDUCATIONAL PROGRAM OVERVIEW The overall goal of our fellowship is to train our fellows in all aspects of Pulmonary, Critical Care and Sleep medicine (PCCM) over a 36-month period of time so that they may be competent in all ACGME requirements. The fellows develop and hone their clinical skills over approx 24-month period of time and pursue research endeavors for approx 12 months during the end of their fellowship. During all 36 months they participate in continuity pulmonary clinic and all divisional conferences. The goals, objectives and competencies vary with each year of training with graduated increased responsibility over the 36 months of fellowship. Year 1 (PGY4) of fellowship training is dedicated to learning the fundamentals of pulmonary & critical care medicine and bronchoscopy. This year is more pulmonary heavy. Year 2 (PGY5) of fellowship training is focused on improving upon clinical skills (in pulmonary and CCM) and developing leadership capabilities. This year is more critical care heavy. Towards the end of the PGY5 year into the PGY6 year, the fellows are allotted research time to develop skills in academic leadership. The fellows are provided dedicated research time with the expectation of scholarly activity in either education, quality improvement, clinical medicine or basic science with the benchmark of a presentation at local or national conferences and or manuscript publications. 2. CORE COMPETENCY OBJECTIVES: A. Medical Knowledge: PCCM fellows must demonstrate knowledge of established evolving biomedical, clinical, epidemiological and social-behavioral sciences, in pulmonary and critical care medicine, as well as the application of this knowledge to their patients. The fellows are expected to acquire this knowledge through 1) direct patient care activities with supervisions and teaching from Pulmonary and Critical Care Medicine (PCCM) faculty, 2) active participation in all fellowship and divisional conferences including Radiology Conference, Pathology Conference, Case conference, Core Lecture Series, Journal club, and Grand Rounds. Fellows are expected to self-direct learning and learn independently through preparation for presentations they give throughout their fellowship. Specific competencies in this area will be detailed in the individual rotations. PGY-Specific Learning Goals and Objectives: 1. Year 1 (PGY4): Fellows are expected to: a. Learn the fundamentals of both pulmonary and critical care topics (as outlined in the individual curricula) through direct teaching from attending rounds, didactic case based lectures given by faculty, through preparation and presentation at core conferences including Pathology Conference, Case conference, Radiology Conference, Journal club as well as through participation in divisional conferences such as Grand Rounds. b.utilize the current literature to read about their patients diseases and learn about pulmonary and critical care disease processes. 2. Year 2 (PGY5): Fellows are expected to (in addition to the above): a. Apply clinical and evidence based medicine to the care of patients. b.demonstrate analytical thinking approach to the management of patients. c. Consistently educate other members of the team, lead teaching discussions on rounds.

2 B. Patient Care: 3. Year 3 (PGY6): Fellows are expected to (in addition to the above): a. Be proficient with the most relevant and current medical literature for both pulmonary and critical care medicine. b.be proficient with the most current guidelines in management of common pulmonary and critical care conditions. c. Lead discussions and education of other fellows, housestaff officers, and medical students. d.demonstrate analytical thinking and sound clinical judgment in managing patients in both pulmonary and critical care environments. Fellows learn to provide compassionate and effective patient care for the treatment of a vast array of Pulmonary and Critical Care disease processes. Fellows are expected to learn the practice of disease prevention, diagnosis, treatment and health promotion for a broad population of patients with diverse age, socioeconomic, racial, and gender makeup. Fellows will learn this practice from faculty during inpatient rounds, through outpatient clinic, and through didactic and case based lectures. Specific competencies in this area will be detailed in the individual rotation curricula. PGY Specific Competencies: a. Year 1 (PGY4): Fellows are expected to: i. Perform inpatient consultations with focused history, physical examination, laboratory and imaging interpretation. ii. Complete full documentation of these consults and communicate the recommended management plan to the primary team. iii. Discuss all consultations with the appropriate attending and learn both at the bedside and by review of the current literature. iv. Develop a patient panel in their continuity pulmonary clinic. b. Year 2 (PGY5): Fellows are expected to (in addition to above): i. Become proficient at gathering relevant data in the evaluation of both pulmonary and critical care patients and focus on developing management skills. ii. Supervise residents and medical students in developing patient care plans and then implementing them effectively. iii. Lead work rounds in the Medical Intensive Care Unit (MICU) in conjunction with the critical care attending and lead teaching rounds on 1-2 patients of their choice. iv. Direct and coordinate care for patients with chronic and complex medical problems both in the inpatient and outpatient settings. v. Continue to manage and grow a patient panel in their continuity pulmonary clinic. c. Year 3 (PGY6): Fellows are expected to: i. Be proficient in the evaluation and management of patients with both pulmonary and critical care disorders. ii. Lead work and teaching rounds on both inpatient pulmonary and inpatient critical care services. iii. Be a primary educator to other members of the health care team as well as patients and their families. iv. Counsel patients effectively on the risks and benefits of diagnostic and therapeutic testing. C. Practice Based Learning and Improvement: PCCM Fellows must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence and to continuously improve patient care based on constant self-evaluation and

3 life-long learning. Fellows are expected to develop skills and habits to identify strengths and deficiencies in their PCCM knowledge and expertise and to set learning and improvement goals to improve upon these weaknesses. Fellows are expected to identify and perform appropriate learning activities, systematically analyze practices and quality improvement methods and implement changes with the goal of practice improvement. Fellows must learn to locate, appraise, and assimilate evidence from scientific studies related to their patients health problems and use information technology to acquire this information. Finally, fellows must facilitate the learning of patients, families and other health-care workers. PGY Specific Competencies: 1. Year 1 (PGY4): The fellow is expected to: a. Identify strengths and deficiencies in their knowledge of pulmonary and critical care medicine based on their feedback received on their performance during inpatient consultation months, presentations, and participation in conferences. b. Facilitate the education of patients, families, students, faculty and other health care professionals. c. Utilize current medical literature and guidelines in learning about the evaluation and management of pulmonary and critical care disease processes. 2. Year 2 (PGY5): The fellow is expected to (in addition to the above): a. Make ongoing improvement in their evaluation and management plans on patients with pulmonary and critical care conditions. b. Lead education of patients, families, students, faculty and other health care professionals c. Become proficient at appraising and assimilating knowledge from pertinent medical literature and educating others through fellow led conferences and journal clubs. d. Identify quality issues within pulmonary or critical care and systematically analyze practice using evidence-based medicine to initiate a quality project or research project. 3. Year 3 (PGY6): The fellow is expected to (in addition to the above): a. Carry out a quality project or research project that was initiated during Year 2 and implement change that will improve patient care or practice. These skills are developed through multiple learning experiences. Fellows learn directly from faculty in inpatient and outpatient settings through rounds, didactics and from the direct faculty supervision of their performance. They learn to practice evidence-based medicine through requirements of case presentations, journal clubs, and core curriculum conferences. They receive both formal electronic feedback as well as direct feedback from supervising attendings that they then incorporate into their daily practice. Specific competencies in this area will be detailed in the individual rotation curricula. D. Interpersonal and Communication Skills: PCCM fellows must demonstrate interpersonal and communication skills that result in effective exchange of information and collaboration with patients, their families, and health professionals. Fellows are expected to work effectively in a variety of healthcare delivery systems in both pulmonary and critical care environments and collaborate with others as part of a multi-disciplinary team. The fellows will learn to communicate effectively with patients and families from a diverse range of socioeconomic and cultural backgrounds. Finally, the fellows are expected to be effective teachers for other members of the health care team. PGY Specific Competencies: 1. Year 1 (PGY4): The fellow is expected to (in addition to the above): a. Clearly and effectively present patients on rounds and communicate effectively with the attending and other health care professionals.

4 b. Clearly and effectively communicate with patients in both pulmonary and critical care settings and communicate the diagnostic and therapeutic plan of care. b. Year 2 (PGY5): The fellow is expected to (in addition to the above): a. Carry increased responsibility in communicating with patients, families, and other health care providers. b. Collaborate effectively with a multi-disciplinary team both in the MICU and in the RCU (chronic ventilator unit) c. Year 3 (PGY6): The fellow is expected to (in addition to the above): a. Communicate effectively with non-physician health care professionals on rotations such as Physiology/Sleep Medicine, and Bronchoscopy. Fellows achieve these competencies by integrating into multi-disciplinary teams in the critical care setting and in the care of patients who are chronically critically ill. They will be evaluated on their ability to communicate with their colleagues as well as their patients through 360 evaluations and patient evaluations, respectively. Fellows work at Mount Sinai Hospital, a tertiary care hospital in East Harlem that will provide a broad range of patients from different cultural and socioeconomic backgrounds. Specific competencies in this area will be detailed in the individual rotation curricula. E. Professionalism: PCCM fellows must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. Fellows are expected to practice medicine with compassion, integrity, and respect for others with sensitivity to a diverse population of patients including but not limited to diversity in gender, age, culture, race, religion, disability, and sexual orientation. Fellows must demonstrate responsiveness to the needs of patients and society that supersedes self-interest; they must demonstrate accountability to patients, society, and the profession, with a commitment to excellence and ongoing development. PGY Specific Competencies: 1. Year 1 (PGY4): The fellow is expected to a. Provide sensitive and unbiased care to patients on the pulmonary and critical care services. b. Be sensitive and receptive to those whom they supervise. c. Be professional and courteous with anyone who is calling upon them for assistance with a pulmonary or critical care patient. 2. Year 2 (PGY5): The fellow is expected to (in addition to the above): a. Be a role model for junior fellows, housestaff officers, and students. 3. Year 3 (PGY6): The fellow is expected to (in addition to the above): a. Show a commitment to excellence and ongoing professional development. These skills are developed through direct role modeling and supervision by PCCM faculty over the duration of the fellowship. Fellows are directly evaluated by supervising faculty as well as by multi-disciplinary groups consisting of physicians and nurses regarding professionalism. In addition, a 360 evaluation as well as a patient evaluation of the fellow are performed annually. These evaluations are regularly reviewed with fellows to ensure that they constantly self-assess their professionalism. F. Systems Based Practice: PCCM fellows must demonstrate an awareness of and responsiveness to the larger context and system of healthcare as well as the ability to call effectively on other resources in the system to provide optimal

5 healthcare for their patients. Fellows are expected to work effectively in various health care delivery settings relevant to the practice of pulmonary and critical care medicine. Fellows are expected to work as members of interprofessional and multi-disciplinary teams to enhance the safety and quality of care of their patients. Fellows are expected to coordinate care of their patients within the various healthcare systems that they work in. The fellows are expected to identify system errors. PGY Specific Competencies: 1. Year 1 (PGY4): The fellow is expected to: a. Learn how to work within different health care systems including a tertiary care hospital (Mount Sinai) and ambulatory clinics (Chest Clinic, Sarcoid clinic, Sleep clinic). b. Partner with other members of a health care team to enhance the safety and quality of care of their patients. c. Learn to coordinate care for their patients either in the inpatient or outpatient setting. d. Learn about the costs of specific medications utilized both in the MICU and in the outpatient setting. 2. Year 2 (PGY5): The fellow is expected to (in addition to the above): a. Become proficient in the coordination of care of their inpatients and outpatients. b. Increase their knowledge about healthcare utilization and cost-effective practice both in the MICU and in the outpatient setting. c. Participate in identifying system errors, dissecting these issues and implementing change. 3. Year 3 (PGY6): The fellow is expected to (in addition to the above): a. Lead multi-disciplinary teams on rounds in the MICU. b. Routinely consider cost awareness and risk-benefit analysis in providing patient care both in pulmonary and critical care. The fellows rotate in different health care systems including a tertiary care center at Mount Sinai Hospital and ambulatory clinics (Chest Clinic, Sleep Clinic, Sarcoid Clinic). Within the hospital, they rotate through different systems including units staffed by house staff and units staffed primarily by nurse practitioners. They participate in multi-disciplinary rounds in the critical care setting as well as the chronic ventilator unit. They are active participants in identifying quality issues and helping to provide solutions that can be adopted by all faculty and fellows (e.g. Quality Initiative Projects). In addition, they receive didactics on this topic throughout the fellowship. 3. Increasing Levels of Responsibility and Level of Supervision Throughout the fellowship, the fellows are supervised in the care of their patients by PCCM faculty. Each rotation has a core group of clinical faculty called key clinical faculty (KCF). On each rotation, an attending has direct supervision of a fellow(s). With each year of additional training, the fellow acquires graduated levels of responsibility for each rotation. Fellows begin by learning the fundamentals of pulmonary and critical care and then progress through PGY5 and PGY6 year with respect to their management skills, procedural skills, and level of responsibility in leading the team and educating members of the team. Ultimately, at the end of the 36 months of training, fellows have gained enough experience and knowledge to independently practice Pulmonary and Critical Care medicine. 4. Faculty Responsibilities On Clinical Rotations A. Review the goals and objectives of the rotation with the fellow at the beginning of each rotation. B. Give constructive feedback throughout the rotation and after the rotation. C. Protect the fellow and self to be able to attend the mandatory conferences. Mandatory conferences for the fellows include Radiology conference, Core Curriculum Lecture Series, Pathology/Case Conference, Journal Club and GR.

6 D. Complete the following evaluations in a timely (within 4 weeks of the end of the rotation) fashion: 1. Mini-cex (twice a year in continuity clinic) 2. Bronchoscopy Evaluation Tool 3. New Innovations Global evaluation 4. Sleep rotation evaluation tool (if applicable) 5. Physiology evaluation tool (if applicable) 6. Interpersonal and Professionalism evaluation (MICU faculty and nurses) E. Provide increasing responsibility to fellows as they rise in training including leading rounds. F. Provide education to the fellows: 1. Direct teaching on rounds 2. Case based didactic lectures 3. Provide relevant evidence based medicine/literature for the fellow to independently read G. Monitor the fellows for stress, fatigue, and compliance with work hours. 5. Educational Resources There are a variety of educational resources that are available to the fellow. These include: A. The Levy Library with online access to standard pulmonary and critical care textbooks as well as relevant publications in pulmonary and critical care. B. Pulmonary and Critical Care reading lists (updated annually by the PD and APD). C. Board Review curriculum (available as a hard-copy or from the internal pulmonary fellowship website). D. A schedule of divisional and external weekly conferences ed by the DOM to all faculty and fellows. 6. Assessment Tools/Methods PCCM fellows are evaluated on the six core competencies with each educational experience using multiple assessment tools. For each rotation that is directly supervised by a faculty member, there is a corresponding New Innovation electronic evaluation form that is to be completed by the attending. The attending receives reminders to complete the evaluation form and the program administrator, Lourdes Mateo, monitors this. Similarly, the PCCM fellows have the opportunity to electronically evaluate their attending on a specific rotation. All evaluations are anonymous. In addition, the fellows can give direct feedback about their experience or attending to the Program Director at any time or during fellowship meetings. In addition to New Innovation tools that evaluate each fellow on all six competencies, we have tailored several assessment forms for specific rotations. These assessment tools have been reviewed with both the faculty and the fellows and the fellows have access to them on their website. A. Evaluation Tools to Assess Fellows: 1. New Innovations Global Evaluation Tool- Faculty to complete within four weeks of the end of a rotation. 2. Mini-Cex- Performed every six months in the Pulmonary Clinic- core preceptor directly observes a history, physical examination, interpretation of data and assessment and plan of a pulmonary clinic patient by the fellow Evaluation Tool- Each fellow gives this assessment form to a health-care worker of their choosing (cannot be their attending or a faculty member of the division). 4. Patient Evaluation form- Form provided to a patient in either the inpatient or outpatient setting by the fellow. 5. Bronchoscopy Evaluation Form- Checklist to evaluate a fellow s competency in pre-bronch assessment, providing sedation and in bronchoscopy skills. Completed by Dr.Timothy Harkin (Director of Bronchoscopy).

7 6. Physiology Evaluation Form- To be completed by Dr. Gwen Skloot (Director of Physiology Laboratory) - assess the fellows ability to interpret PFTs and CPET studies. 7. Interpersonal and Professionalism Form- Completed by all MICU faculty and nurse manager with nursing input to assess the MICU and NF fellow s professionalism and interpersonal skills. 8. Research Evaluation Tool- To be completed by research mentors. B. Assessments Completed by Fellows: 1. New Innovation assessment of faculty members- anonymous electronic feedback regarding supervising attending at the end of each rotation. 2. End of the Year Survey. 3. Evaluation of rotation. Clinical Competency Committee: The new accreditation system (NAS) has set up a system whereby fellows need to meet certain milestones within the three years of training. These milestones correspond to the 6 competencies. A fellow s performance is evaluated by a Clinical Competency Committee made up of KCF (Drs Dua, Poor, Rho, Harkin, Feinsilver, Braman, Rogers, DiFabrizio, Mathur, Powell). They will meet on a semi annual basis to review each fellow s progress and then determine if there are any deficiencies in meeting milestones. If a fellow is found to be deficient in milestones, they will meet with the PD to discuss strategies on improvement. Fellows will meet with the PD on a semi-annual basis to review their performance.

8 PULMONARY, CRITICAL CARE & SLEEP MEDICINE FELLOWSHIP ICAHN SCHOOL OF MEDICINE AT Mt Sinai RESEARCH ROTATION GOALS, OBJECTIVES AND CORE COMPETENCIES During the 2 nd and 3 rd year fellows have an opportunity to pursue supervised research for an average of 12 months in total. During these months the fellows are not on clinical rotations, but are still required to attend educational conferences, continuity clinics, and subspecialty clinic. Therefore, while this is considered to be protected time to pursue research, fellows are still gaining important fund of knowledge and education while seeing patients in the outpatient setting and attending educational conferences. The fellow may also have clinical duties for weekend calls dispersed throughout the research blocks but no weeknight call during their research time. The Program Director (PD) and associate PD (APD) will begin the discussion of research focus with the fellow at the end of the first year and beginning of second year of fellowship. The PD on an annual basis collects information from all faculty regarding ongoing projects that fellows may participate in. In addition, the fellows are encouraged to initiate research questions on their own and to find an appropriate mentor to assist them in developing the project (sometimes even outside the division). After exploring what a fellow s interests are, the PD will recommend specific mentors and projects. The fellow will then meet with several possible research mentors and choose accordingly. Select fellows will be offered a fourth year of fellowship (non-acgme). This fellowship year will be protected research time with a focus on developing skills needed to become a successfully funded independent researcher. Responsibilities of the Fellow: 1. Fellows are expected to meet at least bi-monthly with their research mentor to review the progress of the project. 2. Fellows are expected to complete all necessary IRB, GCO or grant paperwork with the assistance of their mentor. 2. Fellows will be expected to present their research once a year at either a research committee meeting or grand rounds. Responsibilities of Research Mentors: 1. The research mentor will guide the fellow with project development, training, execution of the research program and will assist the fellow in following the designated timeline. 2. The research mentor and fellow will meet at least bi-monthly to review the progress of training and the research project. 3. The research mentor will inform the fellow of any available grant opportunities, upcoming meetings related to their research, and opportunities for presentation of research data both locally and nationally.

9 4. Research mentors will formally assess the fellow once a year with written and verbal feedback. This will occur more often if needed. Goals of the Research Experience: Fellows will have the opportunity to participate in clinical, educational or quality-improvement related research for later half of 2 nd yr of fellowship into first half of 3 rd year of fellowship. The overall benchmark for success is measured with the fellow s chosen trajectory in career. The overall goal of the fellowship is to produce academic leaders; the research component of the secondthird year is integral for this to occur. Competency based objectives: I. Patient Care: Fellows learn to provide compassionate and effective patient care for the treatment of a vast array of Pulmonary and Critical Care disease processes. a. The fellows are expected to appropriately care for patients involved in clinical research projects. b. The fellows are expected to become proficient at gathering relevant data in the evaluation and enrollment of patients in clinical research. II. III. IV. Medical Knowledge: The fellows must demonstrate knowledge of established evolving biomedical, clinical, epidemiological and social-behavioral sciences, in pulmonary and critical care medicine, as well as the application of this knowledge to their patients. a. Fellows are expected to learn to develop a research question. b. Fellows are expected to gain detailed knowledge of the scientific literature related to their area of research. c. Fellows are expected to learn methods for data analysis through lectures by the pulmonary faculty and formal coursework, when needed. Practice Based Learning: Fellows must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence and to continuously improve patient care based on constant self-evaluation and life-long learning. Fellows are expected to develop skills and habits to identify strengths and deficiencies in their Pulmonary and Critical Care knowledge and expertise and to set learning and improvement goals to improve upon these weaknesses. a. Fellows are expected to generate and test a research hypothesis using appropriate methodology. b. Fellows are expected to acquire skills in analytical and critical thinking through direct teaching by their mentor, by other pulmonary faculty and by teachers in formal research training programs. c. Fellows are expected to learn about the IRB process and process of obtaining informed consent on subjects. d. Fellows are expected to learn how to prepare and present a scientific presentation. e. Fellows are expected to prepare abstracts for scientific presentations and scientific manuscripts. Professionalism: Fellows must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. a. Fellows are expected to exhibit appropriate levels of interest and commitment to their chosen research program. b. Fellows are expected to exhibit honesty and scientific integrity related to data collection, record keeping, ethical human research, humane use of animals, and presentation and publication of data. V. Interpersonal and Communication Skills: Fellows must demonstrate interpersonal and communication skills that result in effective exchange of information and collaboration with patients, their families, and health professionals.

10 a. Fellows are expected to interact on a collegial level with all other members of the research team and other scientific collaborators. b. Fellows must demonstrate the ability to present their research work and findings to a group of fellows and faculty. c. Fellows must demonstrate the ability to present their research in a larger forum including local or national meetings. VI. Systems Based Practice: Fellows must demonstrate an awareness of and responsiveness to the larger context and system of healthcare as well as the ability to call effectively on other resources in the system to provide optimal healthcare for their patients. a. Fellows are expected to be able to conduct research within the limitations and rules of their healthcare system. b. Fellows are expected to understand the function of institutional regulatory boards to protect the rights of human and animal subjects.

11 Fellows Conference Guidelines 1. Monday 4:00 PM Pathology or Case Conference: Mandatory to attend: We alternate path conference with case conference. For path conference an assigned fellow presents 4-5 interesting cases with histological review by the pathology team. After each case presentation, the fellow gives a one-slide discussion on evidenced based facts regarding the disease. For case conference: two fellows present a case each, and discuss in-depth the literature or evidence based knowledge surrounding that topic. These topics can be selected by the presenting fellow or can be suggested by attendings depending on available cases. Case Conference: Bi Monthly Conference - Mondays at 4 pm (alternating weeks with Path conference). A. Goal of the Conference: 1. To present diverse and complex pulmonary or CCM cases. 2. To review a specific facet of a case with an extensive evidence-based review of the literature: this could be a discussion about a rare entity or a more specific question as it relates to the diagnosis, management or prognosis of a more common pulmonary or CCM disorder. B. Specifics about the conference: 1. Two fellows will be given (or choose) a case each ahead of time. Each fellow will present a brief history of the patient and a thoracic radiologist will present the films (+/-pathology if available). Following the presentation the fellow will then address a specific question about the case and discuss this topic. 2. Note: this topic should be discussed with Dr Poor or Dr Dua in advance of the conference. 3. The presentation should be a literature review using high quality pulmonary/critical care journals and should be presented on PowerPoint. 4. The entire presentation should be approximately minutes long. Path Conference: Bi Monthly Conference- Mondays at 4 PM (alternating weeks with Case conference) A. Goal of the Conference: a. To present interesting and diverse pulmonary and critical care pathology. b. To apply the clinical and radiological findings to the histo-pathology of the case. B. Specifics about the conference: a. One fellow will review the case list on mount sinai box which will serve as a repository of all the bronchoscopy cases done for biopsy along with their pathology. b. Additionally fellows can ask either the consult attendings or Drs. Harkin and Beasley for interesting cases and will choose 4-5 cases to present. c. They will provide a list with the name and MRN to Dr Beasley at least 1 week in advance of the conference. d. A brief clinical history should be presented by the fellow and then the radiology will be reviewed by the radiologist and Dr Beasley will review the pathology. e. After which, the fellow should prepare a single slide of key take-home points about the disease entity in bullet points. 2. Tuesday 4:00 and/or 5:00 PM Pulmonary/Critical Care Core Lecture series: Mandatory to attend: Presentations include core pulmonary and critical care topics, introduction to research methodology, and classic pulmonary physiology. These cover our core academic curriculum.

12 3. Wednesday 7:30 AM Thoracic Oncology Conference: Encouraged but not mandatory: Join the thoracic oncologists, radiation oncologists, surgeons, pathologists and radiologists in reviewing surgical cases from the prior week. 4. Wednesday 3:00 PM ICCM Grand Rounds: Encouraged but not mandatory: The Institute of Critical Care Medicine Grand round are a series of weekly lectures and presentations from visiting and local faculty on various critical care topics. 5. Thursday 4:00 PM Radiology Conference: Mandatory to attend: This conference is designed to review interesting radiology (CXRs, Chest CTs) and to discuss management of challenging cases on the consult #1 service, MICU or chest clinic hence fellows on any service can present interesting cases. But primarily this conference is the consult fellow s responsibility. Pulmonary and Thoracic Surgery attendings sometimes also bring cases to be presented. For cases presented by the consult fellow, the history, and results of tests such as bronchoscopy or biopsy must be known. You must have approximately 5 cases to present each week. You put up the name/mrn, the Radiologist reads and discusses the imaging to generate a differential diagnosis, and then the history and final diagnosis is revealed by fellow. Radiology Conference: Weekly - Thursdays at 4 PM A. Goal of the Conference: To present interesting and diverse pulmonary and critical care radiological findings. This conference is led by the expert interpretation of thoracic radiologists. B. Specifics: a. The pulmonary consult fellow should be prepared with at least 5-6 cases in the pulmonary folder on PACS. b. The fellow should be prepared with the basic history on the patient and the diagnosis if diagnosis is known. c. After the thoracic radiologist provides his interpretation of the films with a differential dx, the fellow is expected to provide a one liner- 67 yo male with history of stage 4-sarcoidosis presenting with massive hemoptysis. d. The fellow should know which radiographs and ct scans (chronologically) the radiologist should focus on. e. The bronchoscopy fellow and any other fellow can present their Chest Clinic patients that have interesting films. This includes outpatients from continuity clinic or the ICU. 6 Friday 12:30 Noon Pulmonary/Critical Care Grand Rounds: Mandatory to attend: Fellows, faculty members, and guest speakers present various clinical and research topics. Each upper level fellow will also be expected to give one presentation a year (regarding their research project). 7 Monday 12:00 PM: Journal Club: Mandatory to attend: three Mondays a month we have journal club in which fellows present pre-selected articles using a standardized format (**see attached**) on a rotating schedule. These are precepted by Dr Juan Wisnivesky, Dr Kusum Mathews and Dr Alison Lee on a rotating basis. 8 Monday 12:30PM: ILD conference: Encouraged but not mandatory to attend: the third Monday of every month is used to hold a combined ILD case conference with NJH, BI and SLR where two or three prepared cases are presented on a rotating basis by different sites (MSH, BI, SLR, NJH), with multidisciplinary discussion with radiologist and pathologist. Cases are prepared either by ILD attendings (Dua or Padilla at MSH site) or by fellows.

13 **Journal Club presentation format** OBJECTIVES: (1) To summarize the best new evidence for pulmonary, critical care, and sleep medicine in the medical literature, one article at a time, assessing its scientific merit and generalizability to our own clinical practice. (2) To train fellows to critically appraise the literature, understand basic study design and limitations, and interpret results and study validity. EXPECTATIONS/FORMAT: Select a recent PCCSM article (within the last 1 year, preferred) to discuss at Journal Club. All articles should be reviewed with your faculty preceptor. Please your article to the faculty/fellows 1 week in advance of your presentation date. NO POWERPOINT SLIDES. Format for presentation: (please contact Kusum Mathews with questions) (NEJM PROCESS Trial used as example). ~30-40 Min: Article outline/discussion ~15-20 Min: General discussion ~5 Min: Summary COMPONENT Definition/Questions Where you will find it Conceptual hypothesis EXAMPLE: Are all elements of EGDT necessary to improve mortality? Operational hypothesis EXAMPLE: In this U.S.-based multicenter trial, is protocol-based EGDT resuscitation or protocol-based standard therapy superior to usual care in improving rate of inhospital death at 60 days from any cause? (within a population of adult, ED patients with suspected sepsis (2+ SIRS) and refractory hypotension or elevated lactate, enrolled between ) Study Design (Methods/Population) EXAMPLE: RCT in ED patients with severe sepsis; Comparison group = usual care General question this study is trying to answer and WHY What is the gap in knowledge? (What do we do know and what DON T we know?) Why does it matter? Specific research question this study is trying to answer and HOW Elements: type of study, outcome metric, exposure/intervention/process metric, measurement tool, population of interest, study period timing Study type, outcomes, metrics/tools Is the primary/secondary outcome appropriate for the question being asked? Why did they choose this study design type? Would another one (e.g., RCT) be better? Who is the target population of the study and why? Too narrow? Too broad? Is there a comparison group? Do the tools they used to measure the exposures/outcomes make sense? Background Background Objectives Methods Methods Discussion 15

14 Findings & Issues (including Validity) EXAMPLE: no significant advantage in 60-day mortality of protocol-based resuscitation over usual care. GROUP DISCUSSION EXAMPLE: What do you think about PROCESS trial s definition of usual care? Results, internal & external validity What were the primary findings of the study? Do you think their conclusions are correct? (Was the research done right?) Any sources of bias or unmeasured confounding? To what extent can the results be generalized? What are the limitations of this study? Clinical impact This is our opportunity to discuss the validity and clinical impact of the article. Please prepare some questions, or identify specific areas in the article to discuss as a group. Results Discussion 16

15 Pulmonary and Critical Care Medicine Fellowship Icahn School of Medicine at Mount Sinai Continuity Pulmonary & Sarcoidosis/ILD & Sleep Clinic Rotation Goals and Objectives The primary goal of this rotation is for fellows to develop the necessary skills to effectively evaluate and manage general and complex pulmonary disorders in an outpatient setting. Year 1 (PGY4) Use evidence-based medicine to guide decision making; Counsel patients and families and provide compassionate and comprehensive care; Coordinate patient care and communicate effectively with referring physicians, other health professionals, and health related agencies. Year 2 (PGY5) Learn both the initial and long-term approaches to providing care for the disorders noted above. Identify appropriate patient candidates for pulmonary rehabilitation. Learn the indications for & complications/benefits of long-term supplemental oxygen therapy, and develop an understanding of the stationary and portable systems by which supplemental oxygen can be delivered. Year 3 (PGY6) Appropriately identify lung transplant candidates and refer in a timely matter. Identify potential candidates for clinical trial enrollment (IPF, COPD, Asthma, Lung Cancer). Patient Care: Fellows must be able to provide patient care that is compassionate, appropriate and effective for the treatment of health problems and the promotion of health. Objectives: Fellows are expected to: 1. Effectively and completely obtain historical information regarding the presentation of patients with pulmonary disease. 2. Develop skills in the unique aspects of physical examination for pulmonary patients. 3. Communicate effectively with patients and families regarding plans for evaluation, management, and prognosis of different pulmonary conditions 4. Coordinate complex outpatient care and communicate effectively with referring physicians and other consultants involved in patient care. 5. PGY Specific Objectives (in addition to the above) a. Year 1 (PGY4): The fellow is expected to (including the above): i. Take a detailed pulmonary history, including recognition of pertinent occupational and environmental exposures that impact lung health. ii. Understand and implement the appropriate diagnostic evaluation for patients with pulmonary complaints, such as dyspnea, cough, and sputum production. iii. Understand and implement the appropriate diagnostic and therapeutic plans for patient with sarcoidosis and sleep disorders. iv. Learn to counsel patients effectively regarding risks and benefits of different diagnostic and therapeutic options. v. Learn to counsel patients regarding the benefits and options for smoking cessation. 17

16 b. Year 2 (PGY5): The fellow is expected to (including the above): i. Improve upon evaluation and management skills of complex pulmonary conditions. ii. Improve upon evaluation, diagnosis and therapy for patients with sarcoidosis and sleep disorders. iii. Counsel patients effectively regarding complex therapeutic options including risks and benefits of immunosuppressive medications for interstitial lung diseases and sarcoidosis. iv. Communicate effectively with referring providers and coordinate health care as part of a team. c. Year 3 (PGY6): The fellow is expected to (including the above): i. Become proficient in the evaluation and management of both common and less common pulmonary diseases. ii. Become proficient in the management of complex sarcoidosis, ILD and sleep disorders patients. iii. Partner effectively with referring providers and coordinate health care as part of a team. Medical Knowledge: Fellows must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social-behavioral sciences, as well as the application of this knowledge to patient care. Objectives: Fellows are expected to learn about the evaluation and management of the following diverse pulmonary conditions: 1.Obstructive lung diseases including asthma, emphysema, chronic bronchitis, and bronchiectasis. 2.Interstitial lung diseases including sarcoidosis, usual interstitial pneumonitis, hypersensitivity pneumonitis, and interstitial lung diseases associated with collagen vascular disease. The fellows are expected to know all of the organ manifestations, radiographic findings, laboratory findings as well as management and therapeutic options of sarcoidosis and ILD. 3.Eosinophilic lung diseases including chronic eosinophilic pneumonia, acute eosinophilic pneumonia and Churg-Strauss Syndrome. 4.Pulmonary infections including atypical mycobacterial diseases and fungal diseases in immunocompetent and immunocompromised hosts 5.Occupational and environmental lung diseases. 6.Chronic respiratory failure secondary to obstructive lung disease and restrictive ventilatory defects. 7.Drug-induced lung diseases. 8.Pulmonary neoplasms. 9.Pleural diseases. 10.Pulmonary vascular diseases including pulmonary embolism and all forms of pulmonary arterial hypertension. 11.Pre-operative assessment of patients scheduled to undergo surgery, such as lung resection and bariatric surgery. 12.Sleep-disordered breathing. 13.Respiratory manifestations of neuromuscular diseases. 14. PGY Specific Objectives (including the above) a. Year 1 (PGY4): The fellow is expected to: i. Know the presentation, natural history, and general principles of management for common pulmonary diseases as listed above. ii. Understand the pathophysiology underlying the development of common lung diseases: 18

17 particularly COPD, asthma, idiopathic pulmonary fibrosis. iii. Understand the role and interpretation of pulmonary function testing and cardio-pulmonary exercise testing in the diagnosis and follow-up of patients with various lung diseases. iv. Understand the indications, interpretation and limitations of diagnostic radiology procedures (i.e. chest x-ray, chest CT scan, ventilation-perfusion scans, PET scans) in evaluation and management of lung diseases. v. Understand the indications, contraindications, and need for monitoring of common pulmonary medications, such as beta-agonist and anti-cholinergic inhalers, steroid inhalers, and systemic steroids. vi. Understand the pathophysiology and immunology of sarcoidosis. vii. Understand the indications, contraindications, limitations, complications and techniques of procedures required commonly by patients with respiratory diseases, including bronchoscopy and thoracentesis, to enable fellows to educate patients about these techniques and to obtain informed consent. b. Year 2 (PGY5): The fellow is expected to (in addition to the above) : i. Understand the indications, contraindications, and need for monitoring of common pulmonary medications, such as beta-agonist and anti-cholinergic inhalers, steroid inhalers, systemic steroids and immunosuppressive regimens. ii. Understand the pathophysiology underlying the development of common lung diseases particularly COPD, asthma, idiopathic pulmonary fibrosis, sleep disordered breathing and respiratory manifestations of neuromuscular disease. c. Year 3 (PGY6): The fellow is expected to (in addition to the above) : i. Understand the indications, contraindications, limitations, and complications of surgical lung biopsy to enable fellows to educate patients about the risk benefit ratio of procedure and impact on management of disease. Practice- Based Learning and Improvement: Fellows must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning. Objectives: Fellows are expected to develop skills and habits to be able to: 1. Identify strengths, deficiencies, and limits in one s knowledge and expertise. 2. Locate, appraise, and assimilate evidence from scientific studies related to their patients health problems. 3. PGY Specific Objectives (including the above) a. Year 1 (PGY4): The fellows are expected to: i. Receive feedback from clinic preceptors regarding presentations, evaluation and management of patients and incorporate that feedback in improving their patient care. ii. Understand current guidelines and literature for the care of the most common general pulmonary conditions such as asthma, COPD, pulmonary nodules and implement appropriate care according to the literature. iii. Understand the current guidelines and literature for the management of sarcoidosis. b. Year 2 (PGY5) : The fellows are expected to (in addition to the above) : i. Incorporate evidence from scientific studies into decision making regarding screening, evaluation, counseling and management of all aspects of patient care. c. Year 3 (PGY6): The fellows are expected to(in addition to the above) : i. Routinely incorporate evidence from scientific studies into decision making regarding 19

18 screening, evaluation, counseling and management of all aspects of patient care. ii. Educate other members of the healthcare team about pulmonary disorders with an expert understanding of the literature. Systems Based Practice: Fellows must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. Objectives: Fellows are expected to: 1. Recognize the need for and coordinate care across multiple disciplines including respiratory therapy, diagnostic and interventional radiology, thoracic surgery, pathology, and other medical services such as cardiology, neurology, rheumatology, oncology, and surgical specialties. 2. Recognize financial considerations and other socio-behavioral factors that may impact a patient s ability to undergo diagnostic evaluation or adhere to a prescribed course of therapy. Fellows should be able to elicit these concerns from patients, and consider alternative management strategies. 3. Evaluate and manage patients in consideration of potential risks and benefits individualized to each patient. 4. PGY Specific Objectives: a. Year 1 (PGY4): The fellows are expected to i. Coordinate care and recognize financial considerations and then seek guidance from the clinic preceptor in decision making and management for the patient. b. Year 2 (PGY5): The fellows are expected to (in addition to the above) : i. Become proficient in the coordination of care for their patients and expected to be able to make sound decision making in light of a patients individualized financial or personal preferences. c. Year 3 (PGY6): The fellow are expected to (in addition to the above) : i. Become adept at individualizing patient management to combine sound clinical judgment along with patient preference. Professionalism: Fellows must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. Objectives: Fellows are expected to demonstrate: 1. The ability to demonstrate compassion, integrity and respect to patients will be observed during direct patient contact. 2. Responsiveness to a patient s needs will be observed during direct patient contact and in the manner of following-up with patients regarding concerns and test results. 3. Fellows must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. 4. PGY Specific Objectives: a. Year 1 (PGY4)- Fellows are expected to: i. Provide sensitive and unbiased care to the patients in the outpatient clinic. ii. Demonstrate professional and courteous behavior to all other healthcare providers involved in the care of the patients. iii. They are expected to be prompt and prepared for all rounds, presentations, and conferences. 20

19 b. Year 2 (PGY5) Fellows are expected to (in addition to the above): i. To recognize the importance of patient preferences when selecting a diagnostic and therapeutic option. ii. They are expected to establish trust with patients and staff. c. Year 3 (PGY6): Fellows are expected to (in addition to the above): i. Demonstrate a commitment to ethical principles pertaining to the provision or withholding of care, patient confidentiality and informed consent. ii. Make management decisions ethically and role model professional behavior for those whom they supervise. Interpersonal and Communication Skills: Fellows must demonstrate interpersonal and communication skills that result in the effective exchange of information and teaming with patients, their families, and professional associates. Fellow must communicate effectively with patients and families across a broad range of socioeconomic and cultural backgrounds Objectives: Fellows are expected to: 1. The ability to take a compassionate, sensitive and accurate history in patients of different backgrounds will be observed during direct patient contact. 2. The ability to explain management objectives and their reasoning to patients and their families will be observed during direct patient contact. 3. The ability to communicate plans for evaluation, results of studies and management plans to referring providers will be observed through evaluation of clinic notes. 4. PGY Specific Objectives: a. Year 1 (PGY4): fellows are expected to: i. Develop these communication skills both verbal and in the written clinic documentation. b.year 2 (PGY5): fellows are expected to (in addition to the above): i. Become proficient in communicating plans of evaluation and management to the patient, families, and referring physicians. c. Year 3 (PGY6): fellows are expected to (in addition to the above): i. Become proficient in communicating difficult plans of management including risk/benefit analysis and tailoring patient care to patient preference. Teaching Methods Multiple teaching methods used for education on outpatient pulmonary medicine. A comprehensive outpatient-reading syllabus focused on the evaluation and management of various pulmonary conditions is provided to the fellows. The references include guidelines and consensus statements from major pulmonary organizations such as the American Thoracic Society and the American College of Chest Physicians. One on one interactions between the clinic preceptor and fellow regarding each individual clinic patient will allow discussion of different aspects of patient care, including such topics as interpretation of pulmonary function testing and radiographic studies, pathogenesis of different pulmonary diseases, general diagnostic evaluation of patients with dyspnea, cough, gas exchange disturbances or other pulmonary complaints, management of patients with a broad range of respiratory disorders (as listed in the overall goals for this rotation). Techniques for thorough physical examination of the respiratory system (including upper and lower respiratory tract and respiratory muscle function) will be observed and reinforced with fellows also in the 21

20 context of outpatient care. The many pulmonary conferences provide opportunity to learn in both the didactic setting and interactive discussions. These include the following conferences: Journal Club (three times a month): The critical review of inpatient and outpatient pulmonary/critical care and sarcoidosis literature. Pathology review through both Pathology conference (alternate Mondays 4 PM). Weekly Thoracic Oncology Conference (Wednesdays 7:30 AM). Bimonthly Case Conference (alternate Mondays 4 PM). Tuesday 4/5 PM lecture series (core curriculum). Assessment Method (Fellows) The fellow will be observed in direct patient care with core competencies evaluated based on their performance. Depth of understanding of the medical problems and complications, and effectiveness at communication will also be assessed by review of clinic notes. Evaluation tools used during this rotation include: 1. Mini-Clinical Evaluation Exercises (360 evaluation tool)- Pulmonary clinic only. 2. Patient evaluations- Pulmonary or Sarcoidosis clinic. 3. New Innovations evaluation to be completed by core clinic faculty as a whole on a semi-annual basis. Assessment Method (Program Evaluation) The Continuity Clinic outpatient fellowship experience is assessed using multiple methods. The Director of the Pulmonary and Sarcoidosis Clinics precepts weekly and routinely meets with the fellows to address systems issues within the clinic. The fellows fill out a formal evaluation (End of the Year Survey), which includes questions regarding the educational experience of this rotation. The pulmonary faculty regularly reviews the fellowship experiences at faculty meetings on a bi-annual basis. The fellows can provide feedback to the PD and associate PD at GFC (general fellowship conversations) held monthly. Level of Supervision The fellow is supervised directly by the clinic preceptor, to whom cases are presented and with whom management plans are generated. All cases are presented prior to the patient being discharged from clinic. The teaching attending sees the patient after reviewing the case with the fellow. A management plan is formulated together and implemented by the fellow. The clinic preceptor reviews and co-signs all clinic notes. Educational Resources A comprehensive outpatient-reading syllabus focused on the evaluation and management of various pulmonary conditions is provided to the fellows for both Pulmonary Clinic as well as Sarcoidosis clinic. The references include review articles, landmark papers, guidelines and consensus statements from the American Thoracic Society and the American College of Chest Physicians and articles from the American Thoracic Society Reading List on topics relevant to the care of outpatients with pulmonary disorders. 22

21 Updated 6/2015 MOUNT SINAI HOSPITAL PULMONARY ROTATION GUIDELINES C. Mount Sinai Hospital In-patient Pulmonary Rotations: 1. There are two concurrent inpatient pulmonary consult services, streamlined predominantly by Dr Patrick Chae, who receives the first consult call and assigns the patient to either Consult #1 or Consult #2 service. 2. A fellow is assigned to Consult #1 for a 2-week period paired with a service attending. The attending schedule is located in the divisional office and may run for one or two consecutive weeks within your blocks (hence you may have the same or two different attendings for your 2-week block). 3. You are to contact the service attending the day BEFORE your first day on consult-service to confirm the rounding schedule with him/her. 4. Every morning Dr Chae rebalances the two consult services lists, hence check-in with him every morning to go over the consult list (as patients get transferred b/w the two lists daily) in an attempt to cap the list of patients on consult #1 at 15 patients by the end of the day. 5. Overnight consult coverage is provided by the night float (NF) fellow with the service attending available as backup this coverage starts at 6PM-7AM. 6. The NF fellow is required to keep a written log of all incoming patient phone calls and the action taken and is expected to forward the RI or FPA related messages to the respective attendings via Daytime phone calls from RI or FPA outpatients are taken by that patient s attending physician until 7PM (followed by NF fellow). 8. If any patient requires transfer to the MICU, contact the MICU fellow (call 45721). 9. Weekend sign-out is done by /verbal communication between the weekday fellow/attending and the weekend fellow/attending. There should again be an sign-out back on Sunday from the weekend coverage updating the in-coming team. 10. Bronchoscopy service: please see bronchoscopy guidelines handout. D. Expectations of the Inpatient Consult Service Attending: a) Daily rounds are to be performed with the fellow (the time of rounds to be determined by the attending the day before, recognizing the fellow s commitments to clinics and conferences see below the mandated conferences). b) It is expected that consults be seen in a timely fashion within 24 hours of the initial call. c) Each patient has to be discussed and seen with the consult attending. The attending has to write their assessment & plan as they co-sign with attestation on EPIC. Follow up notes are written as needed dictated by the service attending. d) Contact with other specialty/sub-specialty teams can be initiated by the attending on service in complicated cases with significant diagnostic dilemmas to direct management. e) Until the fellow is certified, the attending or a senior fellow has to provide supervision for all procedures (thoracentesis, pleural biopsy, chest tube placement), while utilizing ultrasound. f) If the attending is not in the hospital, then the fellow must have easy access to the attending for emergencies by pager or cell phone or office number. g) The attending has to help identify important and interesting cases for the fellow to present at conferences (Thurs radiology conference). 23

22 E. Conferences (Consult Fellow is responsible for preparation for #5): same and more detailed info in the Fellows Conferences Guidelines folder. 1. Monday 4:00 PM Pathology or Case Conference: Mandatory to attend: We alternate path conference with case conference. For path conference an assigned fellow presents 4-5 interesting cases with histological review by the pathology team. After each case presentation, the fellow gives a one-slide discussion on evidenced based facts regarding the disease. For case conference: two fellows present a case each, and discuss in-depth the literature or evidence based knowledge surrounding that topic. These topics can be selected by the presenting fellow or can be suggested by attendings depending on available cases. 2. Tuesday 4:00 and/or 5:00 PM Pulmonary/Critical Care Core Lecture series: Mandatory to attend: Presentations include core pulmonary and critical care topics, introduction to research methodology, and classic pulmonary physiology. These cover our core academic curriculum. 3. Wednesday 7:30 AM Thoracic Oncology Conference: Encouraged but not mandatory: Join the thoracic oncologists, radiation oncologists, surgeons, pathologists and radiologists in reviewing surgical cases from the prior week. 4. Wednesday 3:00 PM ICCM Grand Rounds: Encouraged but not mandatory: The Institute of Critical Care Medicine Grand round are a series of weekly lectures and presentations from visiting and local faculty on various critical care topics. 5. Thursday 4:00 PM Radiology Conference: Mandatory to attend: This conference is designed to review interesting radiology (CXRs, Chest CTs) and to discuss management of challenging cases on the consult #1 service, MICU or chest clinic hence fellows on any service can present interesting cases. But primarily this conference is the consult fellow s responsibility. Pulmonary and Thoracic Surgery attendings sometimes also bring cases to be presented. For cases presented by the consult fellow, the history, and results of tests such as bronchoscopy or biopsy must be known. You must have approximately 5 cases to present each week. You put up the name/mrn, the Radiologist reads and discusses the imaging to generate a differential diagnosis, and then the history and final diagnosis is revealed by you. IT IS IMPERATIVE YOU REVIEW WHICH CASES YOU WILL BE PRESENTING WITH YOUR ATTENDING beforehand. 6. Friday 12:30 Noon Pulmonary/Critical Care Grand Rounds: Mandatory to attend: Fellows, faculty members, and guest speakers present various clinical and research topics. Each upper level fellow will also be expected to give one presentation a year (regarding their research project). 7. Monday 12:00 PM: Journal Club: Mandatory to attend: three Mondays a month we have journal club in which fellows present pre-selected articles using a standardized format on a rotating schedule. These are precepted by Dr Juan Wisnivesky, Dr Kusum Mathews and Dr Alison Lee on a rotating basis. 8. Monday 12:30PM: ILD conference: Encouraged but not mandatory to attend: the third monday of every month is used to hold a combined ILD case conference with NJH, BI and SLR where two or three prepared cases are presented on a rotating basis by different sites (MSH, BI, SLR, NJH), with multidisciplinary discussion with radiologist and pathologist. Cases are prepared either by ILD attendings (Dua or Padilla at MSH site) or by fellows. 24

23 F. Pulmonary On-Call: Evening coverage of consults is provided by the NF fellow starting at 6 PM. This includes answering phone calls from outpatients cared for at the Faculty Practice or RI (starting from 7PM, prior to which individual attendings take their own calls). A log of phone calls with the action taken for each is communicated with the appropriate FPA/RI attendings for these patients. Attending back up is provided for any questions or problems and fellows should not hesitate to call or page for assistance (service attg). G. Consults: The pulmonary consult is a template on EPIC labeled ms ip md pulmonary consult service note. All patients must have a consult note filled out within 24 hours and have the attending co-sign with attestation of the plan. It is very important that the consult template is filled out in such a way that it is in compliance with billing. Follow up notes are progress notes and are to be edited appropriately to remove extraneous information such that old information isn t automatically carried forward. 25

24 Revised Jun 2015 BRONCHOSCOPY GUIDELINES The Bronchoscopy rotation is part of the first, second and third year curriculum for the Pulmonary and Critical Care Medicine (PCCM) Fellows. It occurs typically in two-week blocks. Third year fellows are available to assist first year fellows in the training, teaching and performance of bronchoscopy. The goals and objectives of the rotation are to be discussed with the (PCCM) fellow at the start of the rotation. The PCCM fellow is to be evaluated upon completion of the Bronchoscopy rotation by the supervising attending, usually this is Dr. Harkin, using the standard fellowship evaluation form. The evaluations are to be discussed in person with the fellows by the attending physician at the end of the rotation. Upon completion of each rotation, the fellows are to evaluate their supervising attending. Core Competency Objectives: Medical Knowledge PGY 4+5: 1. Gains knowledge in bronchoscopy in the following areas: a. Obtaining Informed Consent b. Adequate Preparation of Patient c. ASA assessment d. Universal Protocols e. Eye protection/ mask/ gown f. Positioning of Patient g. Disinfection of Hands h. Pre-medication i. Assessment of Vital Signs j. Anticipation of Potential Difficult Airway k. Smooth insertion via Nares and/or Mouth l. Topical anesthesia of Vocal Cords m. Topical anesthesia within Airways n. Inspection of Tracheo-bronchial Tree Understanding of Airway Anatomy o. Identification of Abnormal Lesions p. Proper Bronchial Wash q. Proper Bronchial Lavage r. Proper Bronchial Brush s. Proper TBNA with knowledge of Endobronchial Ultrasound t. Proper Bronchial Biopsy u. Proper TBBX (Trans-Bronchial Biopsy) v. Smooth Removal of Bronchoscope w. Proper use of Fluoroscopy, Radiation Badge, and Lead Protection x. Proper care of Bronchoscope y. Check Chest x-ray if Applicable z. Procedure Note PGY 6: in addition to the above 1. Develop experience in interventional bronchoscopy including endo-bronchial ultrasound, balloon dilation, laser, cryotherapy, Endobronchial valve placement and stent placement. 26

25 Patient Care PGY 4+5: 1. Performs bronchoscopy and takes appropriate measures to ensure patient safety. 2. Demonstrates understanding of contraindications to bronchoscopy. 3. Demonstrates ability to perform focused history and physical examination of patients before bronchoscopy including evaluation of asthma, COPD, coagulopathies and other potentially procedure limiting conditions (such as being on anti-plt agents). 4. Demonstrates understanding of indications for early termination and side effects of bronchoscopy. 5. Recognizes the appropriate clinical context for bronchoscopy. 6. Understands necessary test results before bronchoscopy. PGY 6: 1. Performs, teaches and supervises first year fellows in bronchoscopy. Practice-Based Learning and Improvement PGY 4+5: 1. Evaluates and improves bronchoscopy through self-evaluation and feedback from attending staff. 2. Improves patient care practices through education of patients and families on the indications, usual risks and complications of bronchoscopy. 3. Understand informed consent process for bronchoscopy. PGY 6: 1. Improves teaching skills by educating and supervising housestaff on the performance and interpretation of bronchoscopy. 2. Knows evidence based medicine for complications of bronchoscopy including bleeding risk and airway risk. Systems-based Practice PGY 4+5: 1. Gains understanding of choosing appropriate bronchoscopic procedures. 2. Gains understanding of appropriate patient scheduling. 3. Demonstrates understanding of importance of dissemination of bronchoscopy results to physicians and patients. PGY 6: 1. Gains experience in managing a bronchoscopy laboratory, including quality control and quality assurance. Professionalism PGY 4+5: 1. Demonstrates effective communication skills in interactions with bronchoscopy lab staff and patients. 2. Demonstrates dependability in the appropriate follow through of test results. PGY 6: 1. Works in an interdisciplinary team to coordinate care for the patient, including working with nursing staff, 27

26 surgeons, anesthesia and pulmonary faculty. Interpersonal Communication Skills PGY 4+5: 1. Communicates respectfully and effectively with staff and patients. 2. Maintains comprehensive, timely, and effective procedure reports and interpretations. PGY 6: 1. Demonstrates effective communication with patients in delivering health care, and planning appropriate follow-up after procedures. BRONCHOSCOPY SUITE: Located in Annenberg 7, Cystoscopy Suite# 34. The code is your life number SCHEDULE: Mondays - 1 PM onwards Tuesdays - 9:30 AM - 5 PM Wednesdays - 1:00 PM onwards Thursdays - 9:30 AM 5PM Fridays - 9:30 AM 5PM The patient s name, unit number, date of birth, location (inpatient or ambulatory), indication (diagnosis) and referring MD will be listed in the bronchoscopy-scheduling calendar (can check with divisional staff: ext 45900). When you want to schedule a flexible bronchoscopy (FB) for a patient: -Call x45900 add the case on the bronchoscopy schedule if calling at least 24 hours ahead of time. The staff should be alerted to any special aspects of the case - e.g. respiratory isolation, if propofol or general anesthesia is needed, if special equipment (e.g. APC) is needed or onsite cytologist is needed. Note should also be made if the procedure is expected to be longer than average, and should then be booked for 2 hours or more. - An to Joanice John (joanice.john@mssm.edu, Dr. Harkin (timothy.harkin@mssm.edu or the covering Bronch MD) should be sent as soon as possible with the following information: Name, MRN, DOB, ASA#, Location (Inpatient vs Ambulatory), need for cytologist, IVCS/General Anesthesia, along with any requests for special equipment (i.e. APC/EBUS). - Bronchoscopy that requires general anesthesia or the use of Propofol must be booked prior to 2 PM the day before and should be booked as general anesthesia. All Intensive Care Unit bronchs are usually done at the bedside using the portable Bronchoscopy unit. No more than 5 FBs are scheduled per day, unless there is an overriding emergency. Suspected tuberculosis cases must ideally have 3 negative AFB in sputum documented and should be the last case of the day (with Respiratory Isolation Specified). If a case is canceled, notify the Endoscopy Holding Area (x46277) immediately. Similarly, same day bronchs are scheduled by calling Endoscopy registration directly at

27 PRE-BRONCHOSCOPY PROCEDURES: Dr Harkin usually performs most of the procedures with some other attendings covering in his absence (Dua, Mathews, Rho). The Bronchoscopy fellow is to contact the referring physician or review the chart in EPIC at least 24 hours before the procedure to discuss the case - a plan should be established regarding the type of procedure (BAL vs. TBBx vs. TBNA vs. all) and region to biopsy. When discussing the case with the referring physician/reviewing the chart in EPIC, it is the bronchoscopy fellow s responsibility to track down radiology films and pre-operative labs results. DO NOT ASSUME LABS WILL BE ON EPIC AND THAT RADIOLOGY WILL BE ON PACS. The Bronchoscopy fellow should then discuss the plan with the Bronchoscopy attending who is performing the procedure. If there is a disagreement regarding the purpose/goals of the procedure or the management plan, the attendings and fellow should discuss them so a decision can be reached. Outpatient clinic cases are to be called the day before the procedure by the referring fellow to address the following issues: -Where they need to go and at what time (see attached instructions). -Medications to take and not to take. -Reminder to bring outside X-Rays, CT scans if they have any. - NPO after midnight for morning cases (routine morning meds should be taken with sips of water). Must be NPO for at least 8 hours before the case. - Strict adult accompaniment requirement to be released home after procedure. FPA patients are to be called the day before the procedure by the bronchoscopy fellow to address the same above issues. The Bronchoscopy fellow is responsible for the pre-operative workup for the patient (see FB- Patient Safety Guidelines). If a cytologist needs to be present, call x47378 to schedule with the cytology fellow at least 1-2 day(s) prior to the case or ask staff (Joanice or Lourdes) to arrange Cytology for the case. Inpatients: -The bronchoscopy fellow should see the patient prior to the procedure, explain the procedure, make sure the patient is NPO, and obtain consent. -Intravenous access is to be established by the floor nurse. -Transported directly to the bronchoscopy suite by patient transport. -A re-assessment form must be filled out by the fellow immediately prior to the procedure to either: confirm no significant change in the patient s status has occurred since the last exam documented in the chart, or to document any change and what has been done to address it and how it impacts on the bronchoscopy. Ambulatory patients: -Register in the registration area in Endoscopy, 7th floor of th Ave. -They are then sent to the Endoscopy Holding area to wait for the procedure. - The fellow sees and assesses the patient there, and the admitting History and Physical form is filled out (see attached form). NOTE: The patient will not be moved to the bronch room until the 29

28 H&P is completed (hospital policy). H&P form may also be filled out by the referring MD within 30 days of the procedure. -Upon arrival to the bronchoscopy suite, the Endoscopy nurse will place an IV and hook the patient up to a monitor that measures Blood Pressure, Heart Rate and Rhythm and Pulse Oximetry. -Consent may be obtained by the Bronchoscopy fellow at that time or at the time of the H&P. Informed consent should include: Risks of moderate sedation (hypotension, respiratory depression). Risks of bronchoscopy: hypoxemia, bleeding (mild-moderate about 5% with biopsy, severe under 1% with biopsy), pneumothorax (about 1-2%, almost exclusively with transbronchial biopsy), death (about 1 in 10,000, almost entirely due to arrhythmia). Risks of interventional procedures (electrocautery, argon plasma coagulation, laser): airway perforation, endobronchial fire (both extremely rare). If the procedures are running on time, you are expected to arrive on time; the Endoscopy staff will not call you unless the case is delayed. The Bronchoscopy fellow may start administering topical anesthesia, usually with topical and intranasal Lidocaine. Conscious sedation with midazolam (Versed) and Fentanyl may only be given once the attending is present in the bronchoscopy suite (See Appendix 1: Agents for Premedication and Sedation during Bronchoscopy). POST-BRONCHOSCOPY PROCEDURES: All patients who undergo Transbronchial Biopsy need to have a Fluoroscopy check in both the apex and the base to look for pneumothorax. Patients who have complaints of chest pain, or have physical exam signs of pneumothorax (including desaturation, tachypnea or tachycardia) should have a chest radiograph post-procedure. At the discretion of the attending, stable, asymptomatic ambulatory patients may also have a chest radiograph. All post-bronchoscopy chest radiographs are to be reviewed by the bronchoscopy fellow and discussed with the assigned attending physician. Documentation procedures: (See EPIC screen caps below) - The fellow is to discharge the patient home after an ambulatory procedure after reviewing the post-bronchoscopy CXR and examining the patient. - In order to discharge the patient home via EPIC click on the Outpatient Areas tab under the patient lists. Click on Manhattan Amb Surg tab then click on the Amb Surg Endoscopy tab. Double click on the patient s name. - Click the Discharge tab on the lefthand column. Then click on the Med Reconciliation. Click on the Mark All Resume tab then the Next button (located at the bottom of the screen. - Establish a Hospital and Principal Diagnosis. Then click on the Ambulatory Surgery/Procedure Discharge link at the bottom. - Click on the Discharge Patient order, Nursing Orders (Patient Cleared for Discharge) include specific instructions regarding discharge, Discharge Activity, Discharge Diet then click the Next button at the bottom of the screen. - Confirm orders. Then Click Next. Finally click the Sign button located at the bottom of the screen on the Review and Sign Page. 30

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