Pulmonary

Competency-Based Curriculum

OVERVIEW
The prevalence of and mortality from lung disease, especially those related to cigarette smoking continue to increase in the early past of the 21st century. In addition the advancement in medical knowledge and technology has allowed for more aggressive evidence based therapy for those with lung disease. For both these reason it is important for the internal medicine trainee to develop and apply working knowledge in the area of pulmonary disease. It is important that both the faculty and trainee integrate this curriculum with that of the other subspecialties of internal medicine.

GOALS

The pulmonary rotation will provide the trainee with a basic understanding of the more common pulmonary disorders which are seen in the the hospital and ambulatory setting as well as other more rare disorders which help the trainee understand the pathophysiology of these diseases.

A: KNOWLEDGE

At the completion of this rotation we expect the resident to:

1. Recognize, evaluate causes of and manage acute exacerbations of obstructive lung diseases, including asthma, COPD, and bronchiectasis (including CF)
2. Recognize, perform diagnostic evaluations and manage causes of hypercapneic and hypoxemic respiratory failure including indications for both non-invasive and invasive mechanical ventilation
3. Recognize, perform diagnostic evaluations and manage causes of respiratory infection such as pneumonia and tuberculosis
4. Recognize, perform diagnostic evaluations and manage cases of pleural effusion
5. Recognize, perform diagnostic evaluations and manage pulmonary masses and nodules
6. Recognize, perform diagnostic evaluations and manage patients with diffuse parenchymal lung disease including Sarcoid, IPF, and BOOP etc.
7. Recognize, perform the diagnostic evaluation and manage patients with hemopytis

B. SKILLS

Upon completion of training we expect our residents to:

1. Recognize, perform diagnostic evaluation and manage patients with pulmonary vascular disorders including pulmonary embolus and pulmonary hypertension.
2. Understand and review pulmonary physiology and pulmonary function testing
3. Recognize, perform diagnostic evaluation and initiate management of sleep Apnea
4. Review the evaluation of CXR interpretation
5. Understand the role of bronchoscopy in diagnostic evaluation.

C. ATTITUDES:

Upon completion of training, we expect our residents to appreciate those attitudes valued and nurtured by pulmonologists, including:

1. Viewing medicine as humane science.
2. Balancing art with science
3. Recognizing the limitations of technology and the value of clinical insight
4. Making difficult judgments when certainty is elusive.
5. Understanding that testing, no matter how advanced or sophisticated, rarely substitutes for thorough, thoughtful evaluation by an informed clinician.
6. Balancing intervention with patience.
7. Recognizing limitations of our interventions.
8. Appreciating the unique circumstances of caring for patients with chronic, usually incurable diseases.
9. Learning the importance of functional considerations.

We expect that the knowledge base acquired by the resident on this rotation will deepen and become more comprehensive as the resident progresses through the program such that the resident will be able to instruct and guide his/her junior colleagues and students in the evaluation and management of patients with pulmonary disease.

EDUCATIONAL EXPERIENCE

A. General

The monthly pulmonary elective for residents is presented by division faculty according to the appended schedule. Residents will be responsible for seeing pulmonary in-patient consultations and will also participate in the outpatient activities and practices of division staff/faculty.

1. Inpatient Experience (IP)

a. Inpatient consultations are called to residents by faculty or their offices.
b. The resident sees all consultations him/herself and verifies that the evaluation of the patient is complete by internal medicine standards.
c. Consultations are presented on rounds to the consulting physician, at times to be mutually arranged. Usual practice is for the resident to join consulting physician for hospital rounds each morning and evening, as applicable.
d. In each instance, the consultation is discussed with referring residents or attending physician, as applicable.
e. It is expected that at the time of presentation to the consulting physician, the residents are totally familiar with the patient's problem(s), have read and reviewed pertinent literature, and are prepared to knowledgeably discuss the problem at hand.

2. Ambulatory Experience (AM)

a. Outpatient activities for residents are conducted as arranged by their supervising attending
b. Residents are expected to attend all sessions, outpatient activities, and practices.
c. Patients are assigned in clinics and offices by the attending physicians. Every effort is made to select patients of "interest".
d. Depending on numbers of individuals on the rotations and clinic/office loads attempts are made to permit residents to spend the first few experiences seeing patients together with attending physicians, so as to better introduce them to the patient evaluation.


3. Didactic Conferences (DC)

  • Numerous monthly conferences are held for the residents throughout the month. They cover a variety of topics in all the major medical subspecialties. Residents will be required to attend each of the conferences that do not conflict with their clinical duties.

    EVALUATIONS

    Assessment Methods (of Resident)

    The evaluation methods that apply to these rotations include some or all of the following:

    • Evaluation of resident competence by faculty attendings (AE)- Formal formative evaluations should occur at the completion of the specific rotation. It is to be based on direct observation on rounds, at conferences, and at the bedside. All faculty members are encouraged to complete the form prior to the completion of the rotation and review their impressions directly with the resident. All completed evaluation forms are returned to the Program Director for review and placed in the resident's permanent file.
    • Mini CEXs may be used when warranted, particularly in the beginning of the academic year.
    • Self-evaluation by In-service training examination scores
    • MKSAP study plan (MKSAP)
    • Participation and presentations at didactic conferences (DC)
    • Multi Source evaluations by patients and staff (MS)

Assessment Method (of Program)

Residents have the ability to evaluate teaching faculty and experience at the end of each rotation. They are encouraged to use this opportunity to give constructive feedback.

Residents are encouraged to maintain a high level of communication with the Program Director and faculty. These informal meetings can be used to disseminate information, receive timely feedback, and for other purposes.

Annually, all residents are required to complete and return an evaluation form of the faculty and the program. Evaluations are collected in a fashion to assure the anonymity of the resident. The feedback received during informal meetings, formal meetings, and the semi-annual evaluation form will be used to make programmatic change.

Competency Based Goals & Objectives:

1) Medical Knowledge

Goals and Objectives-PGY1 Learning Activities* Assessment
Describe the epidemiology, genetics, natural history, clinical expression of pulmonary disorders encountered in the inpatient setting. IP, AM, DC AE, DC, MKSAP
Describe the structure and function of the lungs, pleura and upper airways IP, AM, DC AE, DC, MKSAP
Summarize an approach to the evaluation of the common presentations of renal disorders IP, AM, DC AE, DC, MKSAP
Goals and Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Summarize an approach to the evaluation of common presentations in this specialty IP, AM, DC AE, DC, MKSAP
Interpret diagnostic tests used in the evaluation of inpatients with suspected lung disorders IP, AM, DC AE, DC, MKSAP
Demonstrate ability to critically appraise and cite literature pertinent to the evaluation of inpatients with pulmonary disorder IP, AM, DC AE, DC, MKSAP

2) Patient Care

Goals and Objectives-PGY1 Learning Activities* Assessment
Effectively perform a comprehensive history and complete physical examination in patients with symptoms affecting this system IP, AM, DC AE, DC, MKSAP
Appropriately select and interpret laboratory, imaging, and pathologic studies used in the evaluation of disorders affecting this system IP, AM, DC AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Construct a comprehensive treatment plan and assess response to therapy. IP, AM, DC AE, DC, MKSAP
Counsel patients concerning their diagnosis, planned diagnostic testing and recommended therapies. IP, AM, DC AE, DC, MKSAP
Utilize validated instruments in the assessment of function and quality of life to monitor and adjust therapy. IP, AM, DC AE, DC, MKSAP

3) Practice-Based Learning and Improvement

Goals and Objectives-PGY1 Learning Activities* Assessment
Identify and acknowledge gaps in personal knowledge and skills in the care of hospitalized and ambulatory patients with related diseases IP, AM, DC AE, DC, MKSAP
Develop and implement strategies for filling gaps in knowledge and skills of patients related diseases IP, AM, DC AE, DC, MKSAP
Integrate and apply knowledge obtained from multiple sources to the care of inpatients and outpatients IP, AM, DC AE, DC, MKSAP
Demonstrate ability to critically assess the scientific literature IP, AM, DC AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Effectively use technology to manage information, support patient care decisions, and enhance both patient and physician education. IP, AM, DC AE, DC, MKSAP
Demonstrate ability to critically assess the scientific literature IP, AM, DC AE, DC, MKSAP
Set and assess individualized learning goals IP, AM, DC AE, DC, MKSAP
Analyze clinical experience and employ a systematic methodology for improvement IP, AM, DC AE, DC, MKSAP
Develop and maintain a willingness to learn from errors, and use errors to improve the
system or processes of care
IP, AM, DC AE, DC, MKSAP

4) Interpersonal Skills and Communication

Goals and Objectives-PGY1 Learning Activities* Assessment
Apply empathy in all patient encounters IP, AM, DC AE, DC, MKSAP
Demonstrate effective skills of listening and speaking with patients, families and other members of the health care team IP, AM, DC AE, DC, MKSAP
Present patient information concisely and clearly, verbally and in writing IP, AM, DC AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Reliably and accurately communicate the patient's and his/her family's views and concerns to the attending IP, AM, DC AE, DC, MKSAP
Compose clear and timely admission and progress notes and consultations IP, AM, DC AE, DC, MKSAP
Counsel patients, families and colleagues regarding side effects and appropriate use of specific medications, providing written documentation when appropriate IP, AM, DC AE, DC, MKSAP
Teach colleagues effectively IP, AM, DC AE, DC, MKSAP

5) Professionalism

Goals and Objectives-PGY1 Learning Activities* Assessment
Be prompt and prepared for all clinical duties IP, AM, DC AE, DC, MKSAP
Recognize the importance of patient primacy, patient privacy, patient autonomy, informed consent, and equitable respect and care to all IP, AM, DC AE, DC, MKSAP
Respect patients and their families, staff and colleagues IP, AM, DC AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Model ethical behavior by reporting back to the attending and referring providers any key clinical findings IP, AM, DC AE, DC, MKSAP
Demonstrate integrity IP, AM, DC AE, DC, MKSAP
Respond to phone calls and pages promptly IP, AM, DC AE, DC, MKSAP

6) Systems-Based Practice

Goals and Objectives-PGY1 Learning Activities* Assessment
Demonstrate effective collaboration with other health care providers, including nursing staff, ancillary staff, therapists, primary care physicians, and consultants in the care of patients with related diseases IP, AM, DC AE, DC, MKSAP
Develop an understanding of the hospital resources available to the evaluation and management of patients with problems encountered by the subspecialty. IP, AM, DC AE, DC, MKSAP
Demonstrate a knowledge of and commitment to the rules governing confidentiality of patient information. IP, AM, DC AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Discuss how the health care system affects the management of inpatients with related diseases. IP, AM, DC AE, DC, MKSAP
Determine cost-effectiveness of alternative proposed interventions. IP, AM, DC AE, DC, MKSAP
Design cost-effective plans based on knowledge of best practices IP, AM, DC AE, DC, MKSAP
Demonstrate awareness of the impact of diagnostic and therapeutic recommendations on the health care system, cost of the procedure, insurance coverage, and resources utilized IP, AM, DC AE, DC, MKSAP

Level of Supervision

Interns are supervised in their care of patients by more senior medical house staff (PGY- 2/3 and Chief Residents) and faculty.

PGY2/3 residents have direct and indirect supervision by Chief Resident and Faculty.

Educational Resources

a. Supervising clinicians-didactic and bedside rounds and concurrent patient care
b. Medical literature including assessment of knowledge using the MKSAP
c. Bedside rounds with team and faculty.
d. Medical Grand Rounds weekly.
e. Scheduled didactic conferences including: medicine morning report, journal club, ambulatory care conference, EBM conference
f. Saint Barnabas Medical Center library, librarians, and online references/resources.

REFERENCES

1. American Thoracic Society Reading List: http://www.thoracic.org/education/careerdevelopment/ residents/ats-reading-list/
2. Global strategy for the diagnosis, management, and prevention of COPD: GOLD workshop summary. For the most current 2008 version of these influential guidelines go to: http://www.goldcopd.com
3. ATS / ERS Task Force: Standards for the diagnosis and treatment of patients with COPD: A summary position of the ATS / ERS position paper. For the most recent update of these guidelines go to: http://www.thoracic.org/sections/copd/index.html
4. National Asthma Education and Prevention Program- Expert Panel Report 3: Guidelines for the Diagnosis and
5. Management of Asthma. http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf
6. West JB, Respiratory Physiology
7. Rose BD, Up to Date
8. Murray, Nadel, Mason and Boushey, Textbook of Respiratory Medicine, 3rd edition, 2000
9. Fishman, AP, Pulmonary Diseases and Disorders, 2nd edition, 1998

FACULTY

Shan, Smita, MD., Education Coordinator
Gagliardi, Anthony, M.D., Department Chair
Green, Douglas, M.D.
Greenberg, Martin, M.D.
Mehta, Chirag, M.D.
Shah, Himanshu, M.D.
Sussman, Robert, M.D.