UAMS Medical Center is an academic, tertiary care center that provides a wide array of experiences in pulmonary diseases and critical care medicine for patient care, research, and QI. The experience in pulmonary diseases is varied and complex. The hospital operates very active critical care units for medical and surgical patients and receives numerous emergent referrals from throughout the state. As a Level I trauma center, it is the site for the fellows’ required surgical ICU and trauma training. At UAMS, the fellow’s inpatient rotations are Pulmonary/CCM Consults, MICU, and a one-month surgical selective.
The MICU service team is comprised of a Pulmonary/Critical Care Medicine attending, fellow, 3 Internal Medicine Residents, and several interns. The Pulmonary/Critical Care Medicine fellow meets with the team before attending rounds to identify potential problems and routine discharges; participates in morning attending rounds; holds daily afternoon work rounds with the MICU team, supervises and/or performs invasive procedures. Key clinical scenarios include all typical MICU patient care issues such airway and ventilator management, shock, sepsis, multiorgan failure, ARDS, coordination of and interaction with multiple consultative services, and end of life issues. The fellow receives training and experience in multiple types of mechanical ventilation including standard modes, high-frequency oscillator ventilation (HFOV), and home ventilator equipment. Induced hypothermia for patients surviving cardiac arrest is also utilized as appropriate.
UAMS Pulmonary and Critical Care Consult/ Cystic Fibrosis Service
The Pulmonary/CCM Consult/CF Team is comprised of an attending, a fellow, and a resident. fellow evaluates and directs the day-to-day consultative care of patients with variety of problems such as community-acquired pneumonia, pleural effusions, and undiagnosed pulmonary disease (e.g. lung masses or nodules, interstitial lung disease, chronic/persistent pulmonary infiltrates, unexplained dyspnea.). The team also serves as the primary team for all cystic fibrosis patients admitted to the hospital. The consult team also sees non-medical critically ill patients (trauma, neurosurgery, surgery) in a consultative capacity for pulmonary problems and ventilator management. Interpretation of chest radiographs, CT’s, ABG’s and PFT’s are stressed, and procedures such as fiberoptic bronchoscopy, chest tubes and pleurodesis are key procedures done by the fellow on this service.
Fellows’ UAMS Continuity Clinics
All fellows have a UAMS Continuity Clinic twice a month where they evaluate, manage and follow patients with a wide variety of pulmonary disorders.
UAMS offers specialized clinics and/or centers in Cystic Fibrosis, Pulmonary Hypertension, Chronic Respiratory Diseases, and Sleep Disorders. Fellows attend several CF clinics per year and have the opportunity to see patients with the faculty in other clinics if desired.
Cystic Fibrosis Experience
Under the direction of Dr. Paula Anderson, UAMS operates an accredited Adult Cystic Fibrosis Center and provides inpatient and outpatient care and teaching experiences with CF patients, who are now surviving well into adulthood and will need increasing access to pulmonologists in the community. The CF Center has ongoing clinical trials and opportunities for clinical research and case reports which enable participating fellows to attend the annual Cystic Fibrosis national meetings.
Central Arkansas Veterans Healthcare System (CAVHS)
The CAVHS is one of the busiest hospitals in the U.S. VA system, is a tertiary referral center and provides a wealth of educational opportunities for P/CCM trainees in both inpatient and outpatient settings, conferences, and research. There are 2 inpatient rotations at the VA Hospital: Pulmonary Consults and MICU. All fellows have a twice-monthly Continuity Clinic at the VA. In collaboration with CAVHS Invasive Cardiology faculty, P/CCM fellows have an added experience with right-heart cardiac catheterization and interpretation of data.
VA Pulmonary Consultation
Inpatients with respiratory disorders on the Medicine Service are cared for by the General Medicine Services. The fellow provides detailed consultations for patients with significant respiratory problems. The fellow sees some consultations in the CCU and SICU as well. The VA 6B Diagnostic Unit provides a unique venue for expedited outpatient workups and handles large numbers of patients with suspected lung cancer as well as a variety of other undiagnosed pulmonary disease e.g., interstitial lung disease, chronic/persistent pulmonary infiltrates, unexplained dyspnea. Bronchoscopy, including TBNA for staging of lung cancer or diagnosis of mediastinal LAD, chest tubes, PFT interpretation, CPET and chest CT are areas of emphasis. The Consult fellow attends the weekly multidisciplinary VA Lung Cancer Conference.
The MICU is a closed unit staffed by the P/CCM attendings, and the P/CCM fellows are an integral part of the MICU team. The CAVHS also is the site of a special CCM learning activity in which the fellows, in the latter part of the third year, spend one month in the VA MICU in a role much like a “junior attending”. During this month, the fellow has a higher level of responsibility and more autonomy in patient care as appropriate to provide progression over the years of training for the advanced level trainee.
Fellows’ VA Continuity Clinics
All fellows have a VA Continuity Clinic twice a month which provides training and experience in the diagnosis and management of COPD, interstitial lung diseases, lung masses, chronic pulmonary infections, dyspnea, cough and pleural disorders; interpretation of PFT’s, chest imaging, and CPET; and a variety of other pulmonary diseases and disorders.
Under the direction of Dr. Raghu Reddy, the CAVHS operates a certified Sleep Disorders Center and Laboratory and provides the required basic pulmonary training in Sleep Disorders. Fellows see patients in the VA sleep clinic during selected months.
Fellows attend a weekly core lecture on key clinical or basic science/physiology topics in Pulmonary and Critical Care prepared and presented by either P/CCM faculty, fellow, or guest faculty from another division or department. Fellows are typically assigned two such presentations per year along with a faculty mentor.
Each weekly case conference is based on several interesting or problem patient cases from the faculty and fellows’ own patient experiences, including review of relevant chest radiographs, CT’s, pathology specimens, PFT’s and other clinical studies. Each attending and fellow is responsible for several case conferences per year and includes a short didactic on some element of evidence-based treatment, pathophysiology, and/or key literature. The conference is relatively informal, with lively discussions and diverse opinions.
Fellows review and critique relevant articles from the medical literature at the monthly Journal Club, which is attended by all division members. Typically, two fellows share the conference time. Senior fellows are responsible for one or more “expanded journal club ” conferences, with increased emphasis on interpreting the medical literature, such as a more in-depth study critique, a didactic on selected statistical methods or design features , or a critique of several related studies .
Fellows’ Monthly Research Meeting
The fellows meet once a month with the program director and selected other P/CCM faculty to discuss plans for research and related scholarly activities and review progress on active projects. Issues covered include ideas for studies, study design, navigating the IRB, and how to overcome roadblocks. For each meeting, the fellow completes a research update sheet describing work completed to date and specific goals for the coming month.
Fellows’ Monthly Meeting with Program Director
The fellows meet monthly with the Program Director to explore fellow concerns or feedback and review policies, procedures and administrative responsibilities.
Morbidity and Mortality Conference
UAMS/VA Multidisciplinary Lung Cancer Tumor Board
Fellows on the Pulmonary Consult services attend the weekly lung cancer conference. The conference is chaired by Interventional Pulmonology specialist Dr. Thad Bartter and is attended by faculty and trainees in Pulmonary Medicine, Thoracic Surgery, Oncology, Radiology and Interventional Radiology, and Radiation Oncology to provide multidisciplinary care for patients with known or suspected lung cancer .
ICU Ethics Conference: Fellows on MICU, and others as desired, attend a monthly multidisciplinary UAMS ICU Ethics Conference comprised of physicians, nurses, other medical personnel and students. with The conference is a case-scenario-based discussion led by Dr. Eduardo Mireles, P/CCM faculty member and UAMS MICU Medical Director, and covers common ethical principles and decision-making dilemmas encountered in the MICU. Other attendees and guest commentators include Chaplains and faculty from Palliative Care Medicine and the Medical Humanities Division.
Internal Medicine Grand Rounds
The weekly Internal Medicine Grand Rounds features excellent presentations by a variety of distinguished UAMS faculty as well as invited guest speakers. A significant percentage of lectures are on topics within the P/CCM core curriculum.
New Fellow Orientation Week
We have instituted a new-fellow orientation week so that for the first week of July, a second- or third-year fellow serves as the “primary” fellow for each Consult service while the first year fellow “shadows” the more senior fellow and Consult team, learning the ins and outs of the assigned hospital and participating in selected consultations and procedures. During this week, a daily agenda for new fellows includes one or more orientation sessions, including meeting with the Program Director to review key practices, policies and procedures as published in the Fellows’ Handbook; several core “survival” lectures; scheduled training in the each institution’s Electronic Medical Record Systems and related computer functions; and bronchoscopy simulation lab. The first year fellow then takes over the Consult service starting the second week of July. This orientation and transition week proved very successful with new trainees and we expect to continue and expand the offerings.
VA MICU Senior Fellow Month
In the 3rd and final year of training, each fellow does a VA MICU rotation as a sort of “junior attending” with an increased level of responsibility for the MICU team and for all aspects of patient care, communication and teamwork. During this month, the fellow independently leads morning MICU team rounds on most days, though the attending is available if needed. The fellow is responsible for teaching during rounds and for providing feedback to the more junior team members regarding their performances. After “fellow rounds” each day, and additionally as needed, the fellow and attending review all the patients, plans and team performance and modify as needed.
The Pulmonary and Critical Care fellows do not take in-house call, but fellows are expected to come into the hospital from home as needed when on call duty. Fellows on average are on call approximately every 7th night and about 16 weekends per year. Night call runs from 5 p.m. to 7 a.m. Weekends are Friday p.m. through Monday morning. Meal vouchers are provided to assist with food purchases while on duty in the hospital.