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Pulmonary Medicine PRINCE GEORGE’S HOSPITAL CENTER INTERNAL MEDICINE RESIDENCY PROGRAM SECTION 17: PULMONARY MEDICINE This section has been reviewed and approved by the Chief, Division of Pulmonary Medicine as well as the Program Director, Internal Medicine Residency Program at Prince George’s Hospital Center. ________________________ ______________________________ Chief, Division Of Pulmonology Program Director, Residency Program I. Overview Pulmonary medicine is the diagnosis and management of disorders of the lungs, upper airways, thoracic cavity, and chest wall. The pulmonary specialist has expertise in neoplastic, inflammatory, and infectious disorders of the lung parenchyma, pleura, and airways; pulmonary vascular disease and its effect on the cardiovascular system; and detection and prevention of occupational and environmental cause of lung disease. Other specialized areas include respiratory failure and sleep-disordered breathing. By the end of their training in internal medicine, residents should be able to evaluate and manage cough, dyspnea, fever with infiltrates, mass or nodule on the chest radiograph, pleurisy, and pleural effusion. He/she should be able to diagnose and manage patients with common respiratory infections: initiate the diagnostic evaluation of respiratory neoplasm; and manage the initial approach to patients with respiratory failure, including those in intensive care units. With more hospitalist jobs requiring interninsts to manage patients on ventilators on medical floors or intensive care units, residents during their rotation should obtain a working knowledge of this subject. The pulmonary specialist will usually assist internist for diagnostic procedures and complicated conditions such as advanced respiratory failure. II. Principle Teaching Methods This consists of frequent encounters with the medicine residents and making that person accountable for performance. It primarily consists of bedside rounds conducted most days of the week, a s well as in radiology. Here most of the teaching will be carried out. The residents will also observe performance of pulmonary function tests in the PFT laboratory and learn interpretation of the results. They will also observe special procedures like bronchoscopies done on the patients that they are following. The residents will also get a working knowledge of mechanical ventilators through rounds and didactics focusing on management of hospitalized patients requiring ventilator support. The resident will have frequent interaction with their supervising attending and rounds will include short 15-30 minute discussions on current medical topics driven by patient encounters, initiated by the residents and completed by the attending physician on most days of the week. Latest information dealing with the topic as provided by literature search and pertinent articles made available to the residents. During the rotation the residents will outpatient Pulmonary office practice three half days a week with Dr. Murthy or Dr. Steinberg. Residents must print out a copy of the ‘Pulmonary Attendance Sheet’ from the end of this section and have it signed for each outpatient day. The residents will also round with Dr. Boyce on hospitalized patients on mechanical ventilation and learn about different ventilator modes and management of patients and acute and chronic ventilation. Residents must have their attendance taken during these rounds. The residents must submit their Attendance Sheet with the program coordinator as a requirement for successful completion of the rotation During the rotation the resident must also analyze a minimum number of diagnostic tests with the staff pulmonologist. The logsheet at the end of this section lists the tests and their minimum number they must interpret for the month. The residents are required to view X Ray and CT films with the attending as well as interpret ABG and PFT results. They are also required to review all Lung biopsy slides with the pulmonary attending physician in pathology irrespective of whether the patient is on staff service or not. This is to allow residents to review pathology report, learn indications for bronchoscopy and lung biopsies as well as learn about the disease process of the particular case. Residents must print a double-sided Pulmonary Logsheet and have it signed by the attending as they complete each requirement. Residents must submit a completed copy to the program coordinator to get credit for the rotation. III. Strengths and Limitations The residents will be exposed to a broad range of clinical problems typical of a community-based practice with emphasis on inpatient illnesses and care. The teaching faculty for the Department of Pulmonology will be committed to teaching and being a strong role model to the residents. They will supervise the residents on consults, interpreting results of radiographic and pulmonary function studies, bedside procedures like thoracentesis, ventilator management and make residents familiar with indication of special procedures like bronchoscopy, VATS. For patients with unusual clinical problems the care may require transfer to tertiary referral center. The residents are encouraged to gain outpatient experience in the subject by shadowing the attending in their private office. Patients in the continuity clinic at Glenridge also offer learning opportunities. The resident can also utilize the opportunity to learn regarding cardiopulmonary rehabilitation from patients who are status post cardiac bypass surgery. IV. Goals and Objectives Legend of Learning Activities Learning Venues: 1. Direct patient care/ consultation 2. Attending rounds 3. Morning report and noon conference 4. Core lecture series 5. Self study Evaluation methods A. Attending rounds on consult patients B. Attending evaluation of PFT, ABG and radiologic interpretation skills C. Direct Observation D. Nurse’s evaluation E. In-training examination Competency: Patient Care Learning Venues Evaluation Methods Interview patients more skillfully, gathers accurate and 1, 2, 3, 4 A, B, C, D essential information with emphasis on pulmonary diseases Examine patients more skillfully with competent and 1, 2, 3, 4 A, B, C, D complete observation of normal and abnormal signs with emphasis on disorders of the pulmonary system Define and prioritize patient’s medical problems 1, 2, 3, 4 A, B, C, D Generate and prioritize differential diagnoses with 1, 2, 3, 4 A, B, C, D appropriate testing and therapeutics Develop rational, evidence-based management 1, 2, 3, 4 A, B, C, D strategies Competency: Medical Knowledge Learning Venues Evaluation Methods Expand clinically applicable knowledge base of the ALL A, B, C, E basic and clinical sciences underlying the care of medical service patients, both out and inpatients with emphasis on pulmonary disorders. Access and critically evaluate current medical ALL A, B, C E information and scientific evidence relevant to patient care Competency: Practice-Based Learning and Learning Venues Evaluation Methods Improvement Identify and acknowledge gaps in personal knowledge ALL A, B, C, E and skills in the care of hospitalized and out patients Develop and implement strategies for filling gaps in ALL, meet with A, B, C, E , attendance knowledge and skills and minimize errors Program Director sheet Competency: Interpersonal Skills and Learning Venues Evaluation Methods Communication Communicate effectively with patients and families, 1,2,3 A, B, C, D with particular emphasis on explanation of complex and multi-system illness and the testing required to confirm diagnostic possibilities Communicate effectively with physician colleagues at 1,2,3 A, C all levels with appropriate consultation when needed Present patient information concisely and clearly, 1, 2 A, C verbally and in writing. Adhere to confidentiality Competency: Professionalism Learning Venues Evaluation Methods Demonstrate respect, compassion, integrity and 1,2,3 A, C, D altruism towards patients, families, colleagues, and all members of the health care team Demonstrate sensitivity to confidentiality, gender, age, 1,2,3 A,C,D cultural differences and disabilities Competency: Systems-Based Practice Learning Venues Evaluation Methods Understand and utilize the multidisciplinary resources ALL A,C,D necessary to care optimally for hospitalized and out patients and the limitations of various practice environments. Collaborate with other members of the health care 1,2 A,C,D team to assure comprehensive patient care Use evidence-based, cost-conscious strategies in the 1,2,3,4 A,C,D care of hospitalized and outpatients V. Educational Content A. Airway Diseases 1) Diagnosis and management of: • Asthma • Bronchiectasis • Bronchitis • Chronic obstructive pulmonary disease • Upper airway obstruction- initiate management 2) Order appropriate tests and interpret results of: • Complete pulmonary function tests (spirometry, measurement of lung volume, diffusing capacity, flow volume loop) • Cardiopulmonary stress test • Pre-operative pulmonary clearance in lung reduction surgery B. Intensive care unit condition 1) Identify and initiate management of • Acute Respiratory Distress Syndrome • Ventilator associated Pneumonia • Tension Pneumothorax • Pulmonary embolism • Pulmonary hypertension 2) Order appropriate tests and interpret results of: • Swan ganz catheter reading • Chest X Ray • CT thorax • Ventilation perfusion scan • Arterial blood gases C. Congenital Lung Disease 1) Understand the diagnostic criteria, long term complications and management of: • Alpha1, antitrypsin deficiency
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