Pulmonary, Critical Care, Sleep & Allergy

Pulmonary Consults

Pulmonary Consult Resident Rotation

This rotation is designed to provide the resident with a practical background in Pulmonary Medicine. The resident(s) on the service will complete pulmonary consultations on hospitalized patients with respiratory problems and staff them with the Pulmonary Consult Team. The rotation includes experience in the management of both simple and complex pulmonary problems, including inpatient care of cystic fibrosis patients, management of immunocompromised hosts in the Bone Marrow Unit and those with acute respiratory failure requiring non-invasive ventilation. Residents will spend some of the rotation, evaluating patients in the UNMC Pulmonary Clinic to get additional experience in the evaluation and management of more severe outpatient pulmonary diseases. The resident will gain more experience in the interpretation of pulmonary function tests. A Blackboard course on Pulmonary Medicine is available and the resident will be expected to take the pre-test at the beginning of the rotation and complete the post-test at the completion. There are also a number of didactic lectures scheduled usually at 11:00 a.m. as a topical review. The resident will be provided with a schedule of these lectures.

Rotation-Specific Goals and Objectives

University of Nebraska Internal Medicine Residency Program UNMC Pulmonary Rotation

Revised 06/2010

The resident(s) and the Chief of Pulmonary Medicine (or his/her faculty designate) will have a face-to-face meeting at the beginning of the rotation to review the learning objectives for the month. The resident should call the Fellow assigned to the Pulmonary Consult Service (See call schedule or call Sheryl Latenser at 943-5515 for the Fellow information) to determine where to meet on the first day. The resident should also meet with the Pulmonary Education Coordinator (559-4021) to review Blackboard requirements.

Global Educational Goals:

  • Learn principles of epidemiology, pathogenesis, diagnosis, treatment, and prevention of pulmonary diseases and sleep disorders. (Epidemiologic factors shall include smoking history, occupational history, environmental exposures, and family history.)
  • Incorporate radiologic, nuclear medicine, and pulmonary function studies into the workup and management of patients.
  • Apply appropriate pharmacologic and nonpharmacologic treatments in the care of patients with pulmonary and sleep disorders.
  • Develop and demonstrate competency in the following skills: thoracentesis, arterial puncture, and interpretation of tuberculin skin testing and pulmonary function tests,.
  • With supervisory assistance of Pulmonary fellows and faculty, serve as an effective consultant from the point of view of patients, family, and referring physicians.  

Service Operation

  • The Internal Medicine resident will be assigned to the inpatient pulmonary service & the pulmonary outpatient consult clinic.
  • The objective of the pulmonary consultation service is to provide high quality and timely care to include:
    • Consultative care for patients at NMC Hospitals. This covers consultations requested by the Emergency Department, the Liver Special Care Unit, the Oncology-Hematology Special Care Unit (OSHU) or other inpatient areas. Note: patients in the AICU or other areas covered by the Critical Care Medicine (CCM) teams are excluded.
    • Primary care of the patients admitted directly to the pulmonary service.
  • The objectives of the Pulmonary Outpatient Consult Clinic are to provide
    • Timely and high quality consultation and follow up outpatient care on new and continuity patients seen earlier in the month.
    • Residents and students with experience in evaluating new and long-term patients in the outpatient setting.
  • Responsibilities of the resident
    • The pulmonary consultation service
      • The residents will be assigned consultations and will be expected to round with the team except during times scheduled for their individual general medicine longitudinal clinic. The resident will be expected to take call at least two weekends per month as scheduled.
      • Examine their patients at least daily unless off duty.
      • Review the laboratory, x-ray, and other new studies at least daily.
      • Write daily progress notes. The note must include the overall assessment and plan for the day. All notes must be timed and dated.
    • The pulmonary outpatient consult clinic
      • Residents are expected to attend the pulmonary outpatient consult clinic at 10 am on designate days. Generally, inpatient rounds are finished before consult clinic. House officers may elect to attend other specialty clinics, including the Asthma, Sleep Disorders and Advanced Lung Disease clinics if there are no inpatient duties.
      • Patients will be assigned by the Consult Attending. All patients must be presented to the Attending. Billing sheets must be reviewed and signed by the Attending.

Call Schedule and Vacations

  • The Resident is assigned weekend at-home call for the inpatient pulmonary consult service during the month. Week-end call begins Friday at 5pm and ends Monday at 8am. On Saturday and Sunday AM the Resident will round on the inpatient consultation service. New consults will be called to the Resident. The patient should be seen, consult written and then reviewed with the Fellow. The Fellow should decide if he or she needs to urgently see the patient at that time and the Fellow should discuss the case with the Attending. When any question arises as to who should see the patient it should be reiterated that it is the primary responsibility of the fellow on-call to see the patient regardless of the availability of the Resident. Phone calls on outpatients and the inpatient consult service will be handled by the resident. They are encouraged to call either the on-call fellow or the on-call attending if there are any questions.
  • The call is at-home call. A resident may be required by the residency program to do cross-cover call while on the Pulmonary service. In the case of an intern, this means the VAMC Admitting Area. (?) Each resident is only allowed to work 24 hours continuously with an additional 6 hours to complete patient care responsibilities and attend required conferences as provided by the ACGME Common Program Requirements. The house officer is excused from the Pulmonary service after this point.
  • Lillian Richards, the department administrator, maintains the call schedule. Please contact her with any special requests.
  • Vacation
      • Requests for vacation must comply with Internal Medicine Department policies and be approved by the chief resident. The request must also be approved by the pulmonary consultation attending depending on the scheduled responsibilities during the anticipated vacation period.

Evaluations by Residents:

  • At the conclusion of each resident's service period, he/she should complete an evaluation form assessing the quality of the rotation; he/she should complete an evaluation that also addresses the teaching undertaken by the attending physician.

Education of Medical Students:

  • Supervision of medical students assigned to the Pulmonary service will be the role of the house officer. The resident will assist the attending staff and fellow in the education of students.

Conferences:

  • Attendance at the Pulmonary lecture series and the PCCM Case Conference on Wednesday at noon are expected of house staff on the rotation. A schedule of the Pulmonary lectures will be distributed prior to the beginning of the rotation. A copy of the lectures is available on Blackboard and the resident will be enrolled in the Pulmonary Medicine Blackboard course. They will be expected to take the pre-test available on the site and at the completion of the lectures and prior to the end of the month must complete the post-test to achieve a satisfactory grade in the Medical Knowledge competency.
  • House officers are required to attend Noon Conference Tuesdays and Thursdays at noon, Grand Rounds every Friday in the Durham Research Center, and the periodic senior seminars held on Mondays in the Eppley Science Hall.

Research:

  • Residents are encouraged to participate in research projects in the Pulmonary division. Pulmonary rotation supervisors can provide a list of available projects upon request.
  • Pulmonary division faculty members are available to mentor scholarly projects undertaken by residents.
  • The residents are encouraged to write up case reports and case series.

Competency-Based Educational Goals and Objectives by Level of Training:

Medical Knowledge:

PGY-1:

  • Use paper and electronic reference and literature sources to learn about pulmonary diseases encountered in practice.
  • Apply knowledge to develop recommendations for management.
  • Be able to describe key features of the following areas:

Pleural disease

Basic ventilator management

Ordering and interpretation of pulmonary function tests

Arterial blood gas analysis

Diagnosis and management of COPD

Diagnosis and management of asthma

Diagnosis and management of interstitial lung diseases

Chest x-ray and chest CT interpretation

Diagnosis and management of sleep apnea syndromes

Diagnosis and management of thromboembolic disease

Evaluation of the solitary pulmonary nodule

Diagnosis and management of occupational lung diseases

Diagnosis and management of drug-induced lung diseases

Indications for diagnostic and therapeutic bronchoscopyPGY-2:

All of the above, and:

  • Demonstrate increased understanding of the above areas of knowledge.

PGY-3:All of the above, and:

  • Show progress in board examination preparation appropriate for level of training, and indicative of successfully passing the board examination.

Methods of Evaluation: Attending evaluation, chart-stimulated recall on rounds.

Attending evaluation, chart-stimulated recall on rounds.

Patient Care:

PGY-1:

  • Prioritize patient problems.
  • Monitor and follow up patients appropriately.
  • Demonstrate caring and respectful behaviors with patients and families.
  • Gather essential/accurate information via interviews, physical examinations, and laboratory studies.
  • Recognize limits in clinical experience and know when to ask for assistance.
  • Elicit common findings on physical examination.
  • Contribute to development and completion of management plans.
  • Recognize deterioration in clinical condition, and takes appropriate initial diagnostic and therapeutic steps to manage the patient.

PGY-2:All of the above, and:

  • Understand and weigh alternatives for diagnosis and treatment of less common pulmonary conditions.
  • Elicit subtle findings on physical examination.
  • Obtain a precise, logical, and efficient patient history.
  • Interpret results of procedures properly.
  • Make informed decisions about diagnosis and therapy after analyzing clinical data.
  • Develop and carry out management plans.
  • Consider patient preferences when making medical decisions.

PGY-3:All of the above, and:

  • Be able to manage multiple problems at once.
  • Reason well in ambiguous situations.
  • Spend time appropriate to the complexity of the problem.
  • Be able to nearly independently develop and carry out management plans.

Methods of Evaluation: Attending evaluation, chart-stimulated recall, mini-CEX observation of patient interaction.

Attending evaluation, chart-stimulated recall, mini-CEX observation of patient interaction.

Professionalism:

PGY-1:

  • Establish trust with patients and staff.
  • Be honest, reliable, cooperative, and accept responsibility.
  • Show regard for opinions and skills of colleagues, particularly in other specialties.
  • Demonstrate respect, compassion, and integrity.
  • Demonstrate sensitivity to patient culture, gender, age, preferences, and disabilities.
  • Acknowledge errors, and work to minimize them.
  • Be effective in the role of consultant.

PGY-2:All of the above, and:

  • Display initiative and leadership.

PGY-3:All of the above, and:

  • Demonstrate commitment to ongoing professional development.

Methods of Evaluation: Attending evaluation, mini-CEX.

Attending evaluation, mini-CEX.

Systems-Based Practice:

PGY-1:

  • Be a patient advocate.
  • Advocate for high-quality patient care and assist patients in dealing with system complexity.
  • Understand how to prescribe oxygen for home use.
  • Understand how to appropriately involve respiratory therapy services for hospitalized patients.

PGY-2:All of the above, and:

  • Apply knowledge of how to partner with health care providers to assess, coordinate, and improve patient care.
  • Use systematic approaches to reduce errors.
  • Participate in developing ways to improve systems of practice and health management.

PGY-3:All of the above, and:

  • Provide cost-effective care.
  • Understand how individual practices affect other health care professionals, organizations, and society.
  • Demonstrate knowledge of types of medical practice and delivery systems.
  • Practice effective allocation of health care resources that does not compromise the quality of care.

Methods of Evaluation: Attending evaluation.

Attending evaluation.

Practice-Based Learning and Improvement:

PGY-1:

  • Understand his/her limitations of knowledge.
  • Show willingness to learn from mistakes.
  • Demonstrate self-motivation to acquire knowledge.
  • Demonstrate the ability to access and apply multiple sources of information to practice evidence-based patient care.
  • Accept feedback and develop self-improvement plans.

PGY-2:

|All of the above, and:

All of the above, and:

  • Undertake self-evaluation with insight and initiative.
  • Facilitate the learning of students and other health care professionals.

PGY-3:All of the above, and:

  • Analyze personal practice patterns systematically, and look for ways to improve.
  • Locate, appraise, and assimilate scientific literature.

Methods of Evaluation: Attending evaluation, chart-stimulated recall, feedback on case presentation.

Attending evaluation, chart-stimulated recall, feedback on case presentation.

Interpersonal and Communication Skills:

PGY-1:

  • Write pertinent and organized notes.
  • Use effective listening, narrative and nonverbal skills to elicit and provide information.
  • Work effectively with other clinical services as a part of the care team.
  • Create and sustain therapeutically and ethically sound relationships with patients and families.

PGY-2:All of the above, and:

  • Provide education and counseling to patients, families, and colleagues.
  • Be able to communicate effectively with primary and other consulting teams, both verbally and in written form.

PGY-3:All of the above, and:

  • Display the ability to resolve conflicts professionally.

Methods of Evaluation: Attending evaluation, with emphasis on review of chart documentation and oral communications by house staff.

Attending evaluation, with emphasis on review of chart documentation and oral communications by house staff.

Resources:Up to Date (available on hospital and clinic computers)

Harrisons Principles of Internal Medicine, current edition

Current Medical Diagnosis and Treatment, current edition

Pulmonary Medicine Blackboard Course (Resident will be registered to login when they begin the month

PULMONARY LECTURE SCHEDULE

SUBJECT TEXTBOOK PAGES LECTURER

Cystic Fibrosis

Pg. 417-422

Dr. Murphy

Thromboembolic Disease

Pg. 357-372

Dr. Boer

Pharmacology, Pulmonary Rehab and Oxygen Therapy

Pg. 102-104, 299, 303-304, 319, 326, 345-348

Dr. Piquette

Lung Cancer, Nodules & Hemoptysis

Pg. 576-599

Dr. Huebert

Pleural Disease, Chest Wall and Neuromuscular Disease

Pg. 436-438, 613-617

Dr. Boer

PFT/Pre Op Eval.

Pg. 10-18, 53-55, 437

Dr. Boer

Occupational Lung Disease

Pg. Pg. 5, 451-453, 452t

Dr. Von Essen

COPD

www.goldcopd.com Guidelines & Resources, Global Strategies
www.thoracic.org Statements & Guidelines, Standards for the Diagnosis & Treatment of Patients.

Pg. 200-203

Dr. Rennard

Asthma

Pg. 265-279

Dr. Poole

Pneumonia Bacterial Typical & Viral Infections

Pg. 109-110, 180-184, 251

Dr. Thompson

Mycobacterial Infection

 

Dr. Romberger

Obstructive Sleep Apnea

Pg. 17-18, 353-54, 393, 437-438, 441-443

Dr. Barkoukis

 

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