Faculty Chair:

Dolores Gomez, MD

Contacts:

El Paso Pulmonary Group

Lung Specialists of Las Cruces:  (575) 532-0303

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Required Experiences:

1. Outpatient Pulmonary clinic with above faculty

2. Inpatient ICU care at Memorial Medical Center

3. Inpatient consultations at Memorial Medical Center

Optional Experience:

Exposure to sleep Lab and process of diagnosis of sleep apnea and appliance fitting

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Weekly Schedule PGY2 or 3:

Sunday	Monday	Tuesday	Wed	Thursday	Friday	Saturday
	Pulm/ICU	Pulm/ICU	Pulm/ICU	Pulm/ICU	Pulm/ICU
	Pulmo/ICU	Pulm/ICU	Didactics	Pulm/ICU	Pulm/ICU

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Requirements:

AOA

Internal Medicine

The program must provide at least thirty-two weeks of clinical training in internal medicine disciplines, including at least eight weeks of general internal medicine experiences during the OGME-1 year. This requirement can be met by either inpatient internal medicine or inpatient family medicine service.

At a minimum internal medicine training must include:

• Twenty-four weeks of inpatient experience.
• Four weeks of training in critical care medicine.
• Didactic and clinical training.

Internal medicine training shall include exposure to the following disciplines, in either inpatient or outpatient settings:

• Allergy and immunology.
• Cardiology.
• Dermatology.
• Endocrinology.
• Gastroenterology.
• Hematology.
• Infectious diseases.
• Nephrology.
• Neurology.
• Oncology.
• Pulmonology.
• Rheumatology.

ACGME

There must be specific subspecialty curricula to address the breadth of patients seen in family medicine. (Core)

The program must ensure that every resident has exposure to a variety of medical and surgical subspecialties throughout the educational program. (Detail)

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Description of Rotation or Educational Experience:

Family physicians are the most broadly trained specialists in the health care profession. Therefore, critical and pulmonary care continue to be part of the training and responsibilities of the family physician. There is a need for family physicians to be able to provide care to the critically ill adult, especially in rural areas and in smaller hospitals. The depth of the critical care experience for each resident will depend upon the expected practice situation of the resident, including the practice location, available facilities and accessibility of subspecialist consultants.

Family physicians caring for hospitalized adult patients require skills and knowledge in ascertaining signs, symptoms and laboratory abnormalities of the critically ill. They must become adept in the diagnosis and management of such cases, as well as acquire the ability to coordinate the chronological flow of care in the hospital (from admission to discharge) and take into consideration the psychosocial issues applicable to each patient and his or her caregivers.

Respiratory related complaints are one of the leading causes of outpatient care visits and respiratory diseases taken as a group are a leading cause of death in the United States, as such an experience and understanding of respiratory and pulmonary diseases is fundamental and important to ensure an adequate education for Family Medicine residents. This rotation will provide an opportunity for residents to hone basic skills and competencies within the realm of pulmonary diseases and critical care.

Expectations:

Residents are expected to arrive to pulm/critical care rotation and continuity clinics on time and to dress and act in a professional manner. The resident will contact preceptors’ office prior to their first day on the rotation in order arrange the initial meeting time and location on day one of the rotation. It is expected that while at the preceptors’ office the residents will be respectful of the office space and personnel. The resident is responsible for maintaining a procedure log as well as completing assigned readings. When possible, residents should accompany the preceptor to the ICU and perform and observe common pulmonary and critical care procedures.

Faculty:

Pulmonolgy faculty will provide precepting during the focused Pulm/Critical care rotation. The faculty and community preceptors are expected to allow the resident to participate in active patient care and procedures when appropriate. The preceptors should also provide time and allowance for explanation and teaching of pulmonary conditions and their treatments. Preceptors who are competently trained must be available to work individually with residents, and to teach and assess performance of residents’ desired skills. The teaching of pulmonary and critical care lends itself well to hands-on training and cognitive education. Therefore, a balance of these two modalities must be used.

Call:

There is no call specific to this rotation.

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Patient Care

Goal

Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents are expected to:

Competencies

• Perform a complete, comprehensive pulmonary consultation in the inpatient and outpatient setting, with specific focus on the pulmonary history and physical examination
• Recognize and respond to signs and symptoms of impending respiratory failure
• Participate in the performance and reading of sleep studies
• Evaluate and manage obstructive, restrictive and thromboembolic pulmonary diseases
• Recognize and appropriately manage the clinical presentations of asthma and pulmonary hypertension
• Understand the basics of mechanical ventilation and which settings affect oxygenation and ventilation

Objectives

• Identify the different stages of asthma
• Interpret pulmonary function tests and arterial blood gases, chest x-rays
• Explain the relative diagnostic features of V/Q scans and chest CT in pulmonary embolus

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Medical Knowledge

Goal

Residents 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. Residents are expected to:

Competencies

• Understand the use of invasive and noninvasive ventilation (ie CPAP, NIPPV)
• Be able to perform standardized comprehensive critical care assessments and develop acute treatment plans.
• Understand the underlying physiologic changes in the various body systems, including diminished homeostatic abilities, altered metabolism, effects of drugs and other changes relating to the critically ill patient

Objectives

• Describe the physiology of obstructive and restrictive pulmonary disease
• Describe the initial evaluation for sleep disorders, COPD, asthma and pneumonia
• List common pharmacologic pulmonary agents used in common pulmonary diseases such as asthma, COPD, obstructive sleep apnea and pulmonary hypertension
• Demonstrate a basic understanding of the conditions that are relevant to the management of the critically ill adult including:
  • Basic science of circulation and respiration
  • Acute renal failure
  • Acid-base imbalance
  • Electrolyte abnormalities
  • Dysrhythmias
  • Hypertensive urgency and emergency
  • Heart failure
  • ARDS
  • Pulmonary embolism
  • Pulmonary hypertension
  • Sepsis
  • Antimicrobial therapy
  • Shock
  • Multisystem organ failure

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Practice Based Learning and Improvement

Goal

Residents 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. Residents are expected to develop skills and habits to be able to:

Competencies

• Recognize self limitations with regards to practice and seek consultation with other health care providers to provide optimal care.
• Assess medical information to support self-directed learning
• Locate, appraise and assimilate evidence from scientific studies related to their patients’ health problems
• Be able to optimize treatment plans using a systematic approach to medical decision-making and patient care, combining scientific evidence and clinical judgment with patient values and preferences

Objectives

• Provide evidence-based article and/or study related to care of patient resident has seen and discuss its relevance to the patients’ care during ICU rounds
• Demonstrate ability to recognize when to consult other specialities to provide optimal care to the patient

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System Based Practice

Goal

Residents 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. Residents are expected to:

Competencies

• Work effectively in various health care delivery settings and systems relevant to their clinical specialty
• Coordinate admissions, inpatient care and throughput within the hospital system
• Incorporate considerations of cost awareness and risk-benefit analysis in patient care
• Advocate for quality patient care and optimal patient care systems
• Work in interprofessional teams to enhance patient safety and improve patient care quality

Objectives

• Work cooperatively as a team member with outpatient staff and inpatient staff caring for patients as demonstrated by direct observation of supervising faculty
• Demonstrate understanding of costs of ICU stay and costs of outpatient pulmonary services including CPAP machines, oxygen

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Professionalism

Goal

Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. Residents are expected to demonstrate:

Competencies

• Compassion, integrity, and respect for others
• Responsiveness to patient needs that supersedes self-interest
• Sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation

Objectives

• Demonstrate compassion, empathy and sensitivity towards hospitalized patients and appreciate that informed adults with decision-making capacity may refuse recommended medical treatment or withdrawal of treatment
• Arrive to outpatient or inpatient service in a timely manner
• Complete consultations in the inpatient and outpatient settings in a timely manner

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Interpersonal and Communication Skills

Goal

Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and teaming with patients, their families, and professional associates. Residents are expected to:

Competencies

• Communicate effectively with patients and families across a broad range of socioeconomic and cultural backgrounds
• Communicate effectively with physicians, other health professionals, and health related agencies
• Work effectively as a member of leader of a health care team or other professional group
• Develop skill at communicating with primary service teams as a consultant
• Maintain comprehensive, timely, and legible medical records

Objectives

• Demonstrate an understanding of the ethical issues in the critical care patient to include:
  • Decision-making capacity
  • Euthanasia
  • Health care rationing
  • Palliative and end-of-life care
• Document clear consultations and communicate this directly to the primary team and recommendations with be clearly delineated in the medical record

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Teaching Methods

Residents will provide medical care to patients under the direct supervision of the attending physician. They will be supervised on all procedures performed in the hospital. The will participate in weekly conferences at the FMC. Residents will be assigned specific reading topics to be completed by the end of their month on the service.

Assessment Method (Residents)

Direct observation with a final global assessment based on a competency scale. All procedures will be recorded on New Innovations.

‍Assessment Method (Program Evaluation)

Residents will be provided with an evaluation of their experiences and given the opportunity to provide feedback of the rotation during their quarterly IEP assessments.

Level of Supervision

The resident is directly supervised by the attending physician during all procedures performed in the hospital. The attending will see all patients on the service each day and will document their involvement in the patient’s care. An Attending will be available the entire time the resident is on the rotation.

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Educational Resources

Readings:

Resources

Bleck TP, Dellinger RP, Dries DJ, el al.

ACCP Critical Care Medicine Board Review. 20

th ed. Northbrook, Il: American College of Chest Physicians; 2009

Brenner M. Current Clinical Strategies: Critical Care Medicine. Current Clinical Strategies Publishing; 2006.

Marini JJ, Wheeler AD. Critical Care Medicine: The Essentials. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins, 2006.

Marino PL. The ICU Book. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins, 2006.

McLean B, Zimmerman JL. Fundamental Critical Care Support. 4th ed. Mount Prospect, Il: Society of Critical Care Medicine; 2007.

Irwin RS, Rippe JM. Manual of Intensive Care Medicine. 5th ed. Philadelphia, Pa: Lippincott Williams & Wilkins, 2009.

Kollef MH, Bedient TJ, Isakow W, et al. The Washington Manual of Critical Care. Philadelphia, Pa: Lippincott Williams & Wilkins, 2007.11

Website Resources

American Academy of Family Physicians. www.aafp.org

American College of Chest Physicians. www.chestnet.org.

American College of Physicians. www.acponline.org.

American Hospital Organization. www.aha.org.

Association of American Medical colleges. www.aamc.org.

Institute for Healthcare Improvement. www.ihi.org.

Society of Critical Care Medicine. www.sccm.org.

Society of Hospital Medicine. www.hospitalmedicine.org.