Pulmonology (VAMC)
Site:
- Education Conference Room, Amarillo VA Medical Center
Instructors:
- Dr. Sergio Muniz and respiratory therapists.
Makeup of team (responsibility of each team member):
- One resident on elective who could be a PGY 1, 2, or 3 resident.
- The resident performs initial evaluation of all pulmonary consult patients including a history and physical examination, provisional diagnosis, further testing and management. This resident is expected to discuss these patients with the pulmonary attending daily, to complete daily progress notes on the patients he/she has evaluated, and also put in a consult note on new consult patients. He/she is expected to do Critical Care rounds in the Intensive Care Unit with the attending each morning. The resident is not expected to make direct adjustment to ventilator settings, but is expected to closely observe the management of patients on a ventilator, including the parameters used to make decisions to intubate and extubate patients and the techniques for weaning patients off a ventilator. He/she is expected observe and participate, under supervision, in the performance of pulmonary procedures such as endotracheal intubation, thoracentesis, pleural biopsy, fiberoptic bronchoscopy. He/she is expected to perform a history and physical and to put a note in the medical records of patients examined in the outpatient pulmonology clinic. The resident is also expected to interact with the supervisor of the Cardio-Pulmonary Diagnostic Laboratory where he/she can observe the performance of pulmonary function tests and venous Doppler flow scans. He/she is expected to actively participate in the diagnostic radiology morning report given on one Tuesday each month. The resident might also be expected to present a lung tumor case at the Wednesday Decision Tumor Board Conference.
- One attending supervises and interacts with the resident daily from Mondays to Fridays on ward rounds, in the Intensive Care Unit, pulmonary consults and a thrice-weekly outpatient pulmonary clinic. The attending is expected to give directions on appropriate history and physical examination of patients with pulmonary disorders, teach appropriate management of these patients and give guidance on the proper interaction with primary care and other providers who might need the help of a pulmonologist, thereby demonstrating the role of a pulmonary/critical care consultant in both an inpatient and outpatient care setting. The attending is expected to give didactic sessions to the residents on major pulmonary topics of interest, to teach the interpretation of pulmonary function tests and radiologic examinations such as plain x-rays and CT scans, demonstrate and supervise the performance of pulmonary procedures such as fiberoptic bronchoscopy, thoracentesis, pleural biopsy, management of patients on a ventilator. He is also expected to give feedback to the residents and other team members on their overall performance.
- One supervisor of the Cardiopulmonary Diagnostic Laboratory assists the resident in interactions with the team of respiratory therapists, exposes the residents to the techniques for performing pulmonary function tests, venous Doppler flow scans, administration of hand held nebulizer therapy, performance of arterial blood draws and gas measurements, technique for endotracheal intubation and adjustment of ventilator settings.
Days per week (night call):
- The team rounds 5 days per week, Mondays to Fridays except on public holidays. On weekends and public holidays, the resident might be expected to meet with the attending when there are critically ill patients being consulted upon. There is no night call with this rotation since it is a completely consultative service. (except one upper level NWTH ICU night call per month possible)
Usual time of attending rounds (meeting place):
- From 8:00am to 9:00am , residents are expected to attend Morning Report on Mondays to Fridays, including the Decision Tumor Board Conference on Wednesday mornings.
- Residents meet with the attending in the Intensive Care Unit at 9:15am and start ICU rounds.
- Residents meet with the Pulmonary attending in clinic on Mondays from 1:00pm to 4:30pm , Wednesdays from 1:00pm to 4:30pm , and Fridays from 1:00pm to 4:30pm. They meet on Tuesdays from 1:00pm to 5:00pm to read pulmonary function test results, to review indications for home oxygen therapy (including C-PAP and bi-pap), and to review sleep study results.
- Other activities which occur at various times during the working day include performance of routine bronchoscopic examinations and review of radiologic studies.
Types of patients encountered:
The VA has a large population of patients with advanced chronic obstructive pulmonary disease, cor pulmonale, restrictive lung disease, pulmonary fibrosis, asthma, lung nodules, lung masses and other respiratory disorders. A broad range of patients will be encountered. Most VA patients are males; there is a small but increasing population of female patients. A large proportion of the patients will be geriatric patients with chronic and multiple health problems. The rotation involves the care of critically ill patients in a consultative setting in the Intensive Care Unit, particularly patients who are on a ventilator. These patients will be primarily managed by the admitting in-patient medicine teams but the pulmonary/critical care consultant and his resident are expected to round on these patients every week day.
Educational goals/competencies:
Patient care:
Residents will learn to perform a detailed and thorough history and physical examination, with emphasis on the examination of the respiratory and cardiovascular systems. Residents will develop the ability to diagnose the different pulmonary diseases and understand the etiology, natural history, usual interventions, and possible complications of each of these conditions. Residents will develop an understanding of the risks of tobacco use and management of complications arising from this. Residents will also understand the indications for use of continuous ambulatory supplemental oxygen therapy, and also the indications for other forms of pressurized oxygen delivery such as c-pap and bi-pap. Residents will understand the different techniques for diagnosing pulmonary disorders including the indications, limitations and interpretation of pulmonary function tests, bronchoscopic evaluation, thoracentesis, pleural biopsy, other relevant diagnostic techniques and the techniques of endotracheal intubation.
Medical knowledge:
Residents will develop a thorough knowledge of the differential diagnosis of pulmonary problems including the evaluation of the symptoms such as cough, sputum production, hemoptysis, shortness of breath, cyanosis; will learn to identify and understand the implications of various abnormal physical findings such as tracheal deviation, percussive dullness, tympany, egophony, bronchial breath sounds, rhonchi, crepitations; will learn to identify and manage radiologic abnormalities such as interstitial fibrosis, pulmonary infiltrates, pleural effusions, lung nodules and masses. Residents will be particularly well-grounded on the management of disorders such as COPD, pulmonary hypertension, cor pulmonale, lung nodules, lung masses, interstitial lung disease, asthma, pneumonia (community and hospital acquired), respiratory failure, and the management of patients on a ventilator. Residents will also learn the humanistic aspects of the management of spectrum of acute life threatening problems such as acute respiratory failure on the one end and chronic incurable illnesses at the other end.
Interpersonal/communication skills:
It is expected that residents in the process of interacting with patients and their families will learn the attributes of good bed-side manner, demeanor and compassion for patients and their families, while performing good and thorough history and physical examinations. Residents will learn how to handle ethical issues that arise in the care of chronically and severely ill patients including patients on a ventilator. Residents will be expected to understand the appropriate use of medical records including records from external visits to other VA and non-VA medical centers. Residents will learn to communicate effectively with non-physician members of the health care team in view of the fact that a major part of their interactions will be with respiratory therapists and the supervisor of the Cardio-Pulmonary Diagnostic section of the hospital.
Professionalism:
Residents will learn to be polite, punctual, and civil in their interactions with members of the health care team, their patients, and patients' families. They will learn the appropriate skills for discussing sensitive issues such as risk factors for HIV infection, counseling on tobacco use, end-of-life discussions with patients and the families of patients who have end stage lung disease, and the ethical management of patients who are on life support equipment. They will learn to treat non-physician medical staff with respect, to understand when these staff has greater expertise than they do and to be comfortable in seeking their help and advise when appropriate.
Practice-based learning and improvement:
It is expected that their experience on this elective will teach residents to manage patients with acute, curable illnesses and those with chronic, debilitating and incurable illnesses and that residents will learn the great deal of comfort that can be provided even in the absence of curative interventions. Also, that they will develop the ability to listen to patients and their families and find ways to provide beneficial care to patients with chronic illnesses. Residents with also learn the role and value of heroic therapies such as cardiopulmonary resuscitation, endotracheal intubation, lung transplant and other invasive surgical treatments.
Systems-based practice:
Residents will interact intensively with ethicists, respiratory therapists, critical care nurses, clinic nurses, bronchoscopy suite staff, and will learn how a healthcare team functions. They will participate in providing outpatient care to patients with chronic illnesses and thereby learn the value of social workers and home health care providers. Residents will understand the use and implications of hospital formularies and the ethical and socioeconomic implications of rationing health care. They will also learn the administrative aspects of providing medical therapies such as home oxygen and pressurized oxygen delivery systems to chronically ill patients. They will also learn to provide cost-effective end-of-life care. They will be continuously expected to access and utilize a computerized medical records system and online medical literature data-bases.
Text/references to be consulted:
- The primary reference text is Textbook of Respiratory Diseases ( Murray , et al. Saunders).
- The Pulmonary and Critical Care latest MKSAP, pulmonary journals especially American Review of Respiratory Care, Chest,
- The New England Journal of Medicine are other sources of reference material.
Methods of evaluation:
Evaluations will be based on daily interaction with the attending, who gives daily feedback on performance, with the input of other members of the team including nurses and respiratory therapists. Their interaction with patients and their families and other medical staff will be continuously evaluated with particular emphasis on professionalism, humanistic attributes, punctuality to conferences and meetings, the quality of presentations on assignments given, and the overall quality of their interaction with their pulmonary attending. At the end of the rotation, the resident will have the benefit of a meeting with the pulmonary attending to discuss his performance and final evaluation.