The goal of the Pulmonary Disease and Critical Care Medicine (PDCCM) training program is to enable fellows to acquire knowledge, skills and experience in the six core competencies (as outlined by the Accreditation Council for Graduate Medical Education, or ACGME) as they relate to the two disciplines. The training program is three years in duration with a minimum of 24 months devoted to clinical training. All of the educational experiences and program content explicitly required for training in each area are present in the combined program. It is expected that the fellows demonstrate a greater depth of medical knowledge, judgment and procedural competence as they progress through the program. Specifically, they are expected to demonstrate greater skills and independence in decision-making regarding patient management and resource utilization. The program provides a minimum of nine months of clinical experience in pulmonary disease and at least nine months of meaningful patient care responsibility in the intensive care unit, with at least six months spent caring for critically ill medical patients and three months devoted to the care of non-medical ICU patients.

The schedule is divided into 12 months for each year. The typical schedule for each year of training is listed below. Overnight continuity of care is provided by a night float team, with in-house overnight call limited to the medical intensive care unit (MICU).

Over the course of the three-year fellowship, each fellow has a weekly continuity clinic. In addition, there is ambulatory experience in pulmonary hypertension/interstitial lung disease clinic and thoracic oncology clinic.

Primary Training Rotations

Critical Care Inpatient Service

Pulmonary Disease and Critical Care Medicine (PDCCM) fellows actively participate in all aspects of the care of medical ICU patients, including evaluation and management, procedures, family meetings, communication with referring and consulting physicians and discharge planning. Fellows learn the indications contraindications, complications, and techniques of the procedures commonly performed in the ICU. They acquire a knowledge base pertinent to critical care including the physiology of cardio-respiratory disease and an understanding of the operation of bedside hemodynamic monitoring systems. As the fellows progress they assume increasing individual responsibility for patients and education of internal medicine residents assigned to the ICU service. Fellows ensure that residents perform procedures safely and according to the highest technical standards. Each third-year fellow is expected to conduct a performance/quality improvement project.

Pulmonary Disease Consult Service

During the six months of the pulmonary consult rotation, the fellow is exposed to a very wide variety of pulmonary diseases in a diverse population. The rotation includes formal instruction, clinical experience and the demonstration of competence in the prevention, evaluation and management of pulmonary diseases. During this rotation, the PDCCM fellows participate in all aspects of patient care. The fellow on the inpatient consult service is called initially for all pulmonary consultation requests. The fellow is responsible for the final content of the presentation of each patient to the attending physician, who sees every patient. The fellow is responsible for daily follow-up and all care of patients on the plumnonary consult service under the guidance of the supervising faculty. All invasive pulmonary procedures are performed by the pulmonary fellows in the bronchoscopy suite or right heart catheterization lab.

Lung Transplantation and End-Stage Lung Diseases

The goal of this rotation is to help the fellow acquire the skills and knowledge necessary to care for patients with end-stage lung disease and to learn the role of transplantation in their management. Fellows care for patients referred for potential transplant as well as both pre- and post-transplant patients. They participate in care in both inpatient and outpatient settings. Additional goals include obtaining an understanding of the role of cardiopulmonary exercise testing, developing an ability to interpret exercise testing and acquiring an improved understanding of hemodynamic monitoring.

Thoracic Surgery

The thoracic surgery rotation is designed to provide the PDCCM fellow with the clinical skill and knowledge base necessary to provide competent clinical consultation (evaluation and management) and care to patients prior to and following thoracic surgical procedures. Expertise in outpatient preoperative evaluation and postoperative late follow-up care are provided during regularly scheduled weekly thoracic surgery clinic.

Trauma/Surgical ICU

The trauma/surgical intensive care (SICU) rotation is designed to provide the PDCCM Fellow with experience in perioperative care for critically ill patients undergoing general surgical procedures and in the care of victims of trauma. Each fellow spends approximately two months formally involved in this rotation during the fellowship. Fellows in the third year of training may elect to rotate on the neuro-ICU service for one month. The PDCCM fellow functions as a member of the SICU team during this month. The PDCCM fellow does not attend continuity clinic during this period but does attend both PDCCM lectures and surgical didactic sessions. The PDCCM fellow experience is enhanced by interaction with peers in the SICU, as the fellow acts in conjunction with and parallel to the surgical critical care fellows.

Pulmonary Disease Out-patient Clinics

• Continuity clinic: The fellows evaluate and treat new and established patients in weekly, one-half day continuity clinics. Faculty physicians attend all clinics and discuss the fellow's assessment and plans before the patient is discharged.
• Thoracic oncology clinic: Fellows evaluate patients with clinical suspicion of lung cancer and arrange for diagnostic procedures or appropriate follow-up. Fellows present the results of the diagnostic evaluation at the weekly, multidisciplinary Thoracic Oncology Clinical Case Conference and participate in the decision-making process that leads to a treatment recommendation for each patient. The clinic meets weekly for one-half day.
• Sleep clinics: Fellows attend a consultative clinic during the sleep rotation where they evaluate patients with sleep related complaints. They attend a CPAP Clinic for patients who are initiating CPAP treatment or have problems with CPAP tolerance. The consultative clinic meets weekly for one-half day and the CPAP Clinic meets twice weekly for one-half day each time.
• Pulmonary hypertension clinic: Fellows see outpatients with pulmonary hypertension under the supervision of a faculty member with special expertise in this area. They learn about invasive and non invasive hemodynamic assesment in the patient population and perform right heart catheterization on these patients when indicated.
• Interstitial Lung Disease clinic: Fellows see patients with suspected or confirmed interstitial lung disease and sarcoidosis. They are involved in both the evaluation of new patients as well as follow up care. In the event that a bronchoscopy is indicated to confirm or exclude the diagnosis, the fellow is responsible for performing this under the suprevision of faculty.

Procedures

The fellows are trained in all aspects of procedures pertaining to the specialty, including but not limited to:

• Fiberoptic bronchoscopy:
  • Tumor destruction/debulking using:
    • Electrocautry, argon plasma coagulation (APC)
  • Trans-bronchial and endo-bronchial biopsies under fluoroscopy if needed
  • Trans-bronchial and endo-bronchial brushing
  • Endo-bronchial ultrasound-guided FNA biopsies (EBUS-FNA)
  • Broncho-alveolar lavage
  • Tracheobronchial stenting
  • Balloon tracheo-bronchoplasty
  • Bronchial thermoplasty (BT) for refractory asthma
  • Navigational bronchoscopy
  • Medical thoracoscopy/pleuroscopy
• Percutaneous tracheostomy
• Pulmonary artery/Right heart catheterization
• Ultrasound-guided thoracentesis and paracentesis
• Pigtail and surgical tube placement and management of drainage systems
• Tunneled indwelling pleural catheter
• Ultrasound-guided central venous catheter placement

Research

To complete the requirements of training, each fellow must perform an independent clinical research project under the supervision of a UF College of Medicine – Jacksonville faculty member. There are monthly research conferences to discuss the progress of these projects.

Fellows are expected to engage in scholarly activity and spend up to 13 months doing research. Five of those months are in the first year of training, three months in the second year and the remaining five in the third year. Research electives may be taken as a one to three month block. At the start of a research elective, the fellow must have an approved project. The fellows continue to take part in the weekly continuity clinic, twice monthly pulmonary artery hypertension clinic and twice monthly thoracic oncology clinic during the research elective, as well as take part in all educational activities of the division including conferences, journal club, etc.

Annual Dean’s Fund Research Awards support resident and fellow scholarly activity. Every spring, a Research Day is held, with residents and fellows from all disciplines presenting their work. An annual award for resident research is a reflection of the emphasis on research in our training programs.

Well-designed studies conducted in collaboration with the faculty give the fellows opportunities to present at regional and national meetings and to publish the results of their scientific projects in peer-reviewed journals.