Curriculum

The goals of training for the UNC Pulmonary and Critical Care Fellowship program are to gain proficiency in all clinical aspects of the subspecialty in order to provide the highest standards of care in any clinical setting and to help develop a scholarly approach to pulmonary medicine, critical care medicine and lung biology enabling them to pursue a variety of career options, including academic medicine and to build foundations for advancement as independent clinical investigators. These skills are delineated in the following core competencies.

Patient Care:

Fellows must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Fellows are expected to demonstrate the following skill with regards to data gathering:

• Be able to perform a complete history with particular focus on specific aspects of importance to the practice of Pulmonary Medicine including the history of the present illness, past medical disorders, social and family history, travel history, environmental, occupational and infectious exposures.
• Be able to perform a complete physical examination with particular focus on specific aspects of importance to the practice of Pulmonary Medicine including examination of the skin, digits and extremities, the mucous membranes, the oropharynx, the examination of the chest with respect to observation of respiratory pattern, rate and accessory muscle use, palpation of chest contours, and percussion and auscultation of the thoracic cavity.
• Utilize information resources available to further the evaluation of the subspecialty patient, including but not limited to old records, computer databases, radiology, bronchoscopy reports, pathology reports and/or specimens, family members, work place and other physicians.
• Utilize information for ICU monitoring, ventilator graphics, and echocardiography to assess the presence and degrees of severity of multiple organ failures

• Develop a complete and relevant differential diagnosis for patients using data from the history and physical, lab tests, culture results, radiology, pulmonary function studies, bronchoscopy and pathology reports with an understanding of the likelihood and consequences of each entity. Non-subspecialty entities must be considered.

• Make informed patient care decisions and create patient management plans that include medication, therapy and diagnostic recommendations in the context of the patients other medications and overall clinical condition.

• Should manage additional data as it becomes available, modifying the differential and management plan and ensure that all providers understand the issues.

• Are expected to achieve a competency providing diagnostic & therapeutic procedures in the outpatient setting and inpatient setting by performing procedures proficiently, minimizing discomfort and risk to patients, including: physical examination, thoracentesis, closed pleural biopsy, bronchoscopy with transbronchial biopsy and transbronchial needle aspiration, airway management, tube thoracostomy, mechanical ventilator management, pulmonary artery catheterization, and other forms of hemodynamic monitoring.

• Fellows should decide on appropriate therapy, whether empiric or definitive, and be aware of the possible toxicities and necessary monitoring for any selected therapy.

• Recognize the importance of and make a habit of consultation with the radiologist and pathologist for diagnosis of diseases of the chest.

• Recognize the role of joint management with Interventional Radiologists, Thoracic Surgeons, Otolaryngologists, General and Transplant Surgeons, as well as Medical and Radiation Oncologists.

Medical Knowledge:

• Demonstrate an investigatory and analytic thinking approach to clinical problems and questions posed in an outpatient pulmonary setting.

• Know and apply the basic and clinically supportive sciences which are appropriate to pulmonary medicine.

• Develop working knowledge of the pathophysiology of respiratory illnesses necessary for diagnosis and management including:

• Asthma

• Chronic obstructive lung disease with and without exacerbation

• Community acquired pneumonia and other respiratory infections, including bacterial, viral, fungal and parasitic organisms in both immunocompetent and immunodeficient hosts.
• Lung cancer, including risk factor management, evaluation and staging
• Sarcoidosis, autoimmune and other inflammatory disorders that affect the pulmonary system.
• Bronchiectasis
• Chronic cough
• Pleural disease
• Tuberculosis
• Hemoptysis
• Thromboembolic diseases
• Preoperative Pulmonary Evaluations
• Idiopathic Interstitial Lung Disease
• Pneumoconioses
• Pulmonary Vascular Disease
• Sleep Disordered Breathing
• End-of-Life care 
• Smoking cessation
• Acute respiratory failure
• All forms of shock syndromes
• Acute metabolic disturbances
• Acute renal failure
• Acute hepatic failure
• Acute neurological emergencies
• Hematologic and Oncologic emergencies
• Acute trauma
• Postoperative surgical complications and emergencies
• Transplant issues including management of immunosuppressive medications and scarce organ allocation

 Practice-Based Learning and Improvement:

• Fellows must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and continuously improve their patient care practices in a life-long learning approach. Fellows are expected to:
• Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness.
  • Use information technology to manage information, access on-line medical information; and support their own education on the clinical problems that they encounter with their clinic patients and inpatients.
  • Facilitate the learning of other members of the health care teams.

Interpersonal & Communication Skills:

Fellows must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients families, and professional associates. Fellows are expected to demonstrate proficiency in the following areas:

• Establish rapport with patients and families as a consulting and managing physician.
• Be effective at obtaining historical data regarding the case from patient, family, and other care providers as appropriate.
• Present new and established patient data to the attending in a coherent and concise manner. In addition, fellows are encouraged and expected to ask for help/advice when unsure of an issue.
• Produce legible, coherent notes, and/or dictate notes which explain the results of all tests you have ordered, documents the current medical regimen and elucidates a clear plan in a timely fashion.
• Recognize the value and importance of collaborative care (health care team approach) and work effectively in a multi-disciplinary setting with respiratory therapists and technicians, nurses, medical assistants, administrative assistants, social services, translators, medical students, and other pulmonary fellows.
• Communicate effectively with referring physicians, physician colleagues and other members of the health care team regarding consultant’s opinions and recommendations.
• Communicate effectively with the nursing and administrative staff regarding scheduled testing and management of the patient.
• Integrate medical management with patient education and provide patients with written plans of action when appropriate or if requested by patients and families.

Professionalism:

Fellows must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Fellows are expected to:

• Advocate for patients by maintaining communication with their primary and outside care providers.

• Provide educational and clinical resources for patients so that they can take advantage of evidence based Guidelines- directed care within the constraints of their economic, educational, and sociocultural backgrounds.

• Demonstrate integrity, empathy, compassion and respect for the patient.

• Demonstrate respect for other members of the health care team including referring physicians, nurses, and other health care professionals and assist them when help is necessary.

• Develop an understanding of and responsiveness to patient differences related to gender, age, culture, religion, sexual preference, socioeconomic status, beliefs, behaviors, & disabilities.

• Recognize the importance of giving advice in a thoughtful manner based on the needs of the individual seeking the consult and provide constructive feedback to those individuals seeking consultative advice.

• Demonstrate respect for patient confidentiality and other patient rights including and understanding of the legal and ethical responsibilities regarding HIV patients and disclosure of results.
• Adhere strictly to the UNC Department of Internal Medicine and Division of Pulmonary Diseases and Critical Care Medicine policies, and act as a model for and proponent of adherence to such policies.
• Demonstrate the ability to provide informed consent for procedures incorporating an in depth understanding of potential complications and probable benefits.
• Acknowledge lapses and errors identify the sources of these errors, and look at mechanisms to minimize errors.

Systems-Based Practice:

Fellows must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Fellows are to develop the following skills:

• Utilize on-line resources/texts and current literature to answer questions that arise during clinical and educational evaluations as well as develop a complete and relevant differential diagnosis, understanding the likelihood for each possibility, and prepare a rational plan for diagnostic work-up.

• Know how diagnostic and therapeutic options differ from one another, including methods of controlling health care costs and allocating resources.

• Understand the limitations and resources of the health care system and impacts on patient management decisions, such as coverage for medications, endoscopic procedures, radiological studies and organ transplantation.

• Practice cost-effective health care and resource allocation that does not compromise quality of care.

• Advocate for quality patient care and assist patients in dealing with system complexities and understand the importance of the individual physician in the larger public health system.

• Know how to partner with other health care providers to assess, coordinate, and improve health care and know how these activities can affect system performance.

Clinical Investigation:

Fellows are expected to gain experience in clinical investigation sufficient to provide an adequate foundation for obtaining independent funding for continued scholarship. Fellows are expected to be able to:

• Perform thorough literature reviews to learn the science underlying any proposed research topic.

• Form a clear hypothesis amenable to testing
• Design experiments and clinical studies that will provide valid and reproducible answers to research questions
• Collect and maintain data appropriate for relevant dependent and independent variables or tests
• Understand basic statistical approaches to analytical problems
• Organize methods and results of experiments into manuscripts worthy of publication in peer reviewed journals
• Write complete proposals for funding of scientific endeavors

• Analyze practice experience and perform practice-based improvement activities using a systematic methodology
• Locate, appraise, and assimilate evidence from scientific studies related to the consultative or management problems and questions that they encounter
• Obtain and use information about their own population of patients and the larger population from which their patients are drawn.