Clinical training takes place on the medical campus of the University of North Carolina at Chapel Hill, and in outpatient specialty clinics of the UNC Health Care System. The UNC system includes North Carolina Children’s Hospital, North Carolina Memorial Hospital, North Carolina Neurosciences Hospital, North Carolina Women’s Hospital and the North Carolina Cancer Hospital. It is a public, academic institution operated by and for the people of North Carolina. The system’s mission is to provide high quality patient care, to educate health care professionals, to advance research and to provide community service.
People from all 100 North Carolina counties and throughout the Southeast are patients at the 803-bed hospital facility – more than 37,000 each year. Additionally, more than 800,000 people are cared for at UNC outpatient practices and clinics each year. Training within this large and dynamic health care system provides our fellows with robust clinical exposure to a diverse patient population, a wide range of common and uncommon pulmonary diseases, and breadth of critical illness.
The first year of fellowship is dedicated exclusively to clinical training. During the latter years of fellowship, 75% of the time is dedicated to a research training program tailored to the specific career interests of the individual fellow, and 25% of the time for continued clinical training during which time clinical skills are advanced, solidified, and fine-tuned.
Clinical training during the first year of fellowship is divided equally among 4 rotations: Ambulatory Pulmonary, Inpatient Pulmonary Service, Outpatient Pulmonary Service and the Medical Intensive Care Unit. Fellows rotate on each service in one month blocks during the first year of training. During years 2 and 3, each fellow spends approximately 2 months per year in the MICU and completes 3 months of non-MICU critical care electives over both years. Additional electives can be arranged on an individual basis based upon fellow preferences, interests and clinical rotations occur in IP learning advance procedures such as EBUS, stinting, chest tube placement and perctrachs.
Inpatient Pulmonary Medicine
It is on this service that the Fellow acquires skills in diagnosing and managing hospitalized patients with lung disease who do not require intensive care. These skills are acquired through running the inpatient pulmonary consultation service and sometimes the inpatient pulmonary medicine ward service (Med-G) with guidance and supervision by attending physicians and sometimes the inpatient . Bronchoscopies on patients on the inpatient pulmonary service and pulmonary consultation service are performed by the inpatient pulmonary medicine fellow. The conduction of Pulmonary function testing (PFT). In addition, the inpatient pulmonary medicine fellow performs the majority of the thoracentesis in the hospital, often as a key educator of the residents.
Outpatient Pulmonary Medicine
During this rotation the fellow participates in a number of pulmonary subspecialty clinics including Allergy and Immunology clinic, Multi-disciplinary Thoracic Oncology Program (MTOP) clinic, Lung Transplant clinic, Pulmonary Hypertension clinic, and their own continuity clinic. During this rotation the fellow performs bronchoscopies on patients seen in the thoracic oncology clinic and outpatient lung transplant patients needing surveillance bronchoscopy. In addition to, the first year fellow places all pulmonary artery catheters in the MICU, and gains skill in pulmonary artery catheterization one day per week in the cardiac catheterization laboratory under the direct supervision of our pulmonary hypertension faculty.
Medical Intensive Care Unit
During the first year, fellows participate in the care of all patients in our 30 bed medical ICU, and provide consultative care to patients in the surgical ICUs. The first year fellow guides the resident team in the evaluation and management a wide spectrum of diseases including hemorrhagic shock from gastrointestinal bleeding, septic shock, cardiogenic shock from massive pulmonary emboli, respiratory failure, liver failure, renal failure, metabolic emergencies, drug overdose and others. Management of respiratory failure and the mechanical ventilator is a primary focus of MICU rotation. The first year fellow performs all bronchoscopies in ICU patients, learns airway management/intubation, and assists the housestaff with the placement of central lines, arterial lines, paracenteses, chest tubes and thoracenteses. With the Interventional Pulmonary team, they may perform percutaneous tracheostomy and chest tube placement. Skills in bedside ultrasound imaging of central veins, the pleural space, the heart and the abdomen are acquired during this rotation.
Second and third year fellows act as the Attending physician for ½ of the MICU beds, directing teaching rounds with the housestaff and supervising patient care.
Non-Medical Critical Care
During the 2nd and 3rd years of fellowship, the fellow participates in 2 week rotations for the total of 12 weeks on the surgical services caring for critically ill surgery patients at UNC Hospitals. These rotations permit the fellow to gain experience with critically ill patients in the surgery/trauma ICU, cardiothoracic ICU, neurosurgery ICU, burn ICU unit, and cardiac intensive care unit.
Fiberoptic bronchoscopy is the dominant procedure of the pulmonologist. Skills in bronchoscopy are obtained at orientation and on each rotation during the first year of training. Training begins with a 1-day bronchoscopy course with our colleagues at Duke University Medical Center, and with simulation in the Procedural Simulation Laboratory. The Fellow becomes skilled in airway inspection, bronchoalveolar lavage, endobronchial biopsy, transbronchial biopsies and transthoracic needle biopsy using endobronchial ultrasound (EBUS). Fellows also have the opportunity to acquire skills in electromagnetic navigation bronchoscopy. Bronchoscopies are performed in our state-of-the art bronchoscopy suite, or in OR 17 which is reserved for EBUS bronchoscopies 1 day each week, and in the intensive care units of UNC Hospitals. Each fellow in our program easily performs over 100 bronchoscopies during their first year.
The outpatient Pulmonary Specialties Clinic at UNC is located at the Eastowne Medical Office Building, about 3 miles from the main UNC campus. Additional outpatient clinics are also located at Panther Creek (general pulmonary) and the Main Hospital (Transplant, Interventional Pulmonology, and Thoracic Oncology).
Eastowne MOB is the main site for outpatient care for UNC’s Department of Medicine. In 2021, construction was completed on this six-story building that houses clinics for nearly all internal medicine subspecialties. In addition, there is an onsite retail pharmacy, imaging center, laboratory, infusion center, ample meeting space, and the Clinical Research Unit. Five dedicated PFT labs are available for same-day pulmonary function testing, including spirometry, lung volumes, 6 minute walk tests and methacholine challenges. At Eastowne, patients are seen in a number of pulmonary specialty clinics staffed by expert providers in COPD, non-CF bronchiectasis, interstitial lung disease, sarcoidosis, cystic fibrosis, alpha-1-antitrypsin disease, asthma, pulmonary hypertension, and general pulmonology.
A major focus of the Department of Medicine currently is the development of multidisciplinary subspecialty clinics to enhance care delivery to patients with specific diseases. For example, under development is a joint Pulmonary/Rheumatology Interstitial Lung Disease clinic, ensuring patients have access to all necessary providers in one physical location. Other multidisciplinary clinics that currently exist or are in development at Eastowne include:
- Vasculitis (pulmonary and nephrology)
- Cystic Fibrosis (pulmonary, endocrine, and psychiatry)
- Pulmonary Hypertension (pulmonary and cardiology)
- Severe asthma (pulmonary and allergy/immunology)
- Sickle Cell (pulmonary and hematology)
Fellows maintain a continuity clinic at Eastowne throughout all three years of fellowship training; continuity clinic occurs weekly during the first year of fellowship and may move to biweekly in years 2/3 depending on research focus. In continuity clinic each week, fellows evaluate new referrals, often from other pulmonologists, and maintain their own panel of follow-up patients with a wide variety of respiratory diseases. During clinic days, fellows will interact with and learn from dedicated precepting pulmonary faculty, specialty nurses, respiratory therapists and a clinical pharmacist. After three years of training in this longitudinal pulmonary clinic, fellows are well-prepared to practice outpatient pulmonology in an academic or clinical setting. Trainees with a particular interest in an area of excellence (cystic fibrosis, pulmonary hypertension, etc.) can choose to have a longitudinal experience in these dedicated subspecialty clinics in their second or third year of fellowship.
To complement the hands-on training, a number of didactic and interactive conferences are available. Clinical conferences are attended by fellows during their research and clinical years. Clinical conferences include the following:
- Clinical Case Conference
- Core curriculum conference
- Combined Critical Care Conference
- Critical Care Boot Camp
- Journal club
- Lung transplant conference
- Multidisciplinary Thoracic Oncology Program conference
- Research Conference
In addition multiple other conferences are available in the School of Medicine and Department of Medicine in particular fields or in general internal medicine.