University of Michigan Health System Internal Medicine Residency Pulmonary & Critical Care Medicine Curriculum: Ambulatory Pulmonary Medicine

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1 University of Michigan Health System Internal Medicine Residency Pulmonary & Critical Care Medicine Curriculum: Ambulatory Pulmonary Medicine Version date: 5/29/12 Subspecialty Education Coordinator: Eric S. White, MD Faculty curriculum authors: Eric S. White, MD and Tammy Clark Ojo, MD Resident curriculum editor: Rotation Goals and Educational Purpose Pulmonary medicine encompasses the diagnosis and treatment of a broad range of disorders that involve not only the respiratory system, but may also arise in different organ systems. By virtue of presenting complaints, the pulmonologist must also be well-versed in disorders of the cardiovascular, gastrointestinal, and rheumatologic systems that may mimic pulmonary disease. Many patients with chronic pulmonary disorders are encountered and managed in the clinic, and the management of these patients differs greatly from typical inpatient pulmonary and critical care medicine practices. The general internist needs to have competency in the initial diagnosis and management of acute pulmonary disorders as well as long-term management of chronic disease. Disorders such as chronic cough, asthma, COPD, and dyspnea are among the most common seen by general internists and therefore require mastery early in the internist s career. Interpretation of common studies, such as chest x-rays and spirometry, will be expected of the general internist. More uncommon disorders, such as interstitial lung diseases, cystic fibrosis, and pulmonary vasculitis syndromes, may be encountered only during training or a handful of times during a career; however, having an index of suspicion is critical for timely referral to a specialist. Finally, a working knowledge of medications used in the care of patients with pulmonary disorders is critical for the internist, since these physicians often coordinate patient care and will undoubtedly be asked to assess for potential side effects. For the above reasons, rather than providing a laundry-list of all pulmonary disorders a general internist might encounter, this curriculum will instead highlight: a) common ambulatory pulmonary disorders; b) interpretation of pulmonary function test and plain chest radiographs; c) pulmonary pharmacology; and d) identification and early work-up of uncommon pulmonary disorders in which mastery is expected by the completion of residency This rotation is currently incorporated into the Ambulatory Care rotation for all house officers, and encompasses a single ½ day clinic weekly. Rotation Competency Objectives

2 As a supplement to the University of Michigan Longitudinal Learning Objectives, the following provides a broad overview of the ACGME General Competencies specific to this rotation: I. Patient Care By completion of the rotation, residents will be able to: a. Perform a Pulmonary-directed History & Physical examination: i. Elicit history, temporal course, pattern, severity, and functional impact of: 1. Dyspnea 2. Cough 3. Chest Pain ii. Identify and recognize severity of classic physical findings: a. Inspection a. Clubbing b. Chest AP diameter c. Cyanosis d. Pursed-lip breathing e. Accessory muscle use f. Scarring b. Auscultation a. Vesicular breath sounds b. Bronchial breath sounds c. Wheezing d. Crackles/rales c. Percussion a. Dullness b. Hyperresonance d. Palpation a. Chest wall deformities b. Egophony iii. Identify and recognize severity of associated non-pulmonary physical findings: 1. Lower/upper extremity edema pulmonary hypertension, PE, fibrosing mediastinitis, SVC syndrome 2. S3, S4 gallops pulmonary hypertension, PE, diastolic dysfunction 3. Abdominal distension hepatic disease with hepatopulmonary syndrome, hepatic hydrothorax 4. Skin abnormalities sarcoidosis, dermatomyositis, scleroderma 5. Joint abnormalities connective tissue disorders, sarcoidosis, collagen vascular diseases b. Understand indications and limitations of, and appropriately order/interpret, imaging studies, pulmonary function studies, and procedures i. Radiology: a. Chest x-ray: PA/Lateral b. Chest CT (conventional, HRCT, volumetric 3D reconstruction, nodule-protocol, PE-protocol) c. PET scanning

3 d. Other (thoracic ultrasound, MRI, etc.) ii. Pulmonary Function Studies a. Spirometry b. DLCO c. Full pulmonary function studies (with lung volumes) d. Six-minute hallwalk/o2 titration e. Cardiopulmonary exercise testing (indications for ordering only) f. Arterial blood gases g. Maximal respiratory pressures iii. Procedures: a. Bronchoscopy i. Transbronchial biopsy ii. Endobronchial biopsy iii. Transbronchial needle aspiration iv. EBUS v. Super-Dimension vi. Bronchoalveolar lavage b. Pleurodesis c. Transthoracic needle aspiration d. Thoracentesis e. Closed pleural biopsy f. VATS iv. Pulmonary rehabilitation c. Formulate appropriate plans of care: i. Integrate subjective and objective information ii. Determine next steps for diagnosis iii. Order appropriate therapeutics II. Medical Knowledge By completion of the rotation, residents should be able to: a. Pharmacology: Discuss the indications, usage, and major side effects of drugs commonly used to manage pulmonary disorders: i. Inhalers a. Corticosteroids b. 2-agonists (short- and long-acting) c. Anti-cholinergics (short- and long-acting) d. Combined therapies ii. Systemic medications a. Corticosteroids b. Immunosuppressants (anti-malarials, cytotoxic agents, antimetabolites, biologic agents) c. Leukotriene antagonists d. Antimicrobials b. Clinical pathology: demonstrate knowledge sufficient for basic interpretation of pertinent laboratory studies

4 i. Pulmonary function studies a. Obstruction b. Restriction c. Neuromuscular disease ii. 6-minute hallwalk iii. Chest X-ray iv. HRCT v. BAL fluid studies (cell count, differential, pathologic interpretation) vi. Pleural fluid analysis III. Interpersonal and Communication Skills By completion of the rotation, residents should be able to: a. Recognize the importance of patient education in the treatment of pulmonary disorders, including smoking cessation, pulmonary rehabilitation, and appropriate use of oxygen. b. Demonstrate communication skills (including listening) that support respectful, culturally competent, and patient-centered care. c. Demonstrate verbal and nonverbal communication that compassionately recognizes the impact of chronic dyspnea and fatigue on family and workplace. d. Dictate outpatient consultation notes to referring physicians that focus succinctly on patient issues and recommendations for care. IV. Professionalism By completion of the rotation, residents should be able to: a. Respectfully and compassionately respond to patients with a multitude of phenotypic expressions of pulmonary disorders. b. Compassionately respond to socio-behavioral and psychiatric complexities of pulmonary conditions. c. Engage patients in effective informed voluntary consent for planned medical management and interventions. d. Understand confidentiality with respect to chronic illness. e. Actively participate in clinics and create medical records in a timely fashion V. Practice-Based Learning and Improvement By completion of the rotation, residents should be able to: a. Utilize information technology to enhance patient education. b. Demonstrate willingness to learn from error, use information technology to support self-education (literature review), and facilitate learning of others. c. In response to measures of quality care, personally monitor and strive to improve skills necessary for optimal management of rheumatologic patients. d. Identify personal areas of knowledge and/or examination skill weaknesses, and seek out clinical opportunities to develop/expand them. VI. Systems-Based Practice By completion of the rotation, residents should be able to: a. Appropriately refer patients for pulmonary rehabilitation. b. Appropriately consult and coordinate with non-medical services c. Strive to provide cost-effective care d. Strive to assist patients in navigating systems of chronic care.

5 Teaching Methods I. Supervised Patient Care: a. The emphasis of the rotation is on experiential learning through consultative management of outpatients. The rotation is 100% outpatient, with clinics located in the A. Alfred Taubman Health Care Center and the Pulmonary Clinic at the Briarwood Campus. II. Independent study: a. Core Clinical Journals i. American Journal of Respiratory and Critical Care Medicine ii. CHEST iii. New England Journal of Medicine b. Texts and Manuals i. Murray and Nadel. Textbook of Pulmonary Medicine ii. Fraser and Paré. Diagnosis of Diseases of the Chest iii. Schwarz and King. Interstitial Lung Disease Evaluation Methods Given the short duration of the elective, formative face-to-face feedback to residents will occur after each clinic session by the supervising attending and again at the end of the rotation. Attending physicians also complete online competency-based evaluations of each resident. The evaluation is shared with the resident, is available for on-line review by the resident at his/her convenience, and is sent to the residency office for internal review. The evaluation is part of the resident file and is incorporated into semiannual performance reviews for directed resident feedback. Because feedback works best when it is bi-directional, residents also complete a service evaluation of the rotation faculty monthly, and should feel free to provide verbal feedback to the Attending Physician. Suggested Reading Asthma 1. National Asthma Education and Prevention Program. Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-Summary Report J Allergy Clin Immunol Nov;120(5 Suppl):S Nelson HS et al. The Salmeterol Multicenter Asthma Research Trial: a comparison of usual pharmacotherapy for asthma or usual pharmacotherapy plus salmeterol. Chest Jan;129(1): Chauhan BF, Ducharme FM. Anti-leukotriene agents compared to inhaled corticosteroids in the management of recurrent and/or chronic asthma in adults and children. Cochrane Database Syst Rev May 16;5:CD

6 COPD 1. Pauwels RA, Buist AS, Calverley PM, Jenkins CR, Hurd SS; GOLD Scientific Committee. 743.Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) Workshop summary. Am J Respir Crit Care Med Apr;163(5): Calverley P et al. Combined salmeterol and fluticasone in the treatment of chronic obstructive pulmonary disease: a randomised controlled trial. Lancet Feb 8;361(9356): Puhan MA et al. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev Oct 5;(10):CD Qaseem A et al. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med Aug 2;155(3): Pulmonary Nodules/Lung Cancer 1. Ost DE, Gould MK. Decision making in patients with pulmonary nodules. Am J Respir Crit Care Med Feb 15;185(4): MacMahon H et al. Guidelines for management of small pulmonary nodules detected on CT scans: a statement from the Fleischner Society. Radiology Nov;237(2): National Lung Screening Trial Research Team. Reduced lung-cancer mortality with lowdose computed tomographic screening. N Engl J Med Aug 4;365(5): Oken MM et al. Screening by chest radiograph and lung cancer mortality: the Prostate, Lung, Colorectal, and Ovarian (PLCO) randomized trial. JAMA Nov 2;306(17): Dyspnea 1. Parshall MB et al. An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. Am J Respir Crit Care Med Feb 15;185(4):

7 Cough 1. Pratter MR, Brightling CE, Boulet LP, Irwin RS. An empiric integrative approach to the management of cough: ACCP evidence-based clinical practice guidelines. Chest Jan;129(1 Suppl):222S-231S. 2. Irwin RS, Madison JM. The persistently troublesome cough. Am J Respir Crit Care Med Jun 1;165(11): Interstitial Lung Disease 1. Wells AU. The clinical utility of bronchoalveolar lavage in diffuse parenchymal lung disease. Eur Respir Rev Sep;19(117): Raghu G et al. 202.An official ATS/ERS/JRS/ALAT statement: idiopathic pulmonary fibrosis: evidence-based guidelines for diagnosis and management. Am J Respir Crit Care Med Mar 15;183(6): Travis, WD et al. American Thoracic Society/European Respiratory Society International Multidisciplinary Consensus Classification of the Idiopathic Interstitial Pneumonias. Am J Respir Crit Care Med Jan 15; 165(2): Pneumonia 1. Akram AR, Chalmers JD, Hill AT. Predicting mortality with severity assessment tools in out-patients with community-acquired pneumonia. QJM Oct;104(10): Segreti J, House HR, Siegel RE. Principles of antibiotic treatment of community-acquired pneumonia in the outpatient setting. Am J Med Jul;118 Suppl 7A:21S-28S. 3. Fine MJ et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med Jan 23;336(4):