Pulmonary and Critical Care Fellowship

During their Pulmonary and Critical Care clinical experience, fellows are expected to develop and refine skills essential for the practice of Pulmonary and Critical Care Medicine including history taking, physical examination, formulating diagnostic and therapeutic plans, performing bronchoscopies, intubations, pleural biopsies, performing and supervising other pulmonary procedures such as ventilator management, thoracentesis, chest tubes, central lines, pulmonary artery catheters, critical care ultrasonography, and arterial lines, and learning to interpret pulmonary function tests.  Elective time for additional dedicated training in epidemiology, lung transplantation, fibrotic lung diseases, asthma, cystic fibrosis, interstitial lung disease, interventional pulmonary, and sleep disorders medicine is available based on the career goals and prior experience of the trainee.

The First Year

The first year of training is a very rigorous clinical year, consisting of five months of critical care rotations, three months of inpatient consultation rotations (including one advanced lung disease experience). Rotations during this year include:

• Medical Intensive Care Unit at Grady Memorial Hospital
  • As one of our busiest (but most well-loved) rotations, the Grady MICU experience has fellows working with four teams of students, interns and residents, and two faculty members, in managing critical-ill patients. Because there is no separate cardiac care unit at Grady, this rotation includes that care of patients with acute coronary syndromes, in addition to more traditional MICU diagnoses. 
• Medical Intensive Care Unit at the Veterans Administration Medical Center
  • Fellows in the VA MICU supervise four medical residents in the care of critically-ill patients. Time permitting, fellows on this rotation also participate in pulmonary consults and associated procedures (generally bronchoscopy and thoracentesis).
• Medical Intensive Care Unit at Emory University Hospital Midtown
  • While fellows on this rotation manage a traditional MICU run by residents, one of the unique aspects of this experience is the opportunity to work with a team of advanced practice providers (Physicians Assistants and Nurse Practitioners) managing a separate team of patients.
• Medical Intensive Care Unit at Emory University Hospital
  • The MICU at EUH offers a unique patient population within our system; many patients admitted to this service have undergone solid-organ or bone marrow transplants, while others are admitted from our advanced lung disease service with interstitial lung disease, pulmonary hypertension or cystic fibrosis.
• Medical Intensive Care Unit at Emory St. Joseph's Hospital
  • This service offers the unique opportunity to work one-on-one with a teaching attending managing a team of advanced practice providers, but without residents. This model of care is very commonly used outside of academic medicine and provides our trainees a perspective on this increasingly prevalent model of care.
• Outpatient Pulmonary rotation
  • During this month, fellows will work with our faculty in both general pulmonary and dedicated sub-subspecialty outpatient clinics. These clinics include those focused on asthma, allergy, interventional pulmonary, sleep, interstitial lund diseases, cystic fibrosis, pulmonary hypertension and lung transplant. Fellows also rotate through our outpatient pulmonary function laboratory during this rotation, which includes experience in performing cardiopulmonary exercise tests.
• The Advanced Lung Disease service at Emory University Hospital
  • This rotation give fellows experience supervising a service of inpatients with complex pulmonary diseases (cystic fibrosis, interstitial lung disease, pulmonary hypertension and lung transplant). As time allows, rotating fellows also participate in affiliated clinics managing outpatients with these disease states.
• Pulmonary consultation at Grady Memorial Hospital
  • This month-long rotation allows fellows to gain experience in providing inpatient consultation of patients with pulmonary disease. This is a busy procedural experience as well, as many of these patients require diagnostic bronchoscopy or thoracentesis during their evaluation.  
• Pulmonary consultation at Emory St. Joseph's Hospital
  • This experience is a procedurally-busy service where the fellow works one-on-one with a Division faculty member. This service also covers the "code met" experience, which leads to a robust intubation experience during the rotation.
• Outpatient pulmonary consultation at the VA Hospital
  • One of the busiest procedural rotations in our system, the VA outpatient rotation has fellows supervising a team of outpatient consultants (including a resident and physicians assistant) in the assessment of patient referred for urgent outpatient evaluation. Many of these patients require diagnostic bronchoscopy with endobronchial ultrasound guided biopsy as part of the work-up, and fellows are expected to facilitate the patients' movement through the system from initial content to procedure to follow-up visit. 
• Anesthesia
  • First-year fellows will spend two weeks with faculty in Emory's Department of Anesthesia, to get a better grasp of basic and advanced airway management.
• Radiology
  • First-year fellows will spend two weeks with our outstanding thoracic radiologists, to gain experience in the interpretation of chest radiographs and CT scans.
• Sleep medicine
  • Fellows will have a two-week experience in sleep medicine. This will predominantly consist of outpatient clinic, but there will be some experience with interpretation of home sleep apnea tests, polysomnograms, and CPAP adherence downloads as well.

Beginning in our first year, and continuing throughout the three-year program, fellows will attend their own bi-weekly continuity clinics at Grady Memorial Hospital and the Veterans Administration Medical Center.  For fellows interested in subspecializing within pulmonary medicine, additional (elective) continuity clinics in pulmonary hypertension, interstitial lung disease, cystic fibrosis, sleep medicine and transplant are available.

The Clinical/Expert/Educator Pathway

Fellows enrolled on the Clinical Educator pathway have several required experiences in which they must participate during their latter two years of training:

• Interventional pulmonology - During this rotation, fellows gain a greater degree of experience in basic bronchoscopy, as well as beginning to develop the skills needed for more advanced procedures, including endobronchial ultrasonography, navigational bronchoscopy, rigid bronchoscopy,  tube thoracostomy, and bedside tracheostomy. Some experience with stenting and endobronchial laser use is also common.
• Trauma unit at Grady - Fellows will rotate with the surgical trauma team at Grady's level 1 trauma center, assisting in the management of the critically ill, injured patients, with the multidisciplinary trauma team.
• Surgical intensive care at EUH - This twenty-bed unit admits both general and specialty surgical patients. The multidisciplinary team consists of supervising faculty from the Departments of Anesthesia, Surgery and Emergency Medicine, as well as residents from each of these specialties.

In addition to a number of other elective experiences, fellows enrolling on our Clinical Educator Track will identify a specific subspecialty within pulmonary or critical care medicine on which to focus; common choices have included interstitial lung disease, pulmonary hypertension, transplantation, interventional pulmonary, sleep medicine, and quality improvement in critical care. During the latter two years of training, fellows will dedicate at least eight months of time in rotations related to this specific domain, consisting of both clinical months and protected time for scholarly projects (including research abstracts, review articles and book chapters). Through this process, the fellow will complete with training program with a "distinction" in this subdomain of pulmonary and critical care medicine.

Each specific sub-subspecialty has its own list of required rotations; as an example, the list of required experiences for fellows interested in focusing on pulmonary vascular disease is provided below:

• Three months of outpatient pulmonary hypertension
• One month of the inpatient advanced lung disease service
• One month of cardiac ultrasonography
• One month of congenital heart disease clinic
• One month of the Emory Hospital cardiac intensive care unit
• Two weeks of cardiothoracic surgery
• Two weeks of interstitial lung disease clinic
• Two weeks of rheumatology clinic

The Physician-Scientist Pathway

The Physician-Scientist pathway is intended for fellows who want to pursue a career focused on research in clinical, translational, epidemiologic, health services, or basic science domains. Fellows who opt to enroll on this pathway will complete their clinical training during the first half of the second year with three months of elective time (which must include one medical critical care month), in addition to the following required experiences:

• Interventional pulmonology - During this rotation, fellows gain a greater degree of experience in basic bronchoscopy, as well as beginning to develop the skills needed for more advanced procedures, including endobronchial ultrasonography, navigational bronchoscopy, rigid bronchoscopy,  tube thoracostomy, and bedside tracheostomy. Some minor experience with stenting and endobronchial laser use is also common.
• Trauma unit at Grady - Fellows will spend either two or four weeks rotating with the surgical trauma team at Grady's level 1 trauma center, assisting in the management of the critically ill, injured patients, with the multidisciplinary trauma team.
• Surgical intensive care at EUH - This twenty-bed unit admits both general and specialty surgical patients. The multidisciplinary team consists of supervising faculty from the Departments of Surgery and Emergency Medicine, as well as residents from anesthesia, surgery and emergency medicine.

At the conclusion of their eighteen months of clinical training, fellows will join one of our Division's NIH-funded T-32 training grants. This grant funds their research experiences, travel to relevant medical meetings, and associated coursework; some fellows on this pathway choose to pursue a full Masters degree through the Rollins School of Public Health at Emory University. Over the course of the next 24-30 months, fellows will engage in research under the supervision of one (or more) of our experienced mentors. Although it is strongly advised that fellows choose a member of our Division as their primary mentor, a fellow may choose to work with a mentor from outside the Division, particularly if that mentor has a collaborative relationship already established with one or more of our faculty. In addition to developing original research projects under the guidance of their mentor, fellows learn how to analyze data, prepare and deliver scientific presentations and write and publish original scientific manuscripts. Successful completion of this track requires fellows to present their scholarly work to both internal and external audiences.

By the conclusion of the first year of training, each fellow selects a primary mentor from among our 90 faculty members; this mentor, along with a secondary mentor selected by the Division's Career Development Committee (CDC), works with the fellow to maintain the trajectory necessary to achieve the goals desired by the trainee. Note that the primary mentor does not need to be the person with whom the fellow plans to do research or work clinically (though this is preferable). The most important aspects of identifying a primary mentor are the personal relationship with the mentee and a track record of success with prior fellows. 

In addition to regular meetings with their primary mentor, senior fellows deliver fifteen-minute semiannual "work-in-progress" presentations to the CDC, which will provide constructive feedback and ideas for potential new directions for the fellow's training and career path.