Division of Pulmonary & Critical Care Medicine

This policy was developed to ensure high level patient care, appropriate supervision of trainees, and to meet the ACGME Program Requirements for Graduate Medical Education in the specialty of Critical Care Medicine. The overall goal of the fellowship in Critical Care Medicine is to provide trainees with the intellectual environment for acquiring the knowledge, skills, clinical judgment, and attitudes that are essential to the practice of pulmonary and critical care medicine. The faculty and Henry Ford Hospital are fully committed to provide the educational program, resources, and facilities to meet this goal.

Objectives of Critical Care Medicine Fellowship training

1. To acquire the necessary knowledge in critical care medicine to understand specific disease processes, including the principles of molecular biology and genetics, physiology, pathophysiology, and an understanding of effective therapies. In addition, trainees will gain necessary knowledge of the psychosocial aspects of disease and understanding of a wide array of cultural beliefs, with unconditional regard to patient autonomy.
2. To acquire knowledge and gain practical experience in the necessary skills required by specialists in critical care medicine, including: technical procedures, critical problem solving, time management, team leadership, continuous quality improvement, critical appraisal of the literature and other components of evidence-based medicine, interpersonal communication, collaborative care, and self-directed learning.
3. To develop the maturity and appropriate attitude necessary to function as a professional in Critical Care Medicine.
4. To gain the knowledge, skills, and professional attitudes to function without supervision at the completion of training as a Critical Care Medicine physician rooted in the six core competencies identified by the ACGME.

All patient encounters for fellows must be reviewed by a Divisional Senior Staff physician.  Fellows are expected to perform initial, independent patient assessments and then present their findings to the assigned, supervising Senior Staff.  After discussion, the Senior Staff will then have an opportunity to evaluate patients and formulate clinical assessments and treatment plans with the fellow.

As fellows progress through their training, they are afforded graduating levels of independence commensurate with their level of training, clinical abilities.  Faculty will maintain supervision, while nurturing greater fellow independence. Faculty provides direct feedback to the fellow, and collective feedback is given through the clinical competency committee.

Excellent communication skills are essential to good medical care.  Successful fellows are able to anticipate possible areas for communications break-down with either patients or clinical colleagues, and take preventive steps to avoid these problems.

The following represent the usual level of responsibility and supervision given to fellows at each level of training.

First year of Fellowship (FY 1)

The first year of fellowship includes twelve months of clinical rotations during which the fellow has responsibility for the diagnosis and treatment of patients with a variety of medical problems. One third of this academic year is spent in the Medical ICU. All admissions are accepted by the MICU fellow and reviewed with the senior staff physician responsible for the patient. A complete diagnostic and therapeutic plan is developed with senior staff physician input and discussion. Throughout all years of training, faculty is available 24/7 for direct and/or indirect supervision in the Medical ICU.

Fellows also spend one month each on rotations in the Surgical and Neurosurgical ICU in the first year. The remainder of the months are spent in elective rotations designed to build upon the foundation of Critical Care Medicine. These rotations include Anesthesia, Bronchoscopy, and Radiology. During each rotation, the patient care responsibilities and faculty supervision are in accordance with the Core Program Requirements and are outlined in the curriculum for each rotation. Fellows are provided with specific goals and objectives for each rotation to achieve proficiency in all of the ACGME Core Competencies.

Our fellows engage in Simulation Center training on basic procedural skills during the first month of training. This is designed to review the fundamental skills essential for the practice of pulmonary and critical care medicine and include intubation, bronchoscopy, ultrasound-guided line placement, ultrasound-guided thoracentesis, and chest tube placement and management. There is also training on specific equipment such as ventilators, video-assisted laryngoscopes, pulmonary arterial catheters, esophageal Doppler monitors, SvO2 catheters, and Vigileo monitors. During the orientation period there is one-on-one supervision of each fellow by a faculty preceptor.

As the year progresses and with increasing experience, fellows are given greater independence, as deemed appropriate by the SSF and care for more complicated surgical patients.

Patient care responsibilities include:

• Reliably perform a history, physical exam and special investigations for the patient.
• Interpret laboratory tests and imaging studies, and relate the data to the clinical presentation.
• Use information technology to support patient care decisions.
• List medical problems, in order of priority, and formulate a diagnostic and therapeutic plan tailored to the needs of the individual patient.
• Counsel and educate patient and families regarding their disease process, diagnostic and therapeutic plan.
• Counsel and educate patient and families as to the procedures, risks and benefits of all planned procedures.
• Perform procedures such as airway management, ultrasound guided central venous catheter placement
• Manage co-existing medical diseases.
• Execute all procedures in a safe and skilled manner, with direct faculty supervision as appropriate.
• Use consultants effectively in the care of their patients.
• Coordinate care for outpatients including ordering tests, and following up with patients on test results.

Fellowship Year 2 (FY 2)

The second year builds upon the medical knowledge and skills gained in the first year and solidifies these concepts. Fellows spend additional time in the Medical ICU and in the Surgical ICU and Neurosurgical ICU. In the Surgical ICU they are supervised by surgical critical care staff and discuss management plans with their supervising staff as well as the patient’s primary surgery staff. In the Neurosurgical ICU all patient encounters are supervised by the rounding neurointensivist. During this level of training, the fellows are assigned increasing responsibilities during while on-call with faculty supervision. There is also time dedicated to develop research interests.

This final year of fellowship also focuses on increased independence and responsibility in preparation for sufficient competence to enter practice without direct supervision at the completion of training. They participate also in the West Bloomfield ICU, which is in contrast to their Medical ICU experience at main campus. There they are responsible for primary decision-making on each patient in the mixed Medical/Surgical ICU and receive direct input and support from senior staff regarding their clinical decisions.

Patient care responsibilities in addition to those of the first year:

• Participate in the management of the critically ill surgical patient
• Participate in the management of the critically ill neurosurgical patient
• Learn the fundamentals of sleep disordered breathing and interpretation of polysomnograms.
• Act as the primary pulmonary consultant on a variety of inpatients
• Perform more advanced procedures such as advanced airway management including bronchoscopic intubation, Blakemore tube insertion, chest tube insertion, bedside diagnostic ultrasound examination in the critically ill patient.
• Exercise independent judgment in the management of myriad critically ill patients. Develop complete diagnostic and therapeutic plans for critically ill patients independently.
• Gain competency in performing all procedures as outlined in the ACGME Program Requirements for Graduate Medical Education in the specialties of Pulmonary and Critical Care Medicine.
• Exercise independent judgment in the management of myriad diseases in pulmonary patients. Develop complete diagnostic and therapeutic plans for pulmonary patients independently.