Pulmonary, Critical Care and Sleep Medicine

Froedtert Hospital is a well-established tertiary referral and recognized transplant center providing care to demographically diverse and medically complex patients. The pulmonary consult service offers a breadth of experience in the diagnosis and management of pulmonary infections, thoracic malignancies, interstitial lung disease, pulmonary hypertension, cystic fibrosis and sleep-related disorders, to name a few, with no paucity of both common and uncommon pathology. Additionally, our robust solid and hematological malignancy services and bone marrow transplant services provide fellows with unique training in the assessment of immunocompromised patients. The pulmonary consult team generally consists of an attending, fellow and several residents and medical students.

Emphasis is placed on developing each fellow’s leadership skills through resident and medical student education, and on proactive triage, assessment and recommendations on consults. Fellows gain proficiency in independently evaluating various forms of chest imaging (X-ray, CT, PET/CT, etc.)

Clement J. Zablocki VA Medical Center is one of the country’s premier VA clinical sites located about 10 minutes from Froedtert Hospital. In addition to providing consultative services, fellows actively participate in a trimonthly Thoracic Tumor Conference, presenting patients with lung cancer or other thoracic neoplastic diseases. A weekly “pulmonary urgent clinic” aids in developing skills in assessment, diagnosis, staging and further triage of pulmonary nodules, masses, parenchymal abnormalities and malignancies. Fellows learn to interpret advanced imaging to help guide the best approach for tissue-based diagnosis.

St. Luke's Medical Center is a private-academic community hospital with a very active Cardiothoracic Surgery Department and the fellows provide consultation to many of these patients who have incurred peri-operative cardiopulmonary complications. This is also the principle site of exposure to cardiopulmonary rehabilitation.

Fellow Continuity Clinics
Fellows will attend a pulmonary continuity clinic one half day per week for all three years of fellowship. This clinic experience may be obtained at the Medical College of Wisconsin Clinics at Froedtert Hospital, VA Medical Center, or both over the course of the training period. Clinics are cancelled during ICU (non-elective) and night float blocks. Close collaboration with a clinic mentor ensures a smooth learning curve into the idiosyncrasies of outpatient medicine with faculty committed to fellow education.

An important strength of the training program is the presence of a closed, 26-bed primary Medical Intensive Care Unit Service at Froedtert Hospital and an 18-bed closed Medical Intensive Care Unit at the VA Medical Center. Overall responsibility for direction and implementation of patient care on this service rests with the Critical Care staff and the Fellow who acts in a key junior attending role. There are separate dedicated nightfloat blocks at Froedtert Hospital and the VA Medical Center. Fellows will rotate through other ICUs including Surgical/trauma Intensive Care Unit, the Neurointensive Care Unit, Cardiovascular Intensive Care Unit and Transplant Intensive Care Unit during their elective critical care time.

Extensive procedural experience is assured through simulation and direct bedside supervision including placement of central and arterial lines, small and large bore chest tubes, thoracentesis/paracentesis, indwelling tunneled pleural catheters, bronchoscopy and bedside tracheostomy, to name a few, as are the fundamental principles of hemodynamic monitoring and stabilization of critically ill patients. Strong emphasis is placed on proficiency in the use of bedside point of care ultrasound (POCUS) for use in diagnostic and clinical decision making. There is also opportunity to gain proficiency in managing various types of mechanical life support including V-V and V-A ECMO, LVADs/RVADs and total artificial hearts as well as extraventricular drain and ICP monitoring, among many others.

At the core of these experiences is a conscious and methodical curriculum aimed at developing master clinicians rooted in principles of physiology, critical thinking and rigorous analysis of evidence based medicine.

Weekly “radiology conferences” are conducted in conjunction with the Chest Radiology department at Froedtert Hospital. The conference consists of two, 30-minute cases presented by the fellow(s) currently on Pulmonary Consults at Froedtert Hospital and the VA Medical Center. Emphasis is placed on basic and advanced techniques in chest imaging, formulation of differential diagnoses and therapeutic strategies for the disorder being presented.

Additionally, pathology is reviewed by our pulmonary pathology during the conference twice monthly with emphasis on interstitial lung disease one session a month and other pulmonary pathology seen on bronchoscopy rotation another session of the month.

Fellows also have the opportunity to rotate through this service on an elective basis. The Radiology Department enjoys a close relationship with the GE Medical Systems and therefore has access to the latest imaging technology.

Considerable experience is gained in a variety of bronchoscopic procedures.

Fellows become proficient in flexible bronchoscopy, linear & radial endobronchial ultrasound (EBUS), navigational bronchoscopy, indwelling tunneled pleural catheter insertion, thoracentesis, and small & large bore chest tube insertion. Exposure to rigid bronchoscopy, tumor debulking, airway stenting, pleuroscopy, endobronchial valve insertion/removal, and bronchial thermoplasty will also be gained.

Pulmonary fellows will perform or assist with all procedures. Fellows will gain insight into procedural indications and post-operative management. Rapid on-site cytopathology (ROSE) is present during cases to increase diagnostic yield.

The fellows are expected to play an active role in teaching and training of students and house staff at the Medical College of Wisconsin. This includes formal lectures and informal conferences in both Pulmonary, Critical Care & Sleep Medicine.

Our faculty are highly invested in the education and professional development of fellows and other trainees. As such, they have been honored with numerous teaching awards across campus, and the medical ICU rotation at Froedtert is frequently chosen by the internal medicine residents as the best teaching service in their training. Moreover, fellows consistently cite the clinical teaching in our ICUs as one of the program’s greatest assets; faculty are valued for their expertise, their accessibility, and their commitment to educating the next generation of intensivists.

In this tradition, fellows’ teaching skills are also nurtured. Fellows are given graduated teaching and leadership responsibilities during ICU rotations. Our program has a fellows-as-teachers curriculum that is intended to provide fellows with clinical teaching skills and more broadly applicable skills in ICU team leadership and supervision.

Finally, fellows have a role in educating one in another through our various didactic activities.

Fellows are encouraged at all stages of their training to participate in investigative projects and are expected to become associated with research being done in Pulmonary, Critical Care & Sleep Medicine or related divisions and departments.

Dedicated research blocks are provided during the second and third year of training. Several well-equipped laboratories are associated with the Division, including the Cardiovascular Research Center and the Pulmonary and Physiology Laboratories at the VA Medical Center.

A monthly “research in progress” (RIP) conference is attended by faculty and fellows. Fellows are taught basics of clinical research, trial design, medical and abstract writing and guided through the formulation of clinical questions. This conference provides a forum for fellows and faculty to update the division on currently running trials, ask and answer questions and be an avenue for fellows to join ongoing projects.

Our division has a dedicated cadre of outstanding research coordinators, and thus fellows can be supported in protocol development, IRB submission, and data collection and organization. Moreover, the Department of Medicine supports fellows’ research in other ways, such as by supporting free in-house biostatistical consultation services and centralized grant application processes.

Our recent fellows routinely present abstracts and posters at national meetings, and there are opportunities to develop large projects with the goal of peer-reviewed manuscript publication. In addition, fellows have successfully written textbook chapters and review articles during their research time.

Core Series
In the first two months of training, fellows will attend core sessions focusing on the most common disorders encountered in critical care, ventilator management, hemodynamics, key topics in physiology, and the basics of critical care echocardiography. New fellows also attend workshops on various ICU procedures, airway management, bronchoscopy and pulmonary function testing during an orientation block held in the first two weeks of July; all clinical duties are excused during this time.

Friday Conference
Each Friday fellows attend a dedicated and protected educational conference built around a three year curriculum in Pulmonary and sleep medicine, Critical Care and board review. Lectures are presented by the department’s faculty in addition to numerous guest lecturers providing focused expertise in their area of clinical excellence.

Advanced Critical Care Physiology
One of the primary goals of our training is to inculcate fellows with a deep appreciation and understanding of the complex physiology of critical illness. Thus, we hold monthly sessions on various physiology topics that include a mix of lecture, interactive learning, and bedside teaching. Selected topics include cardiopulmonary interactions, optimizing PEEP, abdominal pressure and its contribution to cardiac and pulmonary physiology, and cerebral blood flow regulation. Our teaching faculty regularly present physiology-focused “chalk talks” at the bedside or immediately after rounds, thereby solidifying these concepts in real time with real patients.

Echocardiography
We are in the process of expanding our existing didactic sessions into dedicated 2-week rotations in critical care ultrasound and critical care echo (CCE). Our goal is to have all Pulmonary and critical care medicine fellows who graduate after 2020 to have sufficient CCE training to sit for the National Board of Echocardiography CCE boards.
Our current curriculum includes a mix of lectures and hands-on training focusing on cardiac and pulmonary applications of ICU ultrasonography. Advanced topics are introduced after fellows have mastered the fundamentals. In teaching CCE, we regularly integrate cardiovascular physiologic principles. Accordingly, we seek to equip fellows with more than technical competence, but we also want fellows to integrate CCE findings into the “big picture” of the patient.

Journal Club
With faculty mentorship, fellows regularly lead critical appraisal of key literature. Various formats are used including a “pro vs con” debate.

Morbidity and Mortality
Held monthly, fellows present one or more cases that highlights a patient safety issue and reviews opportunities for continuous quality improvement.