Pulmonary, Critical Care & Sleep Medicine - Fellowship Program
The Warren Alpert Medical School of Brown University and its affiliated teaching hospitals offer a 3-4 year training program in Pulmonary and Critical Care Medicine. The medical school faculty of 30 full-time hospital-based Pulmonary/Critical Care clinicians and research scholars provide a broad and diverse environment for clinical education and research training. Four hospitals participate in the clinical program: Memorial Hospital of Rhode Island, Rhode Island Hospital, the VA Medical Center and the Miriam Hospital. Research training may be hospital based or conducted on the University campus. Four fellowship positions are offered each year for training in Pulmonary and Critical Care Medicine. Additional years for research training are encouraged. Positions for the fellowship are filled through the National Resident Matching Program for Pulmonary Diseases. Fellows who wish to pursue an academic career in Pulmonary Medicine may be eligible for fourth and fifth years of training.
The purpose of the fellowship is to prepare board eligible or certified internists for a career in clinical or academic Pulmonary and Critical Care Medicine. In all aspects of the educational program, the Fellow is encouraged to develop an attitude of scholarship and the intellectual curiosity to remain in the informational forefront of the discipline throughout his or her professional lifetime. Training is carried out in a scholarly academic atmosphere that provides a wide exposure to clinical Pulmonary and Critical Care Medicine and clinical and basic science research.
The training program is specifically designed to:
- Provide the basic and clinical knowledge to become respected consultants in Pulmonary and Critical Care Medicine
- Develop the ability to perform relevant invasive procedures
- Develop the ability to interpret pulmonary function and polysomnography tests and direct a clinical laboratory
- Develop a critical mind by pursuing investigative questions
- Develop the skills and credentials necessary to pursue a career in academic Medicine
The first 12 months of the fellowship are relatively structured and devoted to clinical activities. Fellows rotate through the core training hospitals during the first year. The curriculum includes 10 months of consultative Medicine and 2 months of Critical Care Medicine. The second year of the program is primarily devoted to either basic or clinical research under the direction of a faculty sponsor. Clinical activity continues in the outpatient department with two half-day clinics per week. The second-year fellow also provides coverage for vacationing first-year fellows. If desired, clinical electives can be arranged with the Program Director for Pediatric Pulmonology, Critical Care Medicine, Occupational Pulmonary Medicine, Thoracic Surgery and Surgical Critical Care. The third year is primarily devoted to Critical Care training in Medical ICUs, Medical/Surgical ICUs, a Respiratory Care Unit and a Neurosurgical ICU. Individuals preparing for a career in academic Medicine can seek further research training under the guidance of a Brown faculty member.
Memorial Hospital of Rhode Island serves a community of 190,000 people in Pawtucket and the surrounding Blackstone Valley region. It is the second largest teaching hospital in the state and is the recipient of nearly five million dollars in federal funds, which support research in a variety of academic disciplines. The hospital is the designated primary care affiliate of the Warren Alpert Medical School of Brown University and supports residencies in Family Medicine and Primary Internal Medicine. The pulmonary fellow, therefore, serves as a consultant to a large number of primary care specialists and trainees. The Occupational Medicine Program of the Memorial Hospital of Rhode Island has an active outpatient service and is available for elective work by our pulmonary fellows.
Rhode Island Hospital is a 721-bed tertiary care hospital with a broad spectrum of pulmonary and critical care diseases. It is the state's largest hospital and the third largest hospital in New England. The 257-bed Women & Infants Hospital on the campus of the Rhode Island Hospital provides unique educational experiences on the obstetrical and gynecologic services for pulmonary fellows. The 18-bed Medical Intensive Care Unit at Rhode Island Hospital has a high turnover of acutely ill patients with multi-system failure and was recently recognized by the National Coalition on Healthcare as one of the ten best in the country. It serves as a referral center for many hospitals throughout southern New England. Rhode Island Hospital also has an 19-bed Respiratory Care Unit. This unit is used for patients without multi-organ failure who are admitted for acute, chronic or impending respiratory failure. These patients are under the care of the pulmonary service and medical house staff. Principles of ventilatory care, weaning and pulmonary rehabilitation are emphasized during daily rounds on these patients. In addition to these units the division also administers an 11-bed neurosurgical ICU with the department of Neurosurgery. All first and second year fellows attend a once-a-week clinic at Rhode Island Hospital as part of their longitudinal experience of outpatient pulmonary care The overnight sleep laboratory affiliated with Rhode Island Hospital has received national certification from the Association of Sleep Disorders Centers. This laboratory provides unique diagnostic and research capabilities for the entire Brown community and serves referrals from the entire region.
The VA Medical Center is a 100-bed teaching hospital staffed by internal medicine residents from all of the Warren Alpert Medical School of Brown University affiliated programs. The Pulmonary Fellow is responsible for an active consultation service with consults from the Medical, Surgical and Psychiatric services. The VA system offers a unique educational experience for the pulmonary fellow by providing an environment with autonomy in decision making and a large number of patients with a variety of lung diseases willing to participate in clinical research. A large number of patients with respiratory failure are cared for in the 8-bed Medical Intensive Care/Coronary Care/Surgical Intensive Care Unit. The pulmonary fellow makes daily rounds in this ICU. The VA Medical Center has a large ambulatory pulmonary service and all first and second year fellows attend a once-a-week clinic as part of their longitudinal experience of outpatient pulmonary care. In addition, fellows consult on outpatients while rotating at the VA Medical Center.
The Miriam Hospital is an acute care general hospital in Providence and is the site of the Rhode Island state tuberculosis clinic. This program, through which the fellows rotate, has a nationally outstanding program of surveillance and care and its faculty are an important state-wide resource for issues of Mycobacterium and related diseases.
We feel that direct involvement of the fellows in a research program will greatly enhance their scholarly development, provide a foundation for logical and critical thinking, and encourage lifelong habits of continuing scholarship. One goal of this experience is to interest fellows in a career in academic Medicine. Through their research experience our fellows:
- Learn the design and interpretation of research studies
- Learn to evaluate investigative methods and the interpretation of their data
- Develop competence in critical assessment of the medical literature and of the results of their work.
The first year fellows are introduced to the research interests of the faculty at our weekly research conferences. During the early springtime of the first year, each first-year fellow will discuss projects with various faculty members and then decide on a research theme. Research opportunities are available in both clinical and basic science within the department in the areas of Sleep, Pulmonary and Critical Care Medicine. In addition, ample opportunities exist outside the department for joint research projects.
One faculty member acts as preceptor for the research project and meets frequently with the fellow to review their work. In addition, fellows and faculty meet at weekly work-in-progress seminars to discuss ongoing projects. Visiting faculty from both American and International institutions visit the Pulmonary Division as well as lecture at pulmonary research conferences. It is expected that a fellow will initiate and complete 1-2 projects during their fellowship experience. Fellows who desire to pursue an academic career are urged to stay beyond the third year to continue their research endeavors under the preceptorship of one of the faculty.
Current fellow research projects:
- PCT levels and microcirculatory abnormalities in septic patients - Dr. Richard Read (2nd year fellow); Preceptor: Dr. Mitchell Levy (Rhode Island Hospital)
- The role of endothelin-induced PKC activation in right ventricular hypertrophy - Dr. Douglas Martin (2nd year fellow); Preceptors: Dr. Elizabeth Harrington, Dr. Sharon Rounds (Providence VA Medical Center), Dr. James Klinger (Rhode Island Hospital)
- Cell cycle related changes in bone marrow-derived hematopoietic stem cells and their propensity to produce lung cells in a murine lung injury model - Dr. David Lee (2nd year fellow); Preceptors: Dr. Peter Quesenberry, Dr. Jason Aliotta (Rhode Island Hospital)
- Pulmonary hypertension in COPD - Dr. Michael Blundin (2nd year fellow); Preceptors: Dr. F. Dennis McCool (Memorial Hospital), Dr. James Klinger (Rhode Island Hospital)
Our goal is to provide an educational environment which fosters the acquisition of the necessary knowledge, skills, clinical judgment and professional attitude that is essential to the practice of Pulmonary and Critical Care Medicine. The curriculum includes:
Daily Consult Rounds: These rounds are conducted by a full-time faculty member and last approximately 3-4 hours per day. These rounds stress pulmonary physiology and its correlation to clinical Medicine. The value of various diagnostic pulmonary techniques is assessed and the fellow becomes expert in reading chest roentgenograms and other imaging procedures that relate to the lungs. A broad spectrum of pulmonary diseases is encountered and the fellow is encouraged to develop a critical analysis of clinical problems and the ability to make appropriate decisions. The fellow becomes familiar with interpretation of pulmonary function testing, modalities of respiratory therapy treatment, and interpretation of exfoliative cytology and lung biopsy material. Competence is assured in the following pulmonary techniques: thoracentesis, chest tube placement with pleurodesis and fibrinolysis, fiberoptic bronchoscopy, transbronchial lung biopsy, fluoroscopy and endotracheal intubation. All procedures are done with a full-time attending present to insure appropriate technique.
Clinical Rotations on the Critical Care Unit: This training experience is on the Medical and Surgical Intensive Care Units at Rhode Island Hospital and the VA Medical Center ICU/CCU. These units have a high turnover of acutely ill patients with multi-system failure. The care of these patients is under the direct supervision of a full-time pulmonary or critical care attending. When assigned to the unit, the pulmonary fellow makes daily rounds with the attending for 3-4 hours per day. Methods of weaning, ventilator management and hemodynamic monitoring are emphasized on daily teaching rounds.
Interventional Pulmonology: We offer extensive training for the fellows in bronchoscopy and have expanded our practice and training in interventional pulmonology. Our clinical and training experience in this field continue to grow every year. We are performing a variety of interventional bronchoscopic procedures including airway stenting, endobronchial brachytherapy, electrocautery and various biopsy techniques. In addition to these procedures, our fellows gain extensive experience with large and small chest tube placement. Fellows will also be exposed to procedures including medical thoracoscopy and endobronchial ultrasound (EBUS). Our fellows consistently graduate each having done well over a hundred bronchoscopies. The opportunity exists for post graduate studies in Interventional Pulmonology at Rhode Island Hospital after completion of the three-year Pulmonary and Critical Care Fellowship
Sleep Medicine: Sleep medicine is a major part of the training of the Pulmonary Division. There is a separate Sleep Clinic at Rhode Island Hospital that the fellows assigned to the Rhode Island Hospital ambulatory experience rotate through. The sleep patients are integrated into the Pulmonary Clinic at the VA Medical Center. Fellows that want a more extensive experience in sleep medicine may elect to do research related to sleep in their second year. The opportunity exists for post graduate studies in Sleep Medicine at Rhode Island Hospital after completion of the three-year Pulmonary and Critical Care Fellowship.
Pulmonary Function Training: While on clinical rotation, the pulmonary fellow observes the technicians as they conduct their tests. Fellows are encouraged to perform spirometry and other tests on the patients. They are responsible for placing indwelling arterial lines in those patients referred for exercise challenges. They interpret the various pulmonary function studies done in the laboratory including the results of spirometry, lung volumes, diffusing studies, arterial blood gases, exercise studies, bronchial inhalation challenges and sleep studies. A pulmonary staff physician reviews the interpretation of the pulmonary fellow on a daily basis.
Pulmonary Clinic: The fellow obtains longitudinal experience in longitudinal ambulatory care of pulmonary patients in weekly clinics at both the VA Medical Center and Rhode Island Hospital. An attending physician is available to provide on-site consultation while the Fellow is seeing his or her patients. All cases are reviewed with an attending physician. At the VA Medical Center, a pulmonary nurse practitioner works with fellows and staff to facilitate outpatient care.
Case Management Conferences: These weekly conferences are held for all fellows by the pulmonary staff. Difficult current cases are presented. The diagnosis and management of a variety of topics are discussed.
Pulmonary Grand Rounds: This weekly teaching conference is held on the Warren Alpert Medical School of Brown University campus with the entire faculty and with pulmonary specialists in the practicing community. This conference begins in September and is preceded during the summer by an introductory lecture series for the clinical fellows. The conference focuses on important topics in clinical Pulmonary Medicine through a case presentation format. Annotated bibliographies are distributed to provide an updated reference base.
Brown Pulmonary Research Seminar Series: This weekly conference is designed to allow pulmonary fellows, Brown faculty and visiting speakers to present their research to an audience that includes clinicians and researchers, both clinical and basic science. These conferences serve as an excellent forum for work-in-progress seminars.
Combined Medical/Surgical/Trauma Teaching Rounds: This conference is held twice a month at Rhode Island Hospital. The management of a variety of diseases encountered in Medical, Surgical and Trauma ICUs is discussed.
Pulmonary Oncology Conference: This multidisciplinary conference is held twice a month at Rhode Island Hospital and attracts faculty from the Divisions of Hematology/Oncology, Radiation Oncology, Thoracic Surgery, Radiology, Pathology and Pulmonary/Critical Care Medicine. Discussions focus on the management of patients with thoracic tumors.
Journal Club: Held monthly, this evidence-based medicine journal club is intended to teach fellows to evaluate critically the current literature in Pulmonary and Critical Care Medicine and assess the likelihood of it changing clinical practice.
Fellow's Radiology Conference: Fellows meet once each month with faculty from the Department of Radiology to learn about interpretation of normal and abnormal chest radiographs.
Allergy/Immunology Grand Rounds: Monthly grand rounds held at Rhode Island Hospital attracting Brown faculty members and visiting speakers.
Pediatric Pulmonary Disease: Electives can be arranged with Dr. Karen Daigle, Director of the Pediatric Pulmonary Division of Rhode Island Hospital, to familiarize fellows with lung problems unique to children. In addition, pediatric cases are reviewed during Pulmonary Grand Rounds.
Student/Resident Interactions: It is our philosophy that teaching itself is an important educational experience. Each Fellow, therefore, is encouraged to participate in the training of Internal Medicine residents and medical students in a variety of ways. For example, fellows present informal conferences to residents and medical students rotating on the pulmonary elective and also are encouraged to teach concepts in physical diagnosis to second year medical students.
Critical Care Training
Critical Care experience is a large component of our training in this program. First year fellows also spend one month in the Rhode Island Hospital Respiratory Care Unit (RICU). In addition, the fellow rotates through the VA medical center, which is a combined outpatient and inpatient Pulmonary/ICU rotation. During the second year, electives can be arranged in Critical Care Medicine. The third year of fellowship training emphasizes Critical Care Medicine. These ICUs are Medical, mixed Medical/Surgical, Neurosurgical and Respiratory Care Units. Elective time can be taken on the Coronary Care Unit, Trauma Surgery ICU, Cardiothroracic surgical ICU or at other specialized training locations.
We believe that each of the participating hospitals brings a unique aspect of Critical Care Medicine to the training program. Critical Care fellows have an in-depth experience working with critically ill medical, general surgical, cardiovascular, thoracic and neurosurgical patients. They learn to perform pulmonary artery catheterization, fiberoptic bronchoscopy, intubations, chest tube insertions and other invasive procedures. Elective rotations in the Coronary Care Unit afford the fellow an additional opportunity to learn acute care cardiology. There is a practical experience in insertion of temporary cardiac pacemakers. The fellow also becomes familiar with the insertion and monitoring of intra-aortic balloon pumps and gains experience in consulting on patients who are post-op from coronary artery bypass surgery.
Stipends and Benefits
It is expected that all first year fellows will enter the program at the PGY 4 level. Salaries for fellows are concomitant with their post graduate level. Funding arranged for fellows to attend educational conferences.
The Pulmonary and Critical Care Medicine program accepts applications through the ERAS electronic application service. We will no longer be processing independent applications by mail through our office.