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The goals of the Pulmonology and Critical Care Medicine Fellowship Program are to provide:
Both goals are equally important. The staff of the Pulmonary and Critical Care Division is committed to devoting their time and expertise to guiding you in achieving these goals.
The Department of Medicine at Tufts Medical Center has a long-standing history of excellence in patient care, teaching and research. The house staff recruited for Internal Medicine training is excellent. The professional staff consists of approximately 150 full-time faculty, 72 house officers and 145 fellows.
As a benefit of being on the main campus of TUSM, there is ample opportunity for collaboration with other Divisions and Departments on campus. Our staff currently collaborates with the Divisions of Infectious Disease, Clinical Decision Making, Hematology-Oncology and Clinical Services Research as well as other Departments such as Anesthesiology, Radiology, Surgery and Pathology.
Collaboration also occurs at the Tufts University School of Medicine, Graduate School of Biomedical Sciences at Tufts University, the USDA Human Nutrition Center on Aging and Brown University's Alpert Medical School in Rhode Island.
The Medical Intensive Care Unit Service is four months and consists of the Pulmonary/Critical Care Attending, first year fellow, three teams of two house officers each, and a fourth year Tufts University medical student. This is a closed ICU service covering the 10 bed Medical Intensive Care Unit (MICU) and medical patients admitted to the adjacent Intensive Care Units when there is overflow.
This rotation provides the fellow with broad experience in medical and neurological critical care. Emphasis is placed on the pathophysiologic basis, diagnosis and management of a broad range of diseases seen in the MICU. Additional education goals include developing technical expertise in critical care bronchoscopy, central line and pulmonary arterial catheter placement, clinical applications of ultrasonography, interpretation of hemodynamic information obtained from pulmonary artery catheters, endotracheal intubation and the application of invasive and non-invasive mechanical ventilation. The fellow will also have the opportunity to teach medical residents and medical students in the MICU setting.
Intensive care unit work rounds are conducted each morning, supervised by the MICU attending and fellow. The focus is on patient care and bedside teaching. Special emphasis is placed on teaching the principles of mechanical ventilation, respiratory and hemodynamic monitoring and critical care decision making. Afternoon rounds are conducted by the MICU fellow and provide an opportunity for the fellow to have a direct supervisory role in the MICU setting.
The case mix in the MICU service provides a broad educational exposure for the first year fellow with extensive experience gained in the management of patients with acute respiratory failure from COPD, asthma, pneumonia, pulmonary hemorrhage, neuromuscular disease and opportunistic lung infection, acute lung injury/ARDS (including application of nitric oxide therapy, prone positioning, lung protective mechanical ventilation strategy), drug overdose, sepsis/septic shock, gastrointestinal bleeding, acute and chronic hepatic failure, diabetic ketoacidosis, acute renal failure and pulmonary hypertension.
The fellow also has the opportunity to participate in a number of ongoing studies in the MICU on various aspects of mechanical ventilation including the application of non-invasive ventilation to improve weaning and extubation outcome, investigation of weaning and extubation predictors and longitudinal epidemiology studies of the outcome of mechanical ventilation. There is also active research in ARDS, the use of sedation and analgesia, end of life decision making and neuroprotective therapy in stroke.
The Inpatient Consult Service lasts three months and consists of a consult attending, consult fellow and one fourth year medical student. Consult rounds are made daily and consist of a review of previously evaluated cases and detailed discussion of new consults. Extensive time is committed to reviewing all radiographic studies (plain radiograph, computerized tomography, nuclear medicine), pathological specimens and pulmonary function test data obtained on patients evaluated by the consult service.
The multitude of reasons for pulmonary consultation provides a broad substrate for educating the first-year fellow. Reasons for consultation include preoperative pulmonary assessment, diagnosis and management of unexplained dyspnea, hypercapnia or hypoxemia, infiltrates in immunocompromised hosts, interstitial lung disease, hemoptysis, pulmonary hypertension, lung masses, pleural diseases, pulmonary embolism, sleep apnea, and difficult to manage COPD and asthma. Consults originate from medical specialty wards including infectious diseases, gastroenterology, nephrology, hematology, bone marrow transplant, oncology, cardiology and general medicine, and from non-medical specialties such as cardiothoracic surgery, orthopedics and obstetrics and gynecology.
The fellow plays a central role in the education of the house staff who request these consultations. In addition, there is ample opportunity to learn from other specialists who often are asked to consult on these complex cases. The fellow obtains significant experience with fiberoptic bronchoscopy, bronchoalveolar lavage and transbronchial biopsy.
During this rotation, the fellow performs consultations on patients in the Coronary Care Unit, Cardiothoracic Unit and Surgical ICU, and rounds on those patients with the staff. The focus of these consultations is often the management of patients with acute lung injury and weaning from mechanical ventilators. The consult service is also responsible for performing consults at the New England Sinai/Boston that provides exposure to subacute and chronic care patients requiring mechanical ventilation and patients undergoing pulmonary rehabilitation. The consult fellow is responsible for reading the pulmonary function tests and the cardiopulmonary exercise tests on a daily basis with the with the consult attending.
Lowell Intensive Care Unit Service: (two months)
First year fellows rotate through the consult service at Lowell General Hospital for two months. The case mix in this setting provides an excellent complement to the tertiary care setting of Tufts Medical Center by offering extensive exposure to an underserved patient population with a wide range of pathology.
This rotation also incorporates an airway experience in the OR at Lowell General with an emphasis on learning the basic techniques of endotracheal intubation. Finally, the fellows on this rotation also get exposure to advanced bronchoscopy/EBUS twice a week as part of the Thoracic Oncology program at Lowell General Hospital.
Electives are completed in three months.
Cardiothoracic Surgery Intensive Care Unit (CTU ICU) rotation is one month long. During this rotation, the first year rotation fellow works with the Cardiothoracic Surgery team for a total of one month. This rotation provides the fellow with comprehensive understanding to the pre-operative patient’s evaluation for cardiothoracic surgery, extensive exposure to the nature of variety cardiothoracic surgical techniques, and the post operative care of these patients during their CTS ICU stay. The fellow will also carry out CTS consultation in other ICUs.
Anesthesia is a three-week, part-time rotation that takes place at the Department of Anesthesiology at Winchester Hospital. The first year rotating fellow spends three weeks shadowing the anesthesiologists in the operative rooms. The goal of this rotation is to be able to perform adequate clinical evaluation in pre and post anesthetic period, improve intubation skills, acquire training in laryngeal mask airway placement and understand the physiology and ventilator management of the OR patients.
Pulmonary Function and Cardiopulmonary Exercise Laboratory elective is a two-week, part-time rotation. The PFT laboratory is equipped with three systems capable of doing full studies (spirometry lung volumes, diffusion and inspiratory and expiratory respiratory muscle strength evaluation), and two systems for screening spirometry.
Additional equipment is available for performing methacholine challenge studies. Approximately 2000 patients underwent PFTs in the laboratory in the past year. As part of the workup for dyspnea of unclear etiology, a number of cardiopulmonary exercise studies are performed, most of which are done with arterial lines in position.
The first-year fellow obtains expertise in the performance and interpretation of both standard pulmonary function tests and cardiopulmonary exercise tests. The laboratory is also the focus of several research projects including resting and exercise physiologic evaluation of patients undergoing bone marrow transplantation, pulmonary function in obesity and the evaluation of a possible non-invasive mechanism to measure gas exchange.
Nutrition Support Service is a two-week, part-time rotation and is combined with one of the pulmonary function laboratory rotations. During this intensive rotation, the first-year fellow participates in the evaluation of critically ill patients in both medical and non-medical intensive care units. Daily rounds are made with the ICU nutritionist and an attending physician from the USDA Human Nutrition Center. The goal is to provide the fellow with expertise in both the nutritional assessment of patients and treatment strategies using enteral or parenteral nutrition.
Echocardiography is a two week rotation deigned to train the pulmonary and critical care fellows on performing focused bedside echocardiographic studies on critical care patients in a goal-directed manner and acceptable accuracy to improve the management and the outcome of these patients.
During the elective rotations in the first year, the fellow attends the Asthma Clinic, which provides the fellow with adequate exposure to the evaluation, diagnosis and proper management of asthmatic patients.
Lowell Intensive Care Unit Service (two months) at Lowell General Hospital. Founded in 1891, Lowell General Hospital is an independent, not-for-profit community hospital serving the Greater Lowell area and surrounding communities. With two primary campuses located in Lowell, Massachusetts, Lowell General Hospital offers the latest state-of-the art technology and a full range of medical and surgical services for patients, from newborns to seniors.
Lowell General Hospital has over 400 licensed in-patient beds, and offers many outpatient services, both at the hospital and at satellite locations nearby. Currently, Lowell General is in the process of expanding critical care bed to accommodate the evolving healthcare needs of the greater Lowell community. There is a 12-bed ICU located at the Main Campus of Lowell General Hospital and a 10-bed ICU at the Saints campus.
The ICU delivers care to critically ill and injured adult patients including traumas, with a focus on cardiac, pulmonary, and unstable post-op/postpartum patients. Critical medical and surgical conditions including sepsis, cardiac, renal GI, oncology, vascular and neurosurgical diagnoses are all within the scope of services in the ICU.
Intensivists manage the majority of ICU patients with cardiologists and surgeons often consulting the intensivists in the management of their patients who need to be in the ICU. If another physician needs to admit a patient into the ICU, they transfer the care of that patient to the intensivist through a verbal hand off report for management of their critical care needs. Our daily intensivist team includes an attending physician who is board certified in critical care medicine, a critical care fellow, Nurse Practitioner (NP) and or Physician Assistant (PA). The team is present in the unit 7 days a week between 7am to 7pm.
Surgical Intensive Care Unit rotation lasts one month during the second year in the 10-bed Surgical Intensive Care Unit (SICU) at Tufts MC. The SICU team consists of a Surgical Critical Care Attending, surgical residents and fourth-year medical students. The fellow gains expertise in postoperative management and surgical critical care. The case mix consists of complex vascular and cardiothoracic procedures, transplantation (cardiac, hepatic, renal) and obesity surgery.
Sleep Medicine Rotation is a one-month rotation that includes individual lectures/workshops with the staff of the Sleep Lab, independent study from a reference list and polysomnographic record review, including overnight stay in the sleep lab. Clinical experience with outpatient assessment and follow-up takes place in the Sleep Medicine Clinic under staff supervision.
The purpose of the curriculum in sleep disorders medicine is to provide a solid foundation for pulmonologists who see patients with sleep disorders in their practice and to serve as a basis for further study in sleep medicine. The option exists for further independent study in the second and third year of training.
Lowell Intensive Care Unit Service (Third year, two months) [this rotation is just like 2nd year)
The Inpatient Consult Service (Third year, One month). Please see above for more details.
The program has a few elective clinical opportunities for trainees looking for some added clinical expertise/exposure. We have an organized Interventional Pulmonary elective at either Beth Israel Hospital or Lahey Clinic. In addition, there is the option for fellows to get extra clinical training in either Asthma or Sleep by participating in these clinics in their third year. Fellows may also arrange their own elective with approval of the program director.
Outpatient Clinics are essential to third-year fellows. Diagnostic workups are now performed in the outpatient setting whenever possible. We have structured the clinic experience to maximize exposure to a wide variety of pulmonary problems including diagnostic work-ups and disease management of obstructive lung diseases, interstitial lung diseases, pulmonary complications in the immunosuppressed patient, lung cancer and pulmonary vascular disease among others.
All fellows attend Pulmonary Clinic one half-day per week. Each clinic is staffed with a different attending physician to ensure exposure to a broad range of cases. This continuity clinic will be the fellows’ base to see patients over the entire three years of training.
In addition, fellows can attend several Pulmonary Subspecialty Clinics:
Tufts Medical Center (Tufts MC), the primary teaching hospital for Tufts University School of Medicine, is an academic medical center providing comprehensive inpatient and outpatient care in the heart of downtown Boston. The 359-bed medical center is one of only two full-service university hospitals in Boston. It has a nationally recognized staff that is committed to providing an integrated, interdisciplinary approach to the diagnosis and management of patients with complicated diseases. Tufts MC has a large and diverse research program with over $50 million of extramural funding. It is ranked among the top academic medical centers receiving National Institutes of Health (NIH) funding.
Lowell General Hospital is an independent, not-for-profit community hospital serving the Greater Lowell area and surrounding communities. With two primary campuses located in Lowell, Massachusetts, Lowell General Hospital offers the latest state-of-the art technology and a full range of medical and surgical services for patients, from newborns to seniors.
Fellows have 5 blocks of research in the second year, followed by 9 blocks of research in the third year.
The primary focus of basic research in the Division is the mechanisms of lung injury and repair. It is anticipated that this research will provide a better understanding of tissue damage and remodeling that occur in a variety of lung diseases including the respiratory distress syndrome and asthma.
Associated with lung injury and repair are tissue responses to both hypoxia and hyperoxia and actions in the lung of vasoactive substances and cytokines. These various cellular reactions are channeled through intermediate cell signaling actions which are being studied in our laboratories. We are also doing work on defining potential antigens that cause sarcoidosis.
Multiple NIH-funded projects are interwoven into the framework of this research. Official project titles include:
An NIH-funded research training grant is coupled to both the above research and other studies done through an association with the Department of Cellular and Molecular Physiology at the adjacent Tufts University School of Medicine. This grant provides salary support for fellows doing basic research and also gives fellows the option of beginning their training in the laboratory rather than on the clinical services.
Clinical Research projects in our division examine predictors of outcomes from mechanical ventilation and for patients with acute lung injury, utility of weaning and extubation predictors, effect of extubation failure on outcome and the pathophysiology of weaning and extubation.
There are several randomized controlled studies in progress including the utility of breathing pattern for weaning/extubation decision making, use of non-invasive positive pressure ventilation to facilitate weaning from mechanical ventilation and the early application of non- invasive positive pressure ventilation to prevent extubation failure. There is ongoing clinical investigation in the use of Non-Invasive Ventilation and pulmonary hypertension.
The Division has done research examining the pathophysiology of exercise limitation in patients with chronic hepatic failure and the hepatopulmonary syndrome, and using cardiopulmonary exercise testing to predict the outcome of hepatic transplantation. There is ongoing investigation into the possible mechanisms of dyspnea experienced in Obese patients and potential causes of respiratory drive changes seen in these patients.
The Division is also collaborating with the Department of Pharmacology and Experimental Therapeutics on a project examining the role of sedation in the ICU. Several clinical outcomes are being investigated such as length of mechanical ventilation, length of ICU stay, and complications of mechanical ventilation.
The Division has a close collaboration with the Bone Marrow Transplant (BMT) service at Tufts MC. In addition to providing an extensive inpatient and outpatient consultation service to those patients, we are developing a number of research protocols in this population that are both clinical and basic science oriented. They include the evaluation of respiratory muscle function post BMT, pulmonary quality of life post BMT, and also studies to determine the effect of BMT on lung injury and repair. These studies are addressing both the physiological and cellular effects of BMT on the lung parenchyma and respiratory muscles.
Several other industry-sponsored clinical projects are currently ongoing these include: Therapeutic treatment for acute lung injury, nosocomial pneumonia, pulmonary hypertension and COPD.
Boston is considered one of the most livable cities in the USA. Cultural and recreational opportunities abound thanks to the large number of colleges and museums in the area and the city’s proximity to the mountains and seashore.
Tufts MC is located in the Chinatown section of downtown Boston. We are minutes away from the historic Boston Common/Boston Public Gardens with the world-famous swan boats and within walking distance to Downtown Crossing. We are also close to Boston’s historic Faneuil Hall Marketplace and the Freedom Trail, as well as to the waterfront and Boston Harbor.
On the outskirts of Boston, you will find beaches and mountains an easy ride, and you will be just 90 minutes from beautiful Cape Cod, the mountains of New Hampshire and the seashores of Maine.
Nicholas Hill, MD - Chief
Christina Anderlind, MD
Marianne Barry, MD
Haval Chweich, MD
Maureen Dziura, MD
Barry Fanburg, MD
Anthony Faugno, MD
Erik Garpestad, MD
Maher Ghamloush, MD
Aarti Grover, MD
Khalid Ismail, MD
Sucharita Kher, MD
Michael McBrine, MD
Ioana Preston, MD
Imrana Qawi, MD
Kari Roberts, MD
Greg Schumaker, MD
Amy Simon, MD
Maher Tabba, MD
Felix Yu, MD
The Pulmonary and Critical Care Program at Tufts Medical Center participates in ERAS an electronic application process set-up by the AAMC. Therefore no formal application is needed. If you would like to forward your Curriculum Vitae to us you may do so by mail, fax or e-mail (see contact information below). Three letters of recommendation need to be submitted to ERAS to complete the application.
We do participate in the Subspecialty Match, so you also need to register at the following site: http://www.nrmp.org.
Michael McBrine, MD
As part of our philosophy of ongoing education, the Division oversees and participates in several high quality clinical and basic science conferences weekly. In addition to the conferences listed below, there are many other clinical and research conferences within TUSM and Tufts MC that are available for fellows to attend throughout the year. These include weekly medical Grand Rounds and the weekly Tupper Research Institute Seminar series, in which the staff of our Division actively participate.
Monday, 12:00 p.m. to 1:00 p.m.
Fellows present interesting and problematic cases from the inpatient and outpatient services to attendings who discuss the cases in a problem-solving format. A clinically relevant topic summary is presented by the fellow under supervision of the attending. This conference also provides a forum for fellows and attendings to discuss diagnostic and therapeutic dilemmas thus helping in the management of complicated cases. The fellow learns to critically review the literature pertaining to a topic.
Third Monday of the month at noon
Recent biopsy and cytology material is discussed with our pulmonary pathologist. Teaching cases are also used for education purposes. The fellows are responsible for a clinical and histological review of specific pathological entities in pulmonary disease.
Wednesday, 12:00 p.m. to 1:00 p.m.
This conference is dedicated largely to basic science research and is an important forum for research discussion. Speakers are drawn from the research community at Tufts University and also from other research centers in the Boston area. Invited investigators from outside the Boston area also speak at this conference or at individually arranged seminars.
This conference provides an introduction for the first year fellows to various research endeavors from cell physiology and molecular biology to gene therapy. Attendance at this conference gives fellows an understanding of the research that is being done in the Division and helps them make an informed decision about their choice of a basic research project in their second and third years. For the second and third year fellows it is a forum to present data from their projects. On the third Tuesday of each month a clinical research conference is held to discuss on-going and future projects.
During the summer and early fall this conference, which is directed toward the fellows, serves as a short introductory course and board review of the major topics in pulmonary and critical care medicine. Lectures are given by our staff members and senior fellows and also by staff from other Divisions at Tufts MC. As the year progresses, the emphasis changes and outside speakers address more specific topics in pulmonary and critical care. At regular intervals, this conference is devoted to Journal Club as well as analysis of exercise physiology and sleep studies.
Bimonthly, Wednesday, 10:00 p.m. to 11:00 p.m.
The goals of this meeting are to: (1) critically evaluate important journal articles pertaining to one’s own area of laboratory investigation; (2) keep abreast of recent advances in the cellular and molecular biology of the lung; (3) learn new techniques and approaches to biomedical research.
Fellows with an interest in pursuing an academic research career are strongly encouraged to participate and contribute. Other participants include post-doctoral fellows, research assistants and other laboratory personnel. Attendings may use this forum to discuss journal articles or to present reviews of specific subject areas related to current research being conducted in the laboratory.
In keeping with our goal of enabling each trainee to fulfill their educational goals, a monthly fellows meeting is held to discuss the all aspect of the fellowship program with the program director. In addition, fellows in the first year will meet with the Assistant Program Director also on a quarterly basis. This will provide feedback for their clinical experiences as well as initiate a discussion of research possibilities.
The fellows will be directed to attending physicians within the section who match their particular research interests to explore research opportunities. From these discussions the fellows will be asked to pick a research project and mentor by January of their first year. This will enable the fellows to begin their research project at the start of their second year. The Attending Physician with whom the fellow pursues a Research Project will remain that fellow's mentor for the remainder of the training program.
Michael McBrine, MD
Pulmonary, Critical Care + Sleep Division
Tufts Medical Center
Biewend Building, 3rd floor
800 Washington St
Boston, MA 02111