INTRODUCTION

The goal of our program is to train physicians for academic careers in Pulmonary and Critical Care Medicine. To achieve this goal, we offer 18 months of clinical training in Pulmonary and Critical Care Medicine, followed by 18 or more months of basic or clinical research training. Academic training is accomplished by intensive, personal faculty supervision of trainees in a setting that provides well-equipped clinical and research facilities and an environment that fosters scientific inquiry.

Since the Program began nearly 50 years ago, approximately 80% of our graduates have chosen careers in full-time academic medicine and research. In addition to academic appointments in Pulmonary and Critical Care Medicine, many of our graduates have been Division Chiefs, Department Chairs, and Deans.  Our program prepares trainees intellectually and scientifically to compete successfully for extramural funding, as evidenced by the 18 NIH K-awards received by recent graduates over the last 7 years.

The Clinical Training Program at UCSF has been directed in turn by John F. Murray, Philip Hopewell, H. Benfer Kaltreider, and Stephen C. Lazarus.  Throughout this period, the Research Training Program has been directed by Jay A. Nadel.

The Training Program in Pulmonary and Critical Care Medicine at UCSF is staffed by 49 full-time faculty involved in the program’s day-to-day operation. Our internationally recognized faculty possess a broad array of clinical and research interests covering the major fields of pulmonary medicine, and lead research programs that are among the best funded in the nation. Some of the faculty are engaged exclusively in laboratory-based research, whereas others are committed to clinical activities and investigations. This mix of interests and activities promotes a balanced approach to training.

The Training Program in Pulmonary and Critical Care Medicine is based in three hospitals: Moffitt-Long Hospital (MLH), San Francisco Veterans Affairs Medical Center (SFVAMC) and San Francisco General Hospital (SFGH). Each of these hospitals provides a unique patient population and training environment, and is staffed by full-time UCSF faculty. Residents and Clinical Fellows in internal medicine and its subspecialties rotate among the three hospitals.  Talmadge King is Chairman of the Department of Medicine at UCSF and oversees the program at all 3 sites.

During the first year, fellows rotate among MLH, SFVAMC and SFGH, where they receive clinical training in pulmonary and critical care medicine, including a sleep rotation at the UCSF/Mt. Zion Hospital.

During the second year, fellows undertake 6 months of critical care medicine training at MLH and SFGH. The remainder of the second year and all of the third year are spent in research training.  Although the ACGME requirements for Pulmonary and Critical Care Medicine are met at the end of 3 years, most fellows devote at least 3 years to research training.

MLH is a 560-bed tertiary care referral center that serves Northern California and neighboring states. The hospital offers special services and procedures that attract referrals of patients with a variety of difficult diagnostic and therapeutic problems. In addition, the outpatient clinics in General Internal Medicine provide primary care to many persons in the Bay Area. This combination of referral and primary care patient populations provides a well-balanced mix for the training and clinical research programs of the institution.

Faculty and Attending Staff

Hal Chapman, M.D. is Chief of the Division of Pulmonary and Critical Care Medicine.

Stephen C. Lazarus, M.D. is Director of the Fellowship Program in Pulmonary and Critical Care Medicine

Jay A. Nadel, M.D. directs the NIH Multidisciplinary Research Training Program in Pulmonary Disease.

Members of the Pulmonary & Critical Care Medicine Attending Physician Staff at MLH include:

• Paul Blanc, MD, MPH (Chief, Division of Occupational and Environmental Medicine)
• Homer Boushey, MD (Chief, Division of Allergy)
• Carolyn Calfee, MD
• Hal Chapman, MD (Chief, Pulmonary and Critical Care Medicine Division)
• Hubert Chen, MD, MPH
• David Claman, MD (Director, Sleep Disorders Center, UCSF/Mt. Zion Hospital)
• Adams Dudley, MD, MPH
• Mark Eisner, MD
• John Fahy, MD
• Anthony Gerber, MD, PhD
• Warren Gold, MD (Director, Pulmonary Function Laboratory)
• Jeffrey Golden, MD (Chief, Bronchoscopy and Medical Lung Transplant Services)
• Steven Hays, MD
• Anh Innes, MD
• Susan Janson, DNSc (Joint appointment with School of Nursing)
• Kevin Kim, MD
• Suil Kim, MD, PhD
• Mary Ellen Kleinhenz, MD (Director, Chest Faculty Practice and Adult Cystic Fibrosis Center)
• Stephen Lazarus, MD (Director, Fellowship Training Program, Co-Director Pulmonary Function Lab)
• Lorriana Leard, MD (Director, Clinical Pulmonary Service, Assoicate Director, Fellowship Training Program)
• Mark Looney, MD
• Michael Matthay, MD (Associate Director ICU)
• Jay A. Nadel, MD (Director, Research Training Program)
• Paul Wolters, MD
• Christine Won, MD
• Prescott Woodruff, MD, MPH
• Doug White, MD

Pulmonary Consultation Service

The MLH Consultation Service is staffed by one Pulmonary Fellow, a medical resident, medical students, and an attending physician. The Fellows are primarily responsible for performing most of the consultations and for supervising the others. The Attending Physicians make rounds daily and are available at all times. There is no in-house night call for fellows but one fellow is available by telephone or long-range beeper at all times.  Weekend coverage is shared with fellows on the Pulmonary Function Laboratory and Lung Transplant rotations. Fellows may participate in the care of adults with cystic fibrosis and recipients of lung transplants.

While on the Consultation Service, fellows perform bronchoscopy, bronchoalveolar lavage and biopsy procedures under the immediate supervision of an attending physician.  Fellows also receive training in specialized interventional bronchoscopy, including stent and fiducial placement, and needle aspiration/biopsy using endobronchial ultrasound (EBUS).  Approximately 75 bronchoscopic procedures are performed each month. Biopsy specimens are reviewed with staff pathologists in the setting of a weekly teaching conference.

The MLH Department of Radiology has long emphasized chest radiology. Interaction between the Pulmonary Consultation Service and Radiology is a firmly established and valuable part of the training programs in both disciplines. Radiographic studies, including standard films, CT scans, PET scans, and magnetic resonance images are reviewed daily with a chest radiologist. In addition, images of special educational merit are viewed and discussed at the weekly Chest Radiology Conference.

Pulmonary Function Laboratory

This is a separate rotation taken by all clinical pulmonary fellows in the first year of training. During this rotation, the fellow performs and interprets tests of pulmonary function. The major emphasis of this rotation is the mastery of advanced pulmonary physiology. In addition, fellows are taught the basic mechanics and logistics of operating a pulmonary function laboratory.

Because of the nature of the patient population at MLH, sophisticated studies of respiratory function are often performed. Thus, in addition to standard screening measurements of lung volumes, flows, diffusion, and arterial blood gases, the laboratory performs inhalation-provocation testing, noninvasive and invasive exercise studies, measurements of lung mechanics, and tests of O2 and CO2 responsiveness. All screening studies are interpreted daily by the fellow and attending physician. Tests other than screening studies are performed by the fellow and supervised by an attending physician.  There is no in-house call for fellows and no telephone or beeper call during the week.  The Pulmonary Function Laboratory fellow rotates weekend on call duties with the MLH Consult Service and Transplant fellows.

Lung Transplant Service

The UCSF Lung Transplant Service is one of the top 10% in volume in the world, performing approximately 30-40 transplants per year.  The Pulmonary Fellows rotate on this multidisciplinary service staffed by Transplant Pulmonologists, Surgeons, Pharmacists, and Nurse Practitioners.  In addition to overseeing the evaluation and management of pre- and post-transplant patients, fellows gain experience in interventional bronchoscopy including transbronchial biopsies, stent placement, and dilatations.  There are specific conferences related to transplant including evaluation for listing, Pathology, and Radiology.  There is no in-house night call for fellows, but one fellow is available by telephone or long-range pager at all times.  The Transplant Fellow rotates weekend coverage with the Pulmonary Consult Service and Pulmonary Function Laboratory fellows.

Intensive Care Unit

The combined Medical-Surgical ICU at MLH is an open unit with 38 beds for critically ill adults. The unit is staffed by fellows in pulmonary and critical care medicine, residents in internal medicine, anesthesiology and surgery and by two attending physicians. Rounds are conducted daily with the attending physician, who is available at all times. Pulmonary fellows rotate through this unit as part of a 6-month critical care training program. As a part of daily rounds, imaging studies on all patients are reviewed with a staff radiologist. During the ICU rotation, fellows acquire experience and training in airway management, ventilator management, and insertion of systemic and pulmonary arterial catheters.  In addition to the Medical-Surgical ICU, fellows rotate through critical care units devoted primarily to Neurology/Neurosurgery, and Cardiology and Cardiothoracic Surgery.

~180 patients are admitted to the ICU each month. These include patients who have had cardiac surgery or other complicated surgical procedures as well as many medical patients. ~80% of patients require mechanical ventilation and 70% require invasive hemodynamic monitoring. There are morning ICU seminars four days per week.

Sleep Disorders Center

All fellows receive training in diagnosis and treatment of sleep-related disorders at the Sleep Disorders Center at Mt. Zion Hospital (which is part of the Moffitt-Long Division) under the direction of David Claman, M.D. Fellows gain additional experience in performance and interpretation of sleep studies during consultation services at the VA Medical Center and the San Francisco General Hospital.

Faculty and Attending Staff

Dr. George H. Caughey, MD is Chief of the Pulmonary and Critical Care Medicine Section.

Members of the Pulmonary & Critical Care Medicine Attending Physician Staff at SFVAMC include:

• Mehrdad Arjomandi, MD
• James K. Brown MD (Direct of Chest Clinic, PF Lab, & Sleep Apnea Program)
• Hubert Chen, MD, MPH
• Lisa Chen, MD
• R. Adams Dudley, MD, MBA
• James Frank, MD (MICU Director)
• Dr. Charles Gherman, MD
• Anh Innes, MD
• Meshell Johnson, MD
• Suil Kim, MD, PhD
• George Su, MD
• Leslie Zimmerman, MD (Director of ICU and Bronchoscopy)

The two clinical rotations for first-year pulmonary fellows at VAMC are:

Pulmonary Consultation Service

Working one-on-one with an attending pulmonary physician, fellows on this rotation serve as inpatient consultants for the Medical and Surgical Services. In addition, they provide rapid turn-around evaluations in ambulatory care for patients referred for lung cancer and receive intensive instruction in performing bronchoscopic procedures including bronchoalveolar lavage as well as transbronchial, airway mucosal, and Wang needle biopsies. At weekly meetings, biopsies are reviewed with a pathologist, and diagnostic and therapeutic approaches are discussed at a Medical-Surgical-Oncologic Chest Conference. Fellows also receive instruction in interpretation of chest imaging studies from a chest radiologist and are responsible for reviewing sleep and pulmonary function studies.

ICU Team

Under a new closed-unit model, the ICU Team provides comprehensive care for MICU patients and participates actively and daily in the care of SICU patients. Two faculty members serve as attendings at all times, usually one pulmonologist and one surgeon or anesthesiologist. The pulmonary fellow on this rotation works with 3 UCSF medical residents, 1 surgical resident, and 1 anesthesiology resident to provide a multidisciplinary approach to the care of these patients.

Consultation and Diagnostic Service

The SFGH Pulmonary Consultation Service is staffed by two Fellows and an Attending Physician. Often there is a senior internal medicine resident and a medical student on the service as well. The fellow is responsible for organizing the daily activities of the service and for immediate supervision of the resident and student. Approximately 50 new consultations are seen each month. In addition, ~60 patients per month with known or suspected HIV infection undergo screening evaluations for respiratory complaints. The majority of these latter patients do not require full consultation or bronchoscopic procedures. ~20 full consultations each month involve HIV-infected patients.

There are daily rounds with the attending physician, who is available at all times. Fellows do not take in-house call, but are available by telephone or beeper. In addition, there are daily rounds with an attending chest radiologist to review all radiographic studies performed on patients being seen by the Consultation Service and all patients in the Medical ICU. There is a very close working relationship between the Department of Radiology at SFGH and the Consultation and ICU services. While on the consultation service the fellow is responsible for performing bronchoscopies under the immediate supervision of an attending physician. Approximately 30 bronchoscopic procedures are performed each month, of which ~50% are for evaluation of known or suspected HIV-related disease. Biopsies are reviewed on a regular basis with staff pathologists, and there are weekly pathology and surgical conferences.

The fellows are responsible for performing special studies of lung function and for interpreting all routine pulmonary function tests and screening sleep studies. These studies are reviewed daily with an attending physician.

Medical Intensive Care Unit

The pulmonary fellows are responsible for consultation in the Medical ICU. The ICU is staffed by three senior medical residents and an attending physician. Primary responsibility for patient care remains with the ward housestaff team and they are supervised in all aspects of patient care by the ICU resident and attending who is the physician of record for each patient admitted to the unit. There are ~50 admissions each month. Of these, ~50% require mechanical ventilation and ~30% undergo invasive hemodynamic monitoring. Unit rounds are scheduled twice a day. The attending physician is available at all times. The fellow also spends time with Respiratory Therapists learning details of ventilators and of overall operation of a Respiratory Therapy Department.

Outpatient Consultation Service

The Consultation Service fellows and attending physician are available daily to see outpatients for whom consultation is requested, usually from 1-3 PM. Consultations are received from a variety of community and SFGH clinics and are answered within one working day.