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Clinical Training at Moffitt-Long Hospital (MLH)

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.

Fellows spend one-third of their first year at MLH, during which they rotate twice through 3 different clinical services: Pulmonary Consultation Service, Pulmonary Function Laboratory, and the Lung Transplant Service.

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, needle aspiration/biopsy using endobronchial ultrasound (EBUS), and whole lung lavage. 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 with one-year survival that consistently exceeds national benchmarks. 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

There are 5 critical care units at MLH, with a combined total of 76 beds. The combined Medical-Surgical ICU at MLH is an open unit with 40 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. First-year Fellows on the Pulmonary Consultation Service see patients in the critical care units as part of this rotation. Second-year pulmonary fellows rotate through this unit as part of a 6-month critical care training program. Rounds are conducted daily with the attending physician, who is available at all times. 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.

Approximately 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. Approximately 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 participate in didactic session and receive hands-on training in the 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. and Ted Omachi, 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.