Section 7: Clinic Descriptions

PCCM Continuity Clinic

Rotation Director: Jeffrey Biberston, D.O.

Rotation Location: Naval Medical Center San Diego

Rotation Duration: Ongoing throughout training (typically weekly half-day sessions)

Trainees/Month: Variable

Educational Purpose and Rotation Description

During the PCCM fellowship at NMCSD, fellows participate in a continuity clinic, typically attending weekly half-day sessions. Their responsibilities include providing consultative and specialty care services for outpatients with a wide range of pulmonary and sleep disorders. This clinic environment is designed to help fellows acquire the knowledge and skills necessary for ambulatory pulmonary and sleep medicine. Exceptions to weekly clinics occur when fellows rotate outside the San Diego metropolitan area. Over 36 months of training, fellows must complete at least 24 months of continuity clinic time. The consult attending serves as the primary mentor during these clinics. Refer to the clinic matrix grid for specific clinic days and times during each rotation.

The pulmonary outpatient continuity clinic offers fellows the opportunity to evaluate, diagnose, and manage a range of pulmonary diseases. Fellows assume responsibility for a panel of adult male and female patients, overseeing all aspects of their care under the supervision of attending pulmonologists. Unless on a rotation outside San Diego (e.g., Intermountain Health or National Jewish), fellows are expected to attend 1–2 half-day clinics per week. Each clinic is typically composed of 2–3 new patients and 2–3 follow-up patients. (Each clinic includes 3 specialty consultation slots and 2 follow-up slots, although specialty slots are sometimes overridden for follow-up visits.) New patient consultations are selected to maximize educational value and expose fellows to various pulmonary conditions. Each clinic is staffed by a dedicated attending physician, who is readily available for consultation. Fellows are responsible for phone calls, prescription refills, and follow-up on laboratory and radiology studies for their patient panel. Any procedures should be scheduled outside clinic hours with appropriate staff supervision. If a fellow is unable to continue care due to absence, his or her patients will be managed by the designated “duty doc” or assigned to another physician.

ROTATION OBJECTIVES

Clinical Knowledge and Experience

Fellows should develop competence in diagnosing and managing:

Obstructive lung diseases (asthma, bronchitis, emphysema, bronchiectasis, cystic fibrosis)
Primary and metastatic pulmonary malignancies
Pulmonary infections (tuberculosis, fungal infections, infections in immunocompromised hosts)
Diffuse interstitial lung diseases
Pulmonary vascular diseases (primary/secondary pulmonary hypertension, vasculitis, hemorrhage syndromes)
Occupational and environmental lung diseases
Iatrogenic respiratory diseases (drug-induced illnesses)
Acute lung injury (radiation, inhalation, trauma)
Pulmonary manifestations of systemic diseases (e.g., collagen vascular diseases)
Respiratory failure (acute/chronic, neuromuscular respiratory drive disorders, ARDS)
Pleural and mediastinal disorders
Genetic and developmental respiratory disorders
Sleep disorders
Pulmonary issues in pregnancy
Preoperative pulmonary evaluations

Procedural Skills

Fellows should acquire knowledge of the indications, contraindications, complications, and limitations of, and gain proficiency in:

Pulmonary function testing (spirometry, flow-volume loops, lung volumes, diffusing capacity, arterial blood gases, exercise studies)
Diagnostic and therapeutic procedures (thoracentesis, pleural biopsy, flexible fiberoptic bronchoscopy, related procedures)
Examination/interpretation of sputum, bronchopulmonary secretions, pleural fluid or tissue, and lung tissue (infectious agents, cytology, histopathology)
Inhalation challenge studies
Percutaneous needle aspiration and/or cutting lung biopsy

Interpretation of Diagnostic Studies

Fellows should develop proficiency in interpreting:

Chest X-rays
Computed axial tomography (CT) scans
Radionuclide scans
Pulmonary angiograms
Other radiological procedures
Sleep studies

Core Competency Development

Fellows will enhance their knowledge, skills, attitudes, and professional attributes by:

Participating in quality improvement activities (e.g., chart review)
Responding to phone messages and notifying patients of test results promptly
Maintaining patient confidentiality (avoid discussions in public spaces)
Obtaining informed consent for all invasive procedures
Arranging appropriate follow-up during absences (leave/TAD)
Utilizing online resources for updated diagnostic and treatment recommendations
Documenting and communicating consult recommendations clearly (both in writing and in person as needed)
Complying with patient privacy regulations (e.g., HIPAA)
Completing clinic notes on the same day and returning them to medical records
Adhering to hospital guidelines when interacting with pharmaceutical or medical equipment representatives
Learning and applying clinical guidelines for common pulmonary diseases
Identifying socioeconomic and language barriers to care
Asking about tobacco use and enrolling patients in cessation programs
Staying informed with current literature (e.g., participation in journal clubs)

ACGME COMPETENCY-BASED GOALS AND OBJECTIVES BY YEAR OF TRAINING

1. Patient Care

Fellows have direct patient contact during continuity clinic rotations. They are expected to gather all pertinent data accurately, form diagnostic and therapeutic plans informed by clinical judgment and current scientific evidence, and communicate effectively with patients, families, and other healthcare professionals to ensure optimal care and outcomes.

First-Year Fellow

Independently evaluate assigned patients (history, physical exam), then discuss findings with attending staff.
Correctly interpret lab and radiology results; present organized data.
Provide ongoing follow-up care until resolution of pulmonary issues.
Develop a basic differential diagnosis for common pulmonary complaints.
Diagnose common pulmonary problems in an outpatient setting.
Ensure execution of the care plan in coordination with patients, referring providers, and other consultants.
Begin acquiring skills in diagnostic bronchoscopy.
Review selected radiology and histopathology with staff, and consult radiologists or pathologists when necessary.
Fulfill all continuity clinic responsibilities.

Second-Year Fellow

Meet all first-year goals, plus:

Demonstrate understanding of pathophysiology, clinical findings, diagnostic methods, and management principles for common pulmonary disorders.
Independently formulate a diagnostic and therapeutic plan for new consultations, supported by primary literature; present to the attending for review.
Perform diagnostic flexible bronchoscopy (if approved for the fellow’s endoscopic supervision level) with minimal staff intervention.
Gain experience in therapeutic bronchoscopy.
Assist in organizing program academic conferences.
By the end of the second year, fellows should be capable of independently and competently practicing Pulmonary Medicine.

Third-Year Fellow

Meet all second-year goals, plus:

Formulate comprehensive differentials for common and complex pulmonary complaints.
Perform diagnostic flexible bronchoscopy independently (if at the appropriate endoscopic supervision level), with staff on standby.
Gain expertise in therapeutic bronchoscopy.

2. Medical Knowledge

Fellows should approach clinical situations analytically and integrate relevant biomedical, clinical, and cognate sciences. Active participation in all pulmonary conferences is expected, and fellows should initiate discussions of scientific studies and maintain knowledge of the latest literature.

First-Year Fellow

Expand from a basic internist-level understanding of pulmonary disorders to a deeper grasp of subtle diagnostic and therapeutic issues.
Generate broad differential diagnoses for patient symptoms potentially indicating pulmonary disorders.
Formulate basic diagnostic and management plans using standard pulmonary references and faculty input.
Develop the ability to propose well-reasoned plans prior to case discussions with staff.
Understand and explain the fundamentals of evidence-based medicine.
Engage in patient-directed learning by reading textbook chapters, review articles, and performing literature searches.
Attend and present at all Pulmonary Conferences.
Demonstrate knowledge of diversity, health literacy, and healthcare disparities.

Second-Year Fellow

Meet all first-year goals, plus:

Conduct literature searches to apply the most up-to-date medical evidence to patient care.
Demonstrate advanced understanding of cultural/gender diversity, health literacy, and healthcare disparities.

Third-Year Fellow

Meet all second-year goals, plus:

Critically evaluate the latest medical literature and apply relevant findings in patient care.

3. Practice-Based Learning and Improvement

Fellows will refine patient care by critically analyzing scientific evidence and applying it to practice. They must understand study design, statistical methods, and how to incorporate evidence-based findings into individual or population-based care. Unusual cases should be discussed in morning conferences.

First-Year Fellow

Critically evaluate scientific evidence to improve patient care.
Apply evidence-based medicine principles (including knowledge of study design and statistics) to individual and population-based care.
Develop the ability to form answerable clinical questions.
Recognize the limits of personal knowledge.
Perform literature searches.
Initiate a Performance Improvement Project in the latter half of the first year, discuss it with the Program Director or designee, collect data, and implement improvements.

Second-Year Fellow

Meet all first-year goals, plus:

Efficiently perform literature searches and apply findings to patient care.
Reassess performance based on the Performance Improvement Project data, analyze the results, and present them to staff during the last quarter of the second year.

Third-Year Fellow

Continue achieving the above objectives and further refine practice-based improvements.

4. Interpersonal and Communication Skills

Fellows will communicate with patients, families, and professional associates. Emphasis is placed on creating and maintaining therapeutic, ethically sound relationships through effective listening and verbal/non-verbal communication.

First-Year Fellow

Develop the ability to interact effectively with patients and families, from initial consultation through follow-up.
Interact respectfully with residents and interns.
Communicate diagnostic and treatment plans clearly with resident teams, nurses, and support staff.
Document consult notes, follow-up notes, telephone consults, and procedural notes thoroughly and accurately.
Present data to attendings in a clear, organized manner, highlighting key issues.
Teach medical students and/or residents rotating on the service.

Second-Year Fellow

Meet all first-year goals, plus:

Learn to negotiate differences of opinion with other consult services.
Present cases to attending staff succinctly, emphasizing assessment and plan.

Third-Year Fellow

Meet all second-year goals, plus:

Lead teaching rounds, demonstrating time management, organized presentations, and the ability to prioritize effectively.

5. Professionalism

Fellows must demonstrate a commitment to professional responsibilities, treating patients respectfully, compassionately, and ethically. This includes responsiveness to patient needs, considering culture, age, gender, and disabilities.

All Fellows (1st, 2nd, and 3rd Year)

Uphold ethical principles regarding care provision, patient confidentiality, and informed consent.
Interact with patients in a compassionate, respectful, and ethical manner, mindful of cultural and individual differences.
Maintain a professional attitude, complete required documentation (MHS Genesis) within 48 hours for timely staff co-signature, and adhere to uniform and military bearing standards.
Attend to assigned duties promptly, arranging coverage if necessary.
Treat all members of the healthcare team ethically and respectfully, prioritizing patient care.

6. System-Based Practice

Fellows must understand and navigate patient care within the context of the military healthcare system. They should recognize how individual and collective professional actions affect other healthcare professionals and systems, and facilitate referrals as necessary.

First-Year Fellow

Demonstrate basic understanding of patient care within the military healthcare system.
Discuss how patient care and professional practices affect other healthcare professionals, considering system constraints.
Coordinate care to other military or civilian facilities as needed.
Navigate multiple clinical data systems confidently.
Understand limitations of referring facilities to address patient needs.
Collaborate with the pharmacy for special-order medications.
Work effectively with pulmonary support staff to schedule procedures.
Identify sources of medical errors and understand the reporting process.

Second-Year Fellow

Meet all first-year goals, plus:

Discuss balancing cost and quality of care.

Third-Year Fellow

Continue fulfilling second-year objectives.

LEARNING VENUES AND TEACHING METHODS

Direct Patient Care

Pulmonary Clinic, 3rd Floor, Building 3
Procedures Suite, 3rd Floor, Building 3
PFT Lab, 3rd Floor, Building 3

Evaluation

Staff members continuously evaluate trainees. At the end of each quarter, staff collectively provide a written evaluation of each fellow’s performance in the continuity clinic, focusing on clinical effectiveness, differential diagnostic skills, and evidence-based practice.

Active Duty CLINIC

Fellows participate in a weekly Friday morning half-day “Active Duty Clinic” during their NMCSD Consult service rotations, as well as during NMCSD elective rotations. This clinic provides care for active-duty patients with various pulmonary and sleep disorders. Fellows must complete at least 9 months of Active-Duty Clinic over the 36-month fellowship. The consult attending serves as the primary proctor. Refer to the clinic matrix grid for assignment details.

Active Duty Clinic Pulmonary Description

Rotation Director: AEA Alex, M.D.

Rotation Location: Naval Medical Center San Diego

Rotation Duration: Throughout training

Trainees/Month: Variable

Educational Purpose and Rotation Description

The pulmonary outpatient active-duty clinic allows fellows to evaluate, diagnose, and treat pulmonary diseases in active-duty military personnel. The clinic aims to streamline referral and evaluation for military members from the Southwest United States and Pacific Rim who need subspecialty pulmonary consultations. All staff physicians, the pulmonary fellow on the inpatient consult service, rotating residents/interns/students, research fellows, and fellows not currently on other clinical services are expected to participate. During clinic, pulmonary function tests, chest radiographs, and labs are performed and reviewed by physicians. Patients requiring further follow-up typically transition to the staff or fellow’s continuity clinic rather than returning to the active-duty clinic. This experience enhances the fellow’s expertise in evaluating dyspnea, chronic cough, asthma, and basic sleep-disordered breathing.

Rotation Objectives

Clinical Experience

Obstructive lung diseases (asthma, bronchitis, emphysema, bronchiectasis, cystic fibrosis)
Primary/metastatic pulmonary malignancies
Pulmonary infections (TB, fungal, immunocompromised hosts)
Diffuse interstitial lung disease
Pulmonary vascular diseases (primary/secondary pulmonary hypertension, vasculitis, hemorrhage syndromes)
Occupational/environmental lung diseases
Iatrogenic respiratory diseases (drug-induced)
Acute lung injuries (radiation, inhalation, trauma)
Pulmonary manifestations of systemic diseases (collagen vascular)
Respiratory failures (ARDS, acute/chronic failure in obstructive diseases, neuromuscular disorders)
Pleural/mediastinal disorders
Genetic/developmental respiratory disorders
Sleep disorders
Pulmonary considerations in pregnancy

Procedural Knowledge and Skills

Pulmonary function tests (spirometry, flow-volume loops, lung volumes, diffusing capacity, arterial blood gases, exercise studies)
Diagnostic/therapeutic procedures (thoracentesis, pleural biopsy, flexible bronchoscopy, related procedures)
Interpretation of sputum, pleural fluid, bronchopulmonary secretions, and lung tissue samples (infectious agents, cytology, histopathology)
Inhalation challenge studies
Percutaneous needle aspiration and/or cutting lung biopsy

Diagnostic Study Interpretation

Chest radiographs
CT scans
Radionuclide scans
Pulmonary angiograms
Other radiologic procedures
Sleep studies

Core Competency Enhancement

Participate in quality improvement (chart reviews)
Return phone messages promptly
Inform patients of test results in a timely manner
Maintain confidentiality (avoid public discussion of patients)
Obtain informed consent for invasive procedures
Arrange appropriate follow-up during absences (leave, TAD)
Use the internet and other resources to acquire current diagnostic and treatment guidelines
Communicate recommendations in writing and in person to referring physicians
Comply with HIPAA regulations
Complete clinic notes the same day and return them to medical records
Adhere to guidelines on interactions with pharmaceutical and medical equipment representatives
Learn and apply hospital/national clinical guidelines for common pulmonary diseases
Identify socioeconomic and language barriers
Screen for tobacco use (including smokeless), encourage cessation, and enroll patients in cessation programs
Keep current with the literature, including participation in journal clubs

Learning Locations and Instructional Methods

Pulmonary Department, 3rd Floor, Building 3
Procedure Suite, 3rd Floor, Building 3
Pulmonary Function Test (PFT) Lab, 3rd Floor, Building 3

Evaluation

Staff will continuously assess trainee performance. At the end of each quarter, the Program Director provides a written evaluation of each fellow’s overall effectiveness in both active-duty and continuity clinics, highlighting the fellow’s clinical practice, diagnostic decision-making, and application of evidence-based medicine.

References and Appendices

Additional resources and detailed clinic guidelines can be found in the program appendices and through the Program Director’s office.