Clinical Rotations

Required inpatient rotations

There are 20 months of required inpatient rotations distributed over the three-year fellowship. The program aims for flexibility in scheduling, but typically tries to front-load clinical work. Typically, fellows have 10 months, 6 months, and 4 months of inpatient rotations in their first, second, and third years, respectively. See a typical training schedule.

There are three major inpatient rotations associated with the fellowship. Fellows spend 9 months in the various critical care units, including the MICU, SICU, and neuro-critical care units; 4 months on the Mary Hitchcock Memorial Hospital (MHMH) pulmonary consultation service; and 5 months at the White River Junction Veterans Administration Hospital (VAMC), where fellows participate in both intensive care and the inpatient pulmonary consultation service. There are also short rotations in airway management and cystic fibrosis (CF), and fellows spend 2 weeks in a ventilator-weaning facility.

• Critical Care Medicine at MHMH: Nine months of critical care medicine are scheduled as one month blocks in the MHMH intensive care unit, spread over the three years of fellowship training. These rotations provide fellows with experience in managing a broad range of critically ill patients along with abundant opportunities to perform a variety of invasive procedures. The fellows’ responsibilities include supervision of house staff in the assessment and management of critically ill patients; provision of immediate consultative services to seriously ill inpatients on medical and surgical services and in the emergency ward; and serving as the initial gatekeeper for intensive care services, including handling telephone requests from outside physicians regarding transfer into the ICU. All ICU coverage is in-house. We have eliminated all 24 hours shifts with a night coverage system.
• Inpatient Pulmonary Consultation Service at MHMH: Pulmonary training includes 4 months on the inpatient consultation service at MHMH. The primary goal of the inpatient pulmonary rotation is to develop the skills necessary for the diagnostic assessment and medical management of complex pulmonary disorders in hospitalized patients. On this service, the fellow is responsible for performing all new inpatient and emergency department consultations at MHMH, along with interpretation of PFTs and any necessary inpatient procedures. The fellow also receives urgent outpatient and outside provider calls and gives advice appropriately. Additionally, urgent outpatient evaluations and procedures are performed by the fellow with attending supervision.
• Inpatient Pulmonary Consultation Service / Critical Care Medicine at VAMC: Five months of training occurs at the Veterans Administration Medical Center in White River Junction, VT. The VAMC also affords fellows the opportunity to supervise house staff in a 7-bed combined medical-surgical intensive care unit, while simultaneously affording opportunities for both inpatient and outpatient consultations and procedures.
• Cystic fibrosis: DHMC is the designated CF center for the state of New Hampshire. During the CF rotation, fellows will care for hospitalized CF patients and participate in the multi-disciplinary CF clinic.
• Airway management: This is a 2-week rotation in the OR supervised by members of the Department of Anesthesiology. The goal is to provide a “jump start” for fellows’ airway management skills.
• Long-term Ventilator Facility: A two-week rotation at the Hospital for Special Care in New Britain, CT, will take place during a fellow's third year. During this rotation, fellows will be directly involved in the management of patients with chronic ventilator dependency.

Required outpatient rotations

In addition to inpatient responsibilities, each fellow participates in outpatient continuity clinics. Outpatient pulmonary consultation (continuity clinic) gives fellows experience with the broad spectrum of pulmonary problems seen in a tertiary care, outpatient pulmonary referral practice.

The primary goal of the outpatient rotation is the development of skills necessary for the diagnostic assessment and medical management of complex pulmonary problems outside the hospital. Although the practice is fundamentally a referral practice, the nature of the clinical problems often requires involvement of the fellow over multiple visits, sometimes extending over years.

Fellows do not have clinic responsibilities during their critical care rotations, but otherwise generally have a weekly clinic at MHMH and the VA. A typical clinic session consists of 1-2 new patient evaluations, and 2-4 follow-up visits. Fellows are expected to present all initial pulmonary outpatient evaluations to a faculty member for discussion and review. Thereafter, the fellow assumes primary responsibility for the patient. This supervised and graded responsibility is closely monitored by attending faculty.

Procedural skills

During the inpatient pulmonary rotations at MHMH and the VAMC and the bronchoscopy rotation, fellows participate in a broad range of procedures, including:

• Conventional bronchoscopy, including the opportunity to perform endobronchial ultrasound. There is also opportunity to participate in other highly-specialized interventional procedures, including navigational bronchoscopy, airway dilatation, Nd-YAG laser vaporization, argon plasma coagulation, PleurX catheter insertion, and stent placement.
• Interpretation of pulmonary function tests, including FeNO measurement, bronchoprovocation challenge and cardiopulmonary exercise testing.

Clinical time in the ICU provides opportunities for acquiring and honing skills, including:

• Insertion of central venous and dialysis catheters.
• Insertion of arterial lines
• Endotracheal intubation
• Chest tube insertion and thoracentesis
• Point-of-care ultrasound

Typical 3-year training schedule