INPATIENT FACILITIES Creighton University Medical Center (CUMC). University of Nebraska Medical Center/University Hospital (UNMC)

Transcription

1 Infectious Diseases Fellowship General Description The Infectious Diseases Fellowship is a two-year postgraduate training program in the Division of Infectious Diseases of Creighton University Department of Medicine along with the Infectious Diseases Division from the University of Nebraska Medical Center and the Omaha VA Medical Center (Nebraska-Western Iowa Healthcare System). Dr. Gary L. Gorby is the Chief of Infectious Disease and is the Program Director for the Fellowship Program. Fellowship Recruitment and Selection Criteria Each year the Infectious Diseases Fellowship Program has openings for two (PGY-4 or higher) trainees with an optional third year for a research training. Positions are filled through the National Residency Match Program (NRMP) using the Electronic Residency Application Service (ERAS). This program does not accept paper applications. Thus, there are four fellows in training at any given time. In order to be eligible for acceptance into the program, the candidate must meet the following criteria: MD or DO US Citizenship, Permanent resident, or J1 Visa status Completed three years of US postgraduate training in an ACGME accredited Internal Medicine Residency Program by the time of entry into the fellowship program. Applicants must complete their ERAS applications in the fall one and one half years prior to the program start date for which they are applying. Applicants must submit all documentation through ERAS. ERAS documents include: complete CV, personal statement, USMLE Step 1, Step 2, and Step 3 scores, and four recommendation letters (including one from your Internal Medicine Residency Program Director) as well as a recent photograph. Once your ERAS file is complete, your application will be reviewed and, if qualified, candidates will offered an invitation to interview for a fellowship position. The interview is extremely important as it allows us to meet the candidate and it provides the candidate with an opportunity to meet our faculty, staff, and current fellows and to personally view our facilities. Please note: We can not consider applications from HB-1 Visa holders.

2 INPATIENT FACILITIES Creighton University Medical Center (CUMC). Creighton University Medical Center is the primary teaching hospital for Creighton University School of Medicine. The current facility was constructed in 1977 and represents a modern, up to date, fully equipped and accredited tertiary care medical center. There are 419 licensed beds with a breakdown of 397 acute care beds and 22 intermediate care beds. There are 75 intensive care unit beds and a telemetry unit for intermediate care. It is a designated shock trauma center for the Omaha metropolitan area and owns and operates a rescue helicopter which is based at the hospital. All members of the hospital staff have faculty appointments at Creighton University. All subspecialties of internal medicine are represented and include nephrology, cardiology, pulmonary medicine, allergy immunology, endocrine, metabolic, neurology, preventive medicine, rheumatology, hematology, oncology, gastroenterology, dermatology, and infectious diseases. Our regional renal dialysis center, as well as the cancer center, provide access to patients with immunocompromised states. All major surgical procedures are performed including general surgery, renal transplant surgery, organ retrieval, orthopedics, urology, cardiovascular, thoracic, neuro, plastic and reconstructive, ENT, gynecology, and ophthalmology. Other primary care services include family practice, obstetrics, and pediatrics. A full complement of support services are available including pathology, microbiology, radiology, nuclear medicine, radiation therapy, rehabilitation medicine, social services, dietary, nursing, psychiatric, pharmacy, nutritional counseling and behavior modification, bone metabolism center, diabetes center, neonatal intensive care, infertility center, hereditary cancer center, speech and audiology center, and epidemiology. The diagnostic microbiology laboratory is directed by Stephen Cavalieri, Ph.D., a full time faculty member in the Department of Medical Microbiology. Dr. Cavalieri plays a large role in training our fellows in the basics of diagnostic microbiology and virology. He also helps oversee diagnostic microbiology laboratory rounds which are made daily by the Infectious Diseases Team. The laboratory is fully equipped, computerized, and serves as the regional reference laboratory for a variety of diagnostic tests including serologic titers, antigen detection, special antimicrobial levels, serum bactericidal titers, toxin assays, and other "nonroutine" requests. The BACTEC system is used for rapid detection of bacteria and mycobacteria. In addition, research laboratories in our Creighton University Department of Medical Microbiology offer unique expertise and assistance in numerous areas. Dr. Philip Lister for evaluation of the resistance mechanisms as well as for susceptibility tests with new antimicrobials. Dr. Richard Goering performs phage typing and plasmid analysis of isolates as needed for epidemiological studies. Dr. Floyd Knoop provides expertise and assays for toxin producing strains of organisms. University of Nebraska Medical Center/University Hospital (UNMC). With a history dating back to 1869, The Nebraska Medical Center is known for excellence, innovation

3 and quality patient care. Nebraska s largest health care facility, they treated more than 26,000 inpatients and 445,000 outpatients in fiscal year As the teaching hospital for the University of Nebraska (UNMC), the 624 acute-care bed facility has an international reputation. The Nebraska Medical Center is home to one of the most reputable and well-known solid organ transplant and bone marrow transplant programs in the country. Their state-of-theart transplant programs provide comprehensive treatment for diseases that affect the liver, intestine, kidney, pancreas and heart. Founded in 1970, The Nebraska Medical Center s kidney transplant program performed the first kidney transplant in Nebraska. Since its inception in 1985, the liver transplant program has been an innovator and leader in adult and pediatric liver transplantation. In 2005, the program reached a milestone shared by very few centers in the country by performing more than 2,000 liver transplants. In 1999 the Lied Transplant Center was opened and provides UNMC researchers and multidisciplinary health care professionals greater opportunities for interaction and collaboration. In 2007 the Intestinal Transplant Program performed more intestinal transplants than any other program in the country. The Nebraska Medical Center is proud to offer one of the most respected oncology and hematology departments in the country. They are the first hospital in the state to receive the Blue Cross and Blue Shield of Nebraska, Blue Distinction Center for Complex and Rare Cancers. Only 88 other medical centers in the United States have earned the same distinction. The Antimicrobial Stewardship program at The Nebraska Medical Center has been active since August Internal Medicine subspecialties include rheumatology, cardiology, gastroenterology, hematology/oncology, infectious diseases, pulmonary medicine, geriatrics, endocrinology and neurology. All surgical subspecialties are likewise represented. Formal training programs also include family practice, pediatrics (including infectious diseases), primary care, obstetrics/gynecology, pathology, nuclear medicine, radiology, ophthalmology and psychiatry. Other than the College of Medicine, UNMC is comprised of several educational units: College of Dentistry, College of Nursing, College of Pharmacy, School of Allied Health Professions, and the Office of Graduate Studies and Research. The commitment of the University to oncologic disease is exemplified by the Eppley Institute for Research in Cancer and Allied Diseases, one of 15 National Cancer Institute research centers. Educational resources on campus include McGoogan Library, which serves as a six-state regional library. Through their online search services, fellows have access to GRATEFUL MED and MEDLINE. CD-ROM technology also allows access to many more databases. The library carries approximately 2,000 journals, including all major infectious diseases and microbiology journals.

4 The diagnostic microbiology lab is supervised Dr. Paul Fey BACTEC and MICROSCAN systems are used for bacterial cultures. Rapid identification of mycobacteria, gonococcus, and chlamydia with DNA gene probes is also available. Given the emphasis on transplants at UNMC, the clinical lab has a large mycology and mycobacterial load. Approximately 8000 fungal cultures per year are performed. Almost 300 mycobacterial cultures per month are also done, with a positivity rate of 4-5%. Finally, the lab is a regional reference lab for a tri-state area. It is currently one of only a handful of labs nationwide evaluating automated viral serology. Nebraska Western Iowa Healthcare System (VAMC). This facility was constructed in 1948 with a modern Ambulatory Care Facility added in 1987 and serves as a regional referral for veteran patients in western Iowa and the entire state of Nebraska. The Omaha VAMC is a Dean's hospital affiliated with Creighton University School of Medicine and UNMC. All physicians on staff have faculty appointments at either or both of these medical schools. The program is fully integrated at the service levels which consist of medicine, surgery, neurology, and psychiatry. The Omaha VAMC has 250 beds with a yearly average of 63.6 patient days per bed broken down as 57.3 surgical, 67.5 medical, 14.9 neurological, 76.1 psychiatric. There are 142 designated surgical beds, 15 designated neurology beds, 68 psychiatry beds and 173 designated medical beds. The surgical intensive care unit has 10 designated beds and the medical intensive care unit has 11 designated beds. The center has a renal hemodialysis and chronic ambulatory peritoneal dialysis unit. A full complement of medical subspecialties are represented including nephrology, cardiology, pulmonary medicine, allergy-immunology, endocrinology, rheumatology, hematology-oncology, gastroenterology, hepatology, dermatology, neurology, and infectious diseases. In addition to infectious diseases, other subspecialties with fellowship programs at this hospital include gastroenterology, hematology-oncology, cardiology, allergy-immunology, and pulmonary. Surgical specialties include general, thoracic, vascular, orthopedic, plastic and reconstructive, ENT, ophthalmology, neurosurgery, urology, and oral surgery. Excellent support services include pathology, radiology, (including ultrasound, computerized tomography, and MRI), nuclear medicine, rehabilitation medicine, social services, dietary, nutritional counseling, and audiology. The diagnostic microbiology laboratory is under the direction of Kim Hemrick. Ms. Hemrick provides instruction in diagnostic microbiology for our fellows, residents and medical students and oversees the daily infectious diseases team's microbiology laboratory rounds. The laboratory utilizes the Bactec and Vitek automated systems for blood cultures and rapid detection, identification and susceptibility testing of clinical isolates respectively. INPATIENT EXPERIENCE Fellows rotate at each of the three affiliated hospitals in three month blocks each year. The remaining three month block is spent on research each year. Each Infectious

5 Diseases Fellow is responsible for 5-10 patients at any given time. The Infectious Diseases Fellow is responsible for the supervision of these patients under the auspices of the attending staff. There are no infectious diseases categorical beds at CUMC, Omaha VAMC, or UNMC. The trainee serves as a consultant on all cases. Trainees participate in acute management of all patients with infectious diseases seen by the service. This includes consideration of appropriate diagnostic, therapeutic, and preventive or infection control measures as needed. As consultants, fellows communicate directly with the consulting primary physicians and with other consultants involved with the patient. In some cases, the primary physicians relinquish to the trainee the entire responsibility for ordering or performing diagnostic tests or procedures as well as for prescribing and monitoring antimicrobial therapy. Patients with chronic illnesses who require continued hospitalization are followed by the Infectious Diseases Service throughout their course to insure appropriate therapy and for educational purposes. In the course of their fellowship, trainees are exposed to virtually every type of infection with the possible exception of some rare tropical diseases. Trainee participation in staffing the Douglas County Travelers Clinic assures their familiarity with common as well as unusual diseases encountered among travelers in foreign lands. The patient mix at the major teaching hospitals complement each other. At CUMC, the trainee's experience includes community-acquired and fellow referral in an adult population whereas patients at the Omaha VAMC tend to be predominantly older male patients. UNMC provides excellent exposure to numerous immunocompromised patients with infectious complications of bone marrow and organ transplantation as well as AIDS. Fellows have the responsibility of planning appropriate diagnostic and therapeutic intervention and staff on each case. The trainee is appointed an Assistant Instructor of Medical Microbiology and of Medicine. Trainees are responsible for coordinating the consultative service and supervising the performance of both the residents and the students. As junior faculty, they participate in teaching, research, and patient care. At the Omaha VAMC trainees are responsible with attending faculty, for approval and supervision of the use of controlled antibiotics. Fellows are not required to take night call in the hospital and share call with residents for night and weekend consultations. AMBULATORY CARE FACILITIES EXPERIENCE At CUMC, outpatients are seen in the adjacent Health Professions Center of Creighton University. It is adequately staffed by competent nurses, has sufficient examining rooms to allow an efficient clinic, and provides outpatient laboratory support with rapid reporting of results. The outpatient clinic wing at the Omaha VAMC was constructed in It is a modern, fully equipped facility with excellent staffing, availability of examining rooms, and outpatient laboratory support. Outpatient intravenous therapy can be provided in this clinic and at the clinics in CUMC and UNMC.

6 The HIV Clinic at UNMC is the largest HIV clinic in a region which includes western Iowa, northern Kansas, the Dakotas as well as Nebraska. Of the 500 patients currently enrolled, approximately 11% of patients are women, 11% are black, and 3% Hispanic, reflecting the demographics of the region. A recent affiliation with the University of Minnesota will allow UNMC access to some ACTG protocols, providing the fellows exposure to advanced HIV clinical research. The Douglas County Health Department Travelers Clinic is under the professional direction of the Infectious Diseases Section, Creighton University School of Medicine. The clinic is located at Douglas County Hospital, which is across the street from the Omaha VAMC. Three months per year, each trainee helps an attending faculty member staff the clinic one afternoon each week. Travelers are counseled on malaria, yellow fever, cholera, viral hepatitis, typhoid fever, travelers diarrhea, polio, AIDS, meningococcal meningitis, rabies, tetanus, influenza, and numerous other preventable diseases. Immunization schedules are devised and malaria prophylaxis is prescribed. This clinic serves travelers each year. Returning travelers who contract tropical diseases consult our Infectious Diseases Section for diagnosis and therapy. The Infectious Diseases Service has over 2,000 outpatient visits annually between the various clinics at CUMC, Omaha VAMC, and UNMC. Trainees are responsible for the diagnosis and therapy of infectious diseases outpatients under the supervision of the attending faculty member. Continuity of care experience is maintained by Fellow participation in patient management and discussions at weekly patient care conferences. Trainees are supervised by full-time Infectious Diseases Faculty. Faculty are present and help staff all clinics. Faculty members help trainees supervise medical students and residents in the outpatient clinic. Fellows may see patients evaluated by the medical students or residents and help formulate their management plans. Each case is reviewed with the faculty member who then interviews and examines the patient. The case is discussed within the group and a decision is made regarding appropriate patient management. EDUCATIONAL PROGRAM All trainees who enter our program are expected to be competent in routine internal medicine procedures based upon their Internal Medicine Residency training program. These routine technical procedures would include such things as lumbar puncture, skin biopsy, thoracentesis, paracentesis, arthrocentesis, and needle aspiration of cutaneous or subcutaneous abscesses. An individual faculty member is responsible for daily rounds at each hospital every month. Creighton University faculty rotate their responsibility between CUMC and the Omaha VAMC. UNMC faculty supervise fellows at UNMC. Faculty rounds usually begin in the microbiology laboratory. The faculty member directs the trainee, resident and student education in the laboratory with the help of the clinical microbiologist(s). The attending faculty then reviews pertinent X-rays or other diagnostic test results with the

7 team. All patients currently followed and new consults are presented to the attending faculty by members of the team including the infectious diseases fellow, resident, or student. New patients are interviewed and examined during bedside rounds by the attending faculty followed by an indepth discussion of salient features of the case. Faculty members assign topics to the trainee and other members of the infectious diseases team for presentation on subsequent rounds. Attending rounds last an average of 4 hours per day on weekdays and 2 hours per day on weekends. First year, fellows spend 4-6 weeks in the diagnostic microbiology, virology, and immunology laboratories. During this time they are trained in the basic laboratory diagnosis of bacterial, mycobacterial, fungal, viral, chlamydia, and parasitic diseases. Fellows are given progressive clinical responsibilities and play a graduated role in patient management as their experience and knowledge progresses. Trainees are encouraged to participate in on-going educational experiences including journal clubs, research conferences, and subspecialty conferences. All fellows are expected to attend the annual Interscience Conference on Antimicrobial Agents and Chemotherapy or the annual meeting of the Infectious Diseases Society. The section of Infectious Diseases pays the fellows' expenses for this trip. The section will also pay for any additional meeting where the fellow presents a scientific paper. Fellows are expected to attend University and VAMC Infectious Diseases conferences, visiting lectureships, and symposia throughout the year. They are encouraged to take advantage of similar conferences held at the Omaha-Midwest Clinical Society and other private hospitals in the community. Fellow will also and the SHEA/CDC Training Course in Healthcare Epidemiology and the STD Update Training course. Each fellow is responsible for preparing one Infectious Diseases Case Conference monthly at the institution where they are rotating. The case conference rotations weekly between Methodist Hospital, CUMC, UNMC, and the Omaha VAMC.. This conference involves coordinating the presentation and discussion of 2-3 interesting cases to the infectious diseases physicians and clinical microbiologists of the Omaha metropolitan area. Fellows are responsible for preparing and giving informal presentations during teaching sessions for residents and students. The fellows also serve as presenters for small group case discussions as part of the yearly Medical Microbiology/Infectious Diseases course for second year medical students. The annual Creighton-University of Nebraska Infectious Diseases Symposium is a unique learning experience for the entire section. National experts are invited to speak on their areas of special expertise. Fellows are given the opportunity to meet and learn from the most distinguished leaders in Infectious Diseases. RELATED DISCIPLINES Creighton University Department of Medicine offers Subspecialty Training Programs in Pulmonary, Cardiology, Allergy/Immunology, and Infectious Diseases. The University of Nebraska Medical Center Department of Medicine has subspecialty training programs in gastroenterology, pulmonary, cardiology, hematology-oncology, and neurology. All

8 subspecialty training programs at Creighton or the University of Nebraska utilize the Omaha Veterans Affairs Medical Center, so there is significant interaction between infectious diseases trainees and other subspecialty training programs. At Creighton University Medical Center and the University of Nebraska Medical Center, trainees have the option of working electively with the Section of Infectious Diseases of the Department of Pediatrics. Dr. Archana Chatterjee, Chief of Pediatric Infectious Diseases, is committed to providing our trainees with excellent exposure to pediatric infectious diseases at the laboratory and clinical level. Faculty members from the adult and pediatric Sections of Infectious Diseases as well as private Infectious Diseases practitioners participate in the Weekly Infectious Diseases Case Conference. They provide additional instruction for Creighton University Infectious Diseases Fellows by sharing their expertise at these joint conferences. One conference each month is devoted to pediatric infectious diseases. Our trainees are invited to all infectious diseases conferences and symposia sponsored by other hospitals and institutions in Omaha. RELATIONSHIP TO THE INTERNAL MEDICINE PROGRAM Internal Medicine residents and students rotate on the Infectious Diseases Service at either CUMC, UNMC, or the Omaha VAMC on a monthly basis. As Assistant Clinical Instructors in the Department of Medicine, Infectious Diseases Fellows are responsible for both teaching and supervising the medical students and residents during this rotation. Fellows direct students and residents to pertinent articles in the current literature and help assign topics to be presented for discussion on daily rounds. Fellows supervise the performance of diagnostic procedures as needed and help teach residents and students some of the essentials of diagnostic microbiology. RESEARCH Trainees have available to them outstanding medical libraries at Creighton University, the State Medical Library at the University of Nebraska Medical Center, and a smaller but very adequate library at the Omaha Veterans Affairs Medical Center. Computer-assisted searches are available for literature review projects. All fellows participate in some form of research activity and three months per year are set aside for this. This may be a retrospective review study, prospective clinical study, or basic laboratory project. Fellows participate in all phases of investigation including development and review of protocols, data collection, data analysis, and data reporting. During clinical studies, trainees learn the requirements of Institutional Review Boards and other agencies such as the Food and Drug Administration. Fellows learn how to obtain potentially lifesaving but investigational antimicrobials from pharmaceutical firms or government agencies for use under "compassionate release" circumstances. Fellows

9 learn to compose abstracts, give scientific presentations, and write manuscripts submitted for publication in peer-reviewed journals. Fellows are mentored by faculty members for all research projects in which they participate. OTHER ASPECTS OF TRAINING The unique alignment of the Infectious Diseases Section with the Departments of Medicine and Medical Microbiology and Immunology is a distinct advantage for our trainees. As internists, section members participate in all the usual Department of Medicine clinical and educational activities. The traditionally close working relationship between the basic science and clinical faculty in the Department of Medical Microbiology and Immunology facilitates basic science instruction of our fellows. Some fellows take the opportunity to work with our basic or clinical microbiology faculty in some of their research projects. For this setting, fellows interact with post-doctoral, doctoral, and masters program graduate students. Fellows are encouraged to audit departmental graduate level courses. For fellows who expect to find themselves in unique practice settings following training, consideration is given to elective rotations that may enhance their preparation; e.g. pediatric infectious disease.