Infectious Diseases/Critical Care Track

HomeFellowship Infectious Diseases Curriculum Infectious Diseases/Critical Care Track
Our goal is to train fellows to become academic clinicians in Infectious Diseases (ID) and Critical Care Medicine (CCM), by fostering a life-long commitment to clinical care, education and scholarly pursuits.  Through the course of the 3-year training program fellows will: learn to independently diagnose and manage a broad range of infectious diseases problems in ambulatory and hospitalized patients; independently manage critically ill patients in all the ICUs; gain an in depth understanding of the pathophysiology of ID and the critically ill; and develop teaching, leadership and research skills.

At the end of the 2nd year of the program all fellows will be able to provide ID related care to patients with fever, upper respiratory, pleuropulmonary, and bronchial infections, urinary tract infections, peritonitis and other intra abdominal infections, cardiovascular infections, central nervous system infections, skin and soft tissue infections, prosthetic device infections, infections related to trauma and bites, gastrointestinal infections, bone and joint infections, infections of the reproductive organs, viral hepatitis, sepsis syndromes, nosocomial infections, HIV management and HIV-related opportunistic infections, infections in immunocompromised or neutropenic patients, infections in patients with leukemia or lymphoma, infections in geriatric patients, and infections in parenteral drug abusers. At the end of the 3rd year of the program all fellows will participate in rotations devoted to the care of the critically ill patient in different settings. The MICU team cares for critically ill patients with a broad spectrum of diseases in a multidisciplinary environment.  Apart from MICU, fellows will rotate through CCU, CVICU, NSICU, and STICU along with other elective/ semi elective rotations.

A key goal is diagnostic accuracy, appropriate utilization of radiographic and laboratory testing, and appropriate cost effective therapy. Additional goals include understanding disease pathophysiology, prevention, epidemiology, pharmacology, and the moral and ethical aspects of medicine as they relate to the infectious diseases inpatients.

Curriculum Description

The curriculum consists of six major components.
1. Inpatient Infectious Disease Consult Services,
2. Critical Care Medicine blocks (ICU),
3. Ambulatory Infectious Disease Clinics,
4.  Conference Series (ID/CCM Didactic and Case Conference),
5. Research and Scholarly Activities,
6.. Specialty Rotations (Pediatric Infectious Disease, Microbiology, Antimicrobial Stewardship, Transplant Infectious Disease/CCM, Travel medicine, Pulmonary, POCUS, Anesthesia and Public Health).  All components of the curriculum are based on the six core ACGME competencies: Patient Care; Medical Knowledge; Practice Based Learning and Improvement; Systems Based Practice; Professionalism; Interpersonal and Communication Skills.  

At the end of the fellowship it is expected that:
  • Fellows must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care as it relates to inpatient ID, CCM, HIV infected patients or patients with ambulatory infectious diseases. 
  • Fellows must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and lifelong learning as it pertains to inpatient ID, CCM, HIV infected patients or patients with ambulatory infectious diseases  
  • Fellows must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. 
  •  Fellows must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles.  
  • Fellows must demonstrate interpersonal and communication skills that result in the effective exchange of information and teaming with patients, their families, and professional associates

ACGME milestones of each component with goals and objectives

Milestones must be met by the end of 3 years of training. For each core competency fellows will have specific milestones they are expected to perform during each rotations. These are outlines on the rotation curriculum for both the ID and CC rotations.  

A fellow must demonstrate the ability to perform each of the Milestones correctly and consistently for the Clinical Competency Committee (CCC) to approve them to practice independently upon graduation.  The ACGME has created a Milestones Review Dashboard to track each fellow’s progress towards meeting the milestones and fellows can access their dashboard at any time on New Innovations.   

Inpatient Infectious Disease Consult Services: Inpatient Infectious Disease Consult Services. Training occurs at two sites the VA and PHR inpatient consult service.  By the end of the fellowship the fellow should complete between 10-12 months combined at these sites.  At these sites the fellow will see a minimum of 250 consults over the course of their fellowship. Goal: To promote fellows’ progression towards autonomous practice through training, mentoring, and clinical experience in consultative services related to the care and management of hospitalized patients with infectious diseases.

ICU rotations: Fellows will participate in a rotation devoted to the care of the critically ill patients- medical, neurosurgical, cardiac ICU, Cardiovascular surgery and surgical and trauma- at two sites VA and PHR.  The team cares for critically ill patients with a broad spectrum of diseases in a multidisciplinary environment.

Expectations during ICU rotations:

Patient care
  • Obtains relevant historical subtleties, including sensitive information that informs the differential diagnosis and modifies care plan based on clinical course 
  • Efficiently utilizes all sources of secondary data to inform differential diagnosis  
  • Recognizes and independently manages disease presentations that deviate from common patterns and require complex decision-making, incorporating diagnostic uncertainty and seek guidance/consultations
  • Appropriately manages situations requiring urgent or emergency care 
  • Consistently demonstrates technical skill to successfully and safely perform and interpret invasive procedures- in all the ICUs   
  • Consistently performs POCUS testing in a safe and effective manner 
Medical Knowledge
  • Possesses the scientific, socioeconomic, and behavioral knowledge required to provide care for complex medical conditions and comprehensive preventive care 
  • Interprets complex diagnostic tests accurately while accounting for limitations and biases 
  • Knows the indications for, and limitations of, diagnostic testing and procedures 
Systems-based Practice
  • Understands the roles and responsibilities of, and effectively partners with, all members of the team 
  • Efficiently coordinates activities of other team members to optimize care. 
  • Reflects upon and learns from own critical incidents that may lead to medical error.
Practice-based Learning & Improvement
  • Routinely reconsiders an approach to a problem, asks for help, or seeks new information 
  • Welcomes unsolicited feedback  and consistently incorporates feedback 
Professionalism
  • Demonstrates empathy, compassion, and respect to patients and caregivers in all situations
  • Prioritizes multiple competing demands in order to complete tasks and responsibilities in a timely and effective manner 
  • Actively manages challenging ethical dilemmas and conflicts of interest 

Interpersonal and Communication Skills
  • Patient-specific health records are organized, timely, accurate, comprehensive, and effectively communicate clinical reasoning 
  • Consistently and actively engages in collaborative communication with all members of the team 
  • Quickly establishes a therapeutic relationship with patients and caregivers, including persons of different socioeconomic and cultural backgrounds 

Team Leader Milestones

Effectively leading ICU team rounds requires the fellow to meet the following goals:
  • Coordinating the patient’s care plan for the day
    • Actively seeks multi-disciplinary input (Pharm, RT, Nutrition, nursing)
    • Ensures the team has a shared understanding of the care plan and assign clear responsibilities  
  • Bedside teaching
    • Over the course of the week covers topics at levels appropriate for all learners (MS-3 through PGY-3)
  • Evaluating students and residents
    • Presentation skills 
    •  Medical knowledge: using appropriate tools (ex. The Dozen Techniques) to help assess their knowledge and clinical reasoning.
  • Efficient time management
    • Is able to prioritize which patients to round on first. (Acute care needs, potential extubations, early transfers, etc.
    • Finds appropriate balance between patient care and teaching/evaluation based on the census and patient acuity. This balance changes from day to day.
    • Meet goal of completing rounds in time to attend noon conference unless critical patient care needs arise.

Ambulatory Infectious Disease Clinic:  Each fellow will have a continuity clinic throughout the duration of their fellowship. Fellows will have 1-2 session a week in the combined Ryan White HIV and Infectious Disease clinic.  The Immunology Center, managed through the USC School of Medicine, is the central coordinating body for the federally-funded Ryan White Treatment Extension Act – Part B program, serving an eight-county area in the Midlands of South Carolina.   The Immunology Center Ryan White clinic is the largest HIV/AIDS clinic in the region.  There are approximately 2000 patients currently enrolled, and about 25 new patients are seen each month. In addition to the Ryan White HIV services, the Immunology Center is the location for our general infectious disease ambulatory practice.  Held simultaneously at the same location fellows will see general infectious disease consults including hospital infectious disease follow-ups; non-Ryan White HIV consults and referrals from community physicians. Patients have a variety of infectious diseases problems, ranging from complex surgical and orthopedic infections, HIV, Hepatitis C, tropical/travel medicine, and zoonoses to general infectious diseases.

At each clinic session fellows will see on average 4-8 patients.  Fellows build their own clinic panel of patients. Over the course of the fellowship, this panel is expected to grow to more than 40 patients, ensuring adequate follow-up.  Throughout their ambulatory clinic experience fellows will follow a minimum of 25 HIV patients.

Goal: To promote fellows’ progression towards autonomous practice through 1.  training, mentoring, and clinical experience in consultative and primary care to patients living with HIV and general ambulatory infectious disease; and 2. An ambulatory continuity experience for patients initially seen on the inpatient infectious disease consults service that requires ongoing infectious disease management.  Fellows will develop an in depth understanding of the basic and clinical science aspects of ambulatory infectious disease, therapeutics, prevention, epidemiology, humanistic, moral and ethical aspects of medicine as they relate to infectious disease outpatient.  Fellows will develop skills as a consultant, and learn to autonomously diagnose and manage outpatients with a broad range of ambulatory infectious diseases problems.

Conference Series (Didactic and Case Conference):   Conference Series consists of Didactic lectures, Journal Club, Research Conferences, and Case Conferences both in ID and CCM.    List of conferences are below. 

Goal: Conferences compliment the clinical experience and provide formal instruction on all aspects of infectious disease and CCM including (but not limited to) hospital epidemiology, infection control, microbiology, infections in patients with major impairments of host defense, research methodology as well as to provide a forum to discuss up to date literature, controversy in infectious disease and CCM and medical errors and complications and management of complicated patients.
The ID conferences will be held on Wednesday and Friday 8-9 am and the CCM conferences will be help at noon on Tuesday, Wednesday and Thursday. 
 
Case Conferences (CC):.The case conference typically involves extended academic discussion and a review of the relevant literature related to a specific patient the fellow had the opportunity to care.  

Journal Club (JC): The Journal Club (JC) reviews recent and pertinent articles concerning various general ID and HIV topics.   

Mandell Review (ID didactics): These lectures will cover the breadth of ID topics expected to be seen on the inpatient consult service, or in ambulatory infectious disease/HIV clinic. This conference will also contain a series of lectures to teach fellows the basic principles of research method.

Research Meeting:  This meeting provides an opportunity to discuss potential research concepts, provide updates on ongoing research projects and review relevant new research as it pertains to infectious disease.

City Wide ID Conference:  This conference typically involves extended academic discussion and a review of the relevant literature related to a specific infectious disease case.  

Genotype Meeting: In this meeting typically difficult HIV and antiretroviral or hepatitis cases with difficult management issues are discussed.

Other Conference:  Fellows will be expected to attend relevant Resident Noon Conferences, Internal Medicine M and M or CPC conferences, Clinic Case Conference, and Grand Rounds.  

Expectations: 
  • While on ID consults the fellow will attend ID core conferences and lectures, but CCM core conferences will be strongly encouraged  
  • While on CCM blocks, the fellow will attend CCM core conferences and lectures, but ID core conferences and lectures will be strongly encouraged 
  • While on research and elective blocks, the fellow is required to attend both CCM and ID core conferences and lectures if feasible. 


Research and Scholarly Activities:  Research training is provided through the monthly Research Lecture Series, Journal Club and research mentoring.  By six months into fellowship training each fellow is expected to identify a research mentor and complete their IRB training.   Fellows are expected to participate in a research and a quality improvement project.  
At the end of the fellowship fellows are expected to demonstrate evidence of scholarly activity either through publications in a peer reviewed journal or presentation at a regional or national meeting.

Goal: is to advance the fellow’s knowledge of the basic principles of research, including how such research is conducted, evaluated, explained to patients and applied to patient care.    
 
Specialty Rotations (Pediatric Infectious Disease, Microbiology, Antimicrobial Stewardship, Infection Prevention, Anesthesia, Transplant ID/CCM, and Public Health): We offer several specialty rotations, that are not part of the ACGME requirements, but that will enhance the fellow’s training and experience.  Each fellow is expected to complete a one month rotation in Pediatric Infectious Disease (Year 1), Microbiology (Year 1) , Transplant Infectious Disease (year2) ; 2-4 weeks Antimicrobial Stewardship (Year 1 or 2),  2 weeks Anesthesia (Year 1)  and 2-4 weeks Infection Prevention (Year 1 or 2).  Additional electives and training can be arranged based on the fellow’s interest including work with the Department of Public Health, HBO, Burns, transplant CCM, travel medicine, international rotations, and M. Tuberculosis training.    

Goal:  Is to provide additional clinical experience and training in the specialty area. 

EVALUATION TOOLS
•    Direct observation
•    Chart review
•    360 multisource evaluations
•    In-service in CCM and ID 

GRADING and EVALUATION

You are evaluated by your attending physicians via New Innovations.  Milestones are evaluated by direct observation and chart stimulated recall.  The CCC also reviews multisource feedback from nursing and respiratory therapy. When completing the rotation evaluation, your attending will review each milestone and indicate one of the following:

Milestone Met: This means they observed you consistently perform the milestone appropriately.

In Progress, on pace: This indicates you are not yet able to perform the milestone consistently.  Your attending feels this is simply a reflection of the fact you haven’t had enough experience performing the milestone to consistently perform it correctly.  The feel you are performing the milestone appropriately for your level of training and anticipate you meeting the milestone by graduation.  


In Progress, with AFI’s: This indicates your attending feels you are generally on pace to meet the milestone but they have identified specific areas for improvement (AFI’s) you should focus on to ensure you meet the milestone by graduation.  Your attending is expected to describe these areas in the comment box with specific examples when possible.

Area of Concern: Your inability to perform this milestone goes beyond simple lack of experience and suggests a critical deficiency.  Again, if your attending checks this box they must provide you with specific details in the comment box and discuss these deficiencies in person with you.  

Not observed:  Your attending did not have the opportunity to observe you attempt the milestone the week they were with you.

Your attending does not make a Pass/Fail determination on your performance on your ICU rotation.  Their responsibility is to document your ability to perform the milestones listed above.  The Clinical Competency Committee makes all Pass/Fail determinations based upon each resident’s documented performance and awards credit for each rotation successfully completed.

Each fellow is asked to complete a monthly evaluation of their attending physician, as well as the rotation. These evaluations are critical in identifying opportunities for improvement within the program.  These are anonymous and reported in an aggregate report to faculty annually.