Goals and Objectives
| | | |
|[pic] | |Infectious Disease Fellowship Program |
Subspecialty Training in Infectious Disease
Policies and Procedures
Curriculum
Division of Infectious Disease
University of Nebraska Medical Center
July 2020
Table of Contents
Infectious Disease Faculty/Personnel 3
Overall Goals and Objectives 4
General Competencies 6
Facilities 9
Specific Program Organization and Content 13
Fellow Requirements 17
Research Training………………………………………………………………………………………………………..…………....18
Evaluations 21
Conferences, Travel, and Non-Program Employment 23
Fellowship Space, Equipment, Books 25
Discipline and Grievances 25
Duty Hours 26
Call Schedule Guidelines…………………………………………………………………………………………………….…......28
Supervision Policy…………………………………………………………………………………………….…………….………....32
Description of Curricula 36
Microbiology………………………………………………………………………………………………………………………..38
Inpatient Infectious Disease Consultation Service………………………...……....…………………………….41
Transplant ID ……………………………………………...........….…….……………………………………………………..44
Oncology ID…………………………………………………………………………………………………..……………..….…..48
Orthopedic ID………………………………………………………………………………………………………………….…...52
Community ID……………………………………………….………………………………………………………………….….55
Research……………………………………………………………………………………………………………………...….…..58
Infection Control/Antimicrobial Stewardship…………………………………………………………..……….....60
Outpatient ID………..……………………………………………………………………………………………………………..63
Pediatric ID…………………………………………………………………………………………………………………………..67
General ID Clinic……....................................................................................................................69
HIV Clinic…………………………………………………………………................................................................71
Appendix I – ACGME Program Requirements for Infectious Disease Fellowship
Appendix II – Evaluations
Fellow Acknowledgement
Infectious Disease Faculty
|FACULTY: For bios, visit unmc.edu/intmed/id |OTHER STAFF |
|Anum Abbas, M.B.B.S. | |
|M. Salman Ashraf, M.B.B.S. |Megan Hoesing, Program Coordinator |
|Sara Bares, M.D. |Jessica Quick, Division Administrator |
|Bradley Britigan, M.D. |Debbie VanCleave |
|Kelly Cawcutt, M.D. |Deanna Hansen |
|Nicolas Cortes-Penfield, M.D. |Regina Ueckert |
|Nada Fadul, M.D. | |
|Diana Florescu, M.D. | |
|Alison Freifeld, M.D. | |
|Andrea Green-Hines, M.D. | |
|Richard Hankins, MD | |
|Angela Hewlett, M.D. | |
|Andre Kalil, M.D. | |
|Lawler, James, MD | |
|Jasmin Marcelin, M.D. | |
|Kari Neemann, M.D. | |
|Mark Rupp, M.D., Division Chief | |
|Elizabeth Schnaubelt, M.D. | |
|Richard Starlin, M.D. | |
|Erica Stohs, M.D. | |
|Susan Swindells, M.B.B.S. | |
|Trevor Van Schooneveld, M.D., Program Director | |
|Andrea Zimmer, M.D., Associate Program Director | |
| | |
|MEDICAL PERSONNEL: | |
|Amanda Bond, PA (Oncology) | |
|Dan Cramer, ARNP (Ortho) | |
|Cassandra Day, PA (Transplant) | |
|Wendy Hamblen, RN | |
|Michelle Henrich, RN | |
|Jen Hrbek, ARNP (Transplant) | |
|Christine Tran, ARNP (HIV) | |
|Ann Fitzgerald, ARNP (HIV) | |
|Rachel Johnson, ARNP (Ortho) | |
|Whitney Knuth, ARNP (Oncology) | |
|Whitney Petersen, ARNP (Community) | |
|Kim Rhodes, ARNP (Clinic) | |
|Ryan Ross, RN | |
|Adia Sikyta, ARNP (Transplant) | |
|Jolene Tijerina, ARNP (Oncology) | |
Infectious Disease Fellowship Overall Goals and Objectives
The primary goal of the Infectious Disease Fellowship Program is for participants to acquire the skills necessary provide expert consultation and management of patients with infectious diseases. Fellows will also acquire the skills necessary to perform and interpret either clinical or basic science research. Fellows will do this through the following components:
• Acquiring an advanced understanding of infectious disease pathophysiology, epidemiology, clinical manifestations, diagnosis, therapeutic management and prevention
• Development of an independent, thoughtful, organized, and flexible approach to the evaluation of patients with symptoms and signs that suggest the presence of an infectious disease
• Development of life-long learning skills that allow the trainee to adapt to the changing spectrum of infectious diseases and their changing management, including changes in the health care system and associated technologies
• Acquiring the professional and interpersonal skills required for effective communication to primary care teams, patients, and colleagues
• Development of effective teaching skills for patients, students, residents, colleagues, and other health professionals
• Acquisition of expertise in the design, performance, analysis, and communication of scholarly activities, involving clinical, epidemiological, and/or basic science research
The ID fellowship curriculum is designed to ensure all fellows achieve proficiency in the core competencies of patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. The successful trainee will be prepared to pass the ABIM exam to become board-certified in infectious diseases.
The fellowship program is designed to give fellows wide exposure to the practice of both clinical infectious diseases and research techniques in infectious diseases. The first year of fellowship is primarily devoted to acquiring clinical proficiency in both inpatient and outpatient aspects of care. The second year is increasingly focused on research activities with continued training in managing continuity of care in the outpatient setting and ID electives. The third year of training better prepares the fellow for a career as a lifelong learner by expanding upon productive and independent research. Details of individual rotations and their goals and objectives are listed later in this curriculum document.
Objectives
All fellows completing the UNMC Infectious Disease fellowship program will be expected to:
1. Develop competence and sophistication in the following as they pertain to infectious diseases in both immunocompetent and immunocompromised patients: history, physical examination, laboratory analysis, diagnostic and therapeutic procedures, and clinical microbiology (medical knowledge and patient care).
2. Develop a substantial fund of knowledge regarding infectious diseases, including their pathophysiology, etiology, epidemiology, and clinical features; to know the optimal use of diagnostic tests to establish the presence or activity of these diseases; and to formulate an appropriate treatment plan which includes infection control protocols (medical knowledge and patient care).
3. Know the mechanisms of action, indications, contraindications, dosages, adverse effects, monitoring required, mechanisms of resistance, cost, and risk-benefit analysis of the agents used to treat infectious disease (medical knowledge, patient care, systems-based practice).
4. Develop skill in literature review, hypothesis generation, techniques of investigation, and data interpretation and presentation (medical knowledge and practice-based learning and improvement).
5. Acquire familiarity in the areas above, as they apply to the main categories of pediatric infectious disease (medical knowledge and patient care).
6. Develop a sound professionalism in providing conscientious, competent, and compassionate care for patients with infectious diseases (professionalism).
7. Possess communication skills that will allow them to work as a member or leader of a health care team (interpersonal and communication skills and systems-based practice).
8. Effectively coordinate patient care within the healthcare system (patient care, interpersonal and communication skills and systems-based practice).
9. Develop competence at communicating effectively with patients and families across a broad range of socioeconomic and cultural backgrounds; with physicians, other health professionals, and health related agencies (patient care, interpersonal and communication skills and systems-based practice).
10. Following the satisfactory completion of two years of clinical subspecialty training, all fellows who have also completed an accredited residency training in internal medicine (and hence are eligible) are also expected to take and pass the subspecialty examination in infectious diseases administered by the American Board of Internal Medicine (medical knowledge).
General Competencies
1. Patient Care
a. Goal: Fellows are expected to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.
b. Objectives: The fellow will be able to:
i. Learn the practice of health promotion, disease prevention, diagnosis, care, and treatment of men and women from adolescence to old age, during health and all stages of illness.
ii. Make informed recommendations about preventative, diagnostic, and therapeutic options and interventions that are based on clinical judgment, scientific evidence, and patient preference.
iii. Develop, negotiate, and implement effective patient management plans and integration of patient care both as a provider of infectious diseases care and consultant to others.
iv. Perform competently the procedures considered essential to the practice of infectious diseases as outlined by the American Board of Internal Medicine (ABIM) and the Accreditation Council for Graduate Medical Education (ACGME).
2. Medical Knowledge
a. Goal: Fellows are expected to demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social-behavioral sciences, as well as the application of this knowledge to patient care.
b. Objectives: Fellows will:
i. Apply an open-minded, analytical approach to acquiring new knowledge.
ii. Assess and critically evaluate current medical information and scientific evidence.
iii. Develop clinical applicable knowledge of the basic and clinical sciences that underlie the practice of infectious diseases.
iv. Apply this knowledge to clinical problem solving, clinical decision-making, and critical thinking.
v. Use their knowledge of infectious diseases to design, implement, and analyze data from independent clinical or basic research.
vi. Acquire a broad fund of knowledge of infectious diseases, their pathophysiology, epidemiology, prognosis, treatment and prevention.
3. Interpersonal and Communication Skills
a. Goals: Fellows are expected to demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals.
b. Objectives: The fellow is expected to:
i. Provide effective and professional consultation to other physicians and health care professionals and sustain therapeutic and sound professional relationships with patients, their families, and colleagues.
ii. Use effective listening, nonverbal, questioning, and narrative skills to communicate with patients and families.
iii. Interact with consultants in a respectful, appropriate manner.
iv. Maintain comprehensive, timely, and legible medical records.
v. Communicate effectively with multi-disciplinary team members, including attendings, advanced practice providers, nurses, case managers, trainees and students.
vi. Create and deliver concise, up to date, and effective discussions of basic and clinical science, bioethics, and the medical literature including the use of appropriate written and electronic teaching aids.
vii. Teach the diagnostic skills and therapeutic techniques of infectious diseases to trainees at a junior level, including other infectious disease fellows, medicine (or other specialty) residents, and medical students.
viii. Submit their research findings for publication in peer-reviewed publications, presentation at scientific meetings, and applications for research funding.
4. Professionalism
a. Goals: Infectious diseases fellows are expected to demonstrate behaviors that reflect a commitment to continuous professional development, ethical practice, and understanding and sensitivity to diversity, and a responsible attitude toward their patients, their profession and society.
b. Objectives: By completion of this program, infectious diseases fellows will be able to:
i. Demonstrate respect, compassion, integrity, and altruism in relationships with patients, families, and colleagues.
ii. Demonstrate sensitivity and responsiveness to the gender, age, culture, religion, sexual preference, socioeconomic status, beliefs, behaviors, and disabilities of patients and professional colleagues.
iii. Adhere to principles of confidentiality, scientific and academic integrity, and informed consent.
iv. Recognize and identify deficiencies in peer performance.
5. Practice-Based Learning Improvement
a. Goals: All infectious disease 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 life-long learning. It is anticipated that fellows already have an understanding of these practices through their completion of an internal medicine residency.
b. Objectives: Infectious disease fellows will build upon their previous learning and refine their skills. They will be able to:
i. Identify areas for improvement and implement strategies to enhance knowledge, skills, attitudes, and processes of care.
ii. Analyze and evaluate practice experiences and implement strategies to continually improve the quality of patient practice.
iii. Develop and maintain a willingness to learn from errors to improve the system or processes of care.
iv. Use information technology or other available methodologies to access and manage information, support patient care decisions, and enhance both patient and physician education.
v. Demonstrate the ability to organize learning opportunities including the selection of conference topics, coordinating speakers, and scheduling conferences.
vi. Incorporate formative evaluation feedback into daily practice.
6. Systems-Based Practice
a. Goals: Fellows are expected to demonstrate both an understanding of the contexts and systems in which health care is provided and the ability to apply this knowledge to improve and optimize health care.
b. Objectives: Infectious disease fellows will be able to:
i. Work effectively in various health care delivery settings and systems.
ii. Coordinate patient care within the health care system.
iii. Incorporate considerations of cost awareness and risk-benefit analysis in patient and/or population-based care as appropriate.
iv. Advocate for quality patient care and optimal patient care systems.
v. Work in interprofessional teams to enhance patient safety and improve patient care quality; and,
vi. Participate in identifying systems errors and implementing potential systems solutions.
Facilities
The educational experience afforded fellows in the internal medicine subspecialty of infectious disease occur in the following venues:
Primary training sites
a. Nebraska Medical Center (NMC)
i. Infectious disease clinics
ii. Inpatient consultation services
b. Specialty Care Center (SCC) – HIV clinic site
Optional Rotations/Secondary Training Site
a. Douglas County Health Center – STD Clinic site
b. Bellevue Medical Center - Community ID rotation
c. Madonna Rehabilitation Hospital (Omaha) – Community ID rotation
d. OrthoNebraska Hospital – Ortho ID rotation
a. Children’s Hospital and Medical Center (elective)
i. Pediatric ID
The primary training site contains inpatient facilities for acute and chronic care at primary, secondary, and tertiary levels; up to date imaging facilities; and fully equipped clinical laboratories providing service on a 24-hour basis. Rehabilitation medicine facilities are available, as are resources for all specialized tests used by infectious diseases specialists.
Specific Program Organization and Content
Inpatient Clinical Experience
The inpatient experience involves providing infectious disease consultation at NM on a variety of infectious disease services. The educational purpose is the diagnosis and management of inpatient infectious diseases and coordination of the transition of care to an outpatient setting. The teaching methods will include teaching rounds and literature reviews with interesting case presentations to the section during city wide case conferences. Patient characteristics will include adult men and women of all ages. Clinical encounters will occur in an inpatient setting. Fellows are encouraged to become involved with ancillary services and personally review all microbiology, radiology and pathology with the appropriate staff.
It is the responsibility of the infectious diseases service to provide detailed consultation for the Department of Internal Medicine and other services. Infectious disease fellows rotate on our various inpatient ID services, during which they encounter a wide variety of infectious diseases. Since the infectious disease service acts in a consultant capacity, by definition the fellows are part of a multispecialty or multidisciplinary team caring for these patients.
The infectious diseases fellow is given primary responsibility for evaluating the patient for whom the consultation was requested. The fellow then presents the case to the attending, who reviews the history, physical examination, and laboratory evaluation in detail. With the oversight of the attending physician, the fellow is responsible for developing a management plan. The subspecialty fellow thus plays a major role in the initial evaluation of the patient and interfacing with the house staff, advanced practice provider, and/or attending physician involved in direct management of the case. In addition, he/she provides reference materials to the primary team and is available to address problems of patient management. He/she follows all patients throughout their hospital course and when appropriate, afterward, in the respective outpatient clinic. The consult fellow is also on-call to consult on patients in the Emergency Room.
The infectious diseases attending will be available at all times to the infectious diseases fellow. Teaching and management rounds will be combined and include discussion regarding the interpretation of clinical data, pathophysiology, differential diagnosis, specific patient management, appropriate use of technology and incorporation of evidence and patient values in clinical decision making and disease prevention.
Schedule by Year:
Year 1: General ID (4-6 mo.), Transplant ID (1-2 mo.), Oncology ID (1-2 mo.), Microbiology (1 mo.), Research (2 mo.), Orthopedic ID (1 month)
Year 2: General ID (1 mo.), Orthopedic ID (1 mo.) Infection Control/Antimicrobial Stewardship (1 mo.), Outpatient ID (1 mo.), Research (4-5 mo.), Transplant ID/Oncology ID (3 mo.), Electives (0-2 mo.)
Optional Year 3: Research (8-10 mo.), Clinical ID Services (1-2 mo.), Electives (1-2 mo.)
Sample rotation schedule schematic:
| |Jul |Aug |Sep |Oct |Nov |
|AM |HIV Clinic | |General ID Clinic | |HIV Clinic |
|PM |HIV Clinic (2nd year | | | | |
| |fellow only) | | | | |
Clinic Schematic:
In the first and second years, fellows have approximately two and five months of research time, respectively. During these months, they do not typically have responsibility for inpatient consultations, but do continue their continuity outpatient clinics. During the third year of training, continuity clinic is optional.
Fellows will also have an outpatient ID month during their second year which will include experiences in the viral hepatitis clinic, travel medicine clinic, wound care clinic, STD clinic, subspecialty ID clinics (transplant, oncology, orthopedics, Non-tuberculous mycobacteria), cystic fibrosis clinic, and other ID related ambulatory experiences.
In all of these settings, the fellow performs his/her own complete evaluation of the patient. He/she then presents his work up to an attending infectious disease specialist, who performs his/her own independent evaluation and provides feedback and guidance to the fellow, while the two arrive at a disposition. This procedure applies for both new and follow-up patients.
Specific Program Content
The specific goals and objectives of the individual clinical rotations are listed separately in this document. Training in infectious diseases includes the development of life-long learning skills. One such skill is self-directed learning through reading, computer-based teaching tools, and the internet. The fellows have access to books, journals and software to supplement their training from lectures and clinical rotations.
Technical and Other Skills
The management of the various infectious disease conditions seen during the fellowship provides extensive experience from which the fellows acquire skill and competence in the various aspects of infectious diseases. Fellows are expected to acquire competence through a combination of instruction and clinical experience in various areas of infectious disease as outlined below.
Knowledge and Competence
| |Topic |Clinical Experience |Lecture |
|a. |Bacterial infections |X |X |
|b. |Fungal infections |X |X |
|c. |Healthcare-associated infections |X |X |
|d. |HIV/AIDS |X |X |
|e. |Infections in patients in the intensive care unit |X |X |
|f. |Infections in patients with impaired host defenses |X |X |
|g. |Infections in surgical patients |X |X |
|h. |Infections in travelers |X |X |
|i. |Parasitic infections |X |X |
|j. |Prosthetic device infections |X |X |
|k. |Sepsis syndromes |X |X |
|l. |Sexually transmitted infections |X |X |
|m. |Viral infections |X |X |
Demonstrate Knowledge:
A. Knowledge of antimicrobials including the mechanisms of action and adverse reactions of antimicrobial agents, antimicrobial and antiviral resistance, and drug-drug interactions between antimicrobial agents and other compounds
B. The appropriate use and management of antimicrobial agents in a variety of clinical settings, including the hospital, ambulatory practice, non-acute-care units, and the home
C. Appropriate procedures for specimen collection relevant to infectious diseases, including but not limited to bronchoscopy, thoracentesis, arthrocentesis, lumbar puncture, and aspiration of abscess cavities
D. Principles of prophylaxis and immunoprophylaxis to reduce incidence of infections
E. Characteristics, use, and complications of antiretroviral agents, mechanisms and clinical significance of viral resistance to antiretroviral agents, and recognition and management of opportunistic infections in patients with HIV/AIDS
F. Fundamentals of host defense and mechanisms of microorganism pathogenesis
G. Development of appropriate antibiotic utilizations and restriction policies
H. Infection control and hospital epidemiology
I. Scientific method of problems solving and evidence-based decision making
J. Indications, contraindications, limitations, complications, techniques, and interpretation of results of diagnostic and therapeutic procedures integral to infectious disease, including the appropriate indications for and use of screening tests/procedures
Formal Instruction
The following formal didactics will be incorporated and mandatory for the infectious disease fellow during all rotations and in each year of training:
1.) Core Conference – Core conferences are included in 2 components.
a. HIV Discussion Group – HIV didactic teaching and discussion will occur at 12PM on the 2nd and 4th Tuesday of each month. This conference includes not only UNMC fellows but also Pediatric ID fellows and ID fellows from Creighton University. (See Appendix A for topics)
b. Core Curriculum – Lectures covering a broad range of infectious disease topics (excluding HIV) will be held at Noon on the 1st and 3rd Thursday of the month. (See Appendix A for topics)
2.) Case Conference/City-Wide – Fellows are expected to attend weekly city-wide ID conference at its various locations, either in person or by teleconference. When conference is held at UNMC (3rd Thursday of month) fellows are expected to present. The two first-year fellows who are not on general ID and a second year fellow will present. This conference is also a quality improvement conference where errors, diagnostic difficulties, and unexpected findings are presented and discussed. The conference is multi-disciplinary and attended by pathology, microbiology, and nursing.
3.) Research Conference – conference is attended by ID division and meets once per month between September and May. A faculty member presents their completed or ongoing research projects. Each fellow present their research efforts near the end of their fellowship.
4.) ID Journal Club – meets monthly with ID division. Fellows present regularly at this conference.
5.) Infection Control/Stewardship Journal Club – meets monthly with faculty, nurses, and pharmacists involved in these areas. Fellows present regularly at this conference.
6.) Board Review – meets twice a month Sept-June. Fellows review board style questions and cases with Dr Van Schooneveld, Dr. Rupp, or Dr Zimmer.
5.) Internal Medicine Grand Rounds – this conference is sponsored by the Department of Internal Medicine and is held weekly. Infectious diseases faculty and fellows are strongly encouraged to attend.
The following is a conference schematic:
|Day |Time |Week 1 |Week 2 |Week 3 |Week 4 |Week 5 |
|Monday |12PM | |Board Review | |Board Review | |
|Tuesday |12PM |Research Conference |HIV Discussion |ID Journal Club |HIV Discussion | |
|Wednesday |12PM |IC/ASP Journal Club | | |Infection Control | |
| | | | | |Committee | |
|Thursday |8AM |Case Conf – Methodist|Case Conf - Bergan |Case Conf - UNMC |Case Conf- VAMC | |
|Thursday |12PM |Core Lecture | |Core Lecture | | |
|Friday |12:00 |IMED GR |IMED GR |IMED GR |IMED GR |IMED GR |
ID fellows have clinical experiences and/or formal instruction in the prevention, evaluation, and management of the following disorders:
A. Antimicrobial agents – mechanism of action, resistance mechanism, drug-drug interactions, spectrum of activity, monitoring parameters, and use in hospital, outpatient and other care settings
B. Microbiology – appropriate specimen collection, microbiologic techniques for organism identification, and methods for determining activity of antimicrobics
C. Disease Prevention – vaccines, prophylaxis, infection prevention and healthcare epidemiology
D. Research and Statistical Techniques – see research section
E. HIV/AIDS – Characteristics, use, and complications of antiretroviral agents, mechanisms and clinical significance of viral resistance, and recognition/management of opportunistic infections
F. Mycobacterial disease – epidemiology, clinical course, manifestations, diagnosis, treatment and prevention
G. Parasitic diseases – epidemiology, clinical course, manifestations, diagnosis, treatment and prevention
H. Common infectious syndromes –
a. Evaluation of the febrile patient, fever and rash, and FUO
b. ID Emergencies
c. Skin/Soft Tissue Infections
d. Urinary Tract Infections
e. Sepsis
f. Upper and Lower Respiratory Tract Infection
g. Peritonitis and Intra-abdominal Infections
h. Gastrointestinal Infections and Foodborne Disease
i. Cardiovascular Infections
j. Catheter-Related BSI and Other HAI’s
k. Osteomyelitis/Diabetic Foot Ulcers/Prosthetic Joint Infection
l. CNS Infections – Meningitis/Brain Abscess/Encephalitis
m. STD's and Infectious of Reproductive Organs
n. Ocular Infections
o. Infections in Immunocompromised Hosts
I. Common Pathogens
a. Malaria
b. Protozoa and Parasites
c. Herpes Viruses – CMV and other Herpes Virues
d. Viral Hepatitis
e. Respiratory Viruses and Influenza
f. Other viruses – Mumps/Rubella/Measles, Filoviruses, etc.
g. Staphylococcus aureus
h. Clostridium difficile infection
i. Endemic Fungal Infections
j. Tickborne and Rickettsial Disease
k. Tuberculosis
l. Other Mycobacterial Diseases/Nocardia
m. Zoonoses
Fellow Requirements
Inpatient consultation services
While serving on the inpatient consultation services at UNMC, the fellow is responsible for seeing all consultations requested from other physicians or other providers in a timely manner. Typically, patients will be seen, and a preliminary note written the same day the consult is requested. All patients must be seen within 24 hours, including weekends. The consult team may include Internal Medicine residents, advanced practice providers, and often students as well. The fellow should generally serve as the “team manager” and assign patients to other physicians or/and advanced practice providers for evaluation and presentation to the attending, as well as providing education to less-experienced physicians/students on the team. Rounds with the consult attending are held daily, at times set by the attending and fellow. The fellow is responsible for making sure that all trainee and student team members are present for rounds, that all consult notes by these members have been written, and that ancillary studies (culture results, imaging, pathology, special tests) are available for review by the attending. On services which also include advanced practice providers (APPs), the fellow should participate in the formation of management plan on all patients on the service, including those seen by the APPs.
The fellow is responsible for daily visits to monitor and document the progress of patients on the consultation service. These may be made by the fellow or by the resident/student who originally performed the consultation. In the latter case, the fellow should verbally review the patients’ progress with the resident/student on a daily basis. Any questions or concerns about patient management by the resident/student warrant personal evaluation of the patient by the fellow. In the case of patients hospitalized for long-term care of non-infectious disease problems, the fellow may decrease the frequency of follow-up visits or “sign-off” the case with the advance approval of the attending physician. The fellow is responsible for following up results of any tests that are pending at the time of “sign off” and should review results with the attending physician on service once they have resulted. They are also responsible for notifying the patient regarding pertinent test results and documenting the conversation and plan in the electronic health record.
The fellow is responsible for inpatient related pages and telephone calls to the infectious disease service, including consultations from the Emergency Department and outside physicians. The fellow is expected to respond to these requests in a timely and professional manner and review the information with the attending physician.
Outpatient services
Fellows assigned to the outpatient clinics at UNMC are expected to see all their assigned patients within the allotted time of the clinic. They are to be present for each clinic as scheduled, unless excused by the Program Director in advance. Fellows must notify the clinic (Ryan Ross/Deanna Hansen and attending) of all approved absences at least 8 weeks in advance. General ID clinic absence coverage should be arranged with a second-year fellow as the clinic will not be canceled if the fellow is absent.
Fellows are responsible for the out-of-clinic management of their primary patients both in the HIV and General ID clinic (e.g., lab follow up, prescription refills, phone calls, letters, etc.). Consultation with the attending physician for that clinic is always available when questions arise. When a fellow is on vacation, coverage must be pre-arranged. Clinic notes are expected to be entered promptly with completed within 24 hours of seeing the patient. Additionally, lab follow up with documentation should occur promptly (generally within 2-3 days of visit).
Conferences
All fellows are expected to attend all scheduled infectious disease teaching conferences unless they are excused. A sign-in sheet is provided, and fellows will attest that they were present for conference. Conference times are in the schedule above. Chronic tardiness is regarded as evidence of unprofessional behavior.
Description of Curricula
Clinical Microbiology, Nebraska Medicine
• This is a first-year rotation.
• Fellows spend one month rotating in clinical microbiology and participate in structured rotations at the different benches in the clinical microbiology laboratory including: primary plating, sub-culturing, susceptibility testing, blood cultures, respiratory, urines, miscellaneous, anaerobes, mycology, mycobacteriology, parasitology, virology, serology, and molecular microbiology. They learn from the medical technologists the basic principles and practices in clinical microbiology and the capabilities of our laboratory. Fellows are expected to participate in microbiology rounds with the laboratory directors and pathology residents and fellows. Dr. Paul Fey, PhD who is the laboratory director supervises this rotation.
General ID Service, Nebraska Medicine
• This is predominantly a first-year rotation.
• There may be medical students, interns and residents on this rotation.
• Fellows on General ID manage a variety of complex General ID problems including endocarditis, infections in the ICU, post-operative infections, complicated skin and soft tissue infection, highly drug-resistant infections, and other unusual clinical syndromes. Fellows on General ID serve as team leaders receiving all consults and directing residents and students. Fellows either directly evaluate or review the case with the other ID team members and make initial recommendations.
Transplant ID Service, Nebraska Medicine
• This rotation occurs during both years of the fellowship.
• There will be APPs present on this rotation
• Fellows spend the month evaluating and managing patients with all forms of solid organ transplant (heart, lung, liver, kidney, small bowel, pancreas, multivisceral) and cardiac device infections (LVAD, artificial heart, etc.). Faculty with expertise in transplant ID supervise fellows and they work with a team of physicians and APPs. First-year fellows are closely supervised by attending physicians. As fellows progress and their ability to assume more responsibility is developed, they begin to take over complete team management.
Oncology ID, Nebraska Medicine
• This rotation occurs during both years of the fellowship.
• There will be APPs present on this rotation
• Fellows spend the month evaluating and managing infections in patients with bone marrow transplant, hematologic malignancy, and other oncology problems. Faculty with expertise in oncology ID supervise fellows and they work with a team of physicians and APPs. First-year fellows are closely supervised by attending physicians. As fellows progress and their ability to assume more responsibility is developed, they begin to take over complete team management.
Orthopedic ID, Nebraska Medicine, Nebraska Orthopedic Hospital
• This rotation occurs during both years of the fellowship.
• There will be APPs present on this rotation
• Fellows spend the month evaluating and managing patients with bone and joint infections including complex osteomyelitis, prosthetic joint infection, and septic arthritis. They work closely with the orthopeadic surgery team to jointly manage these complex infection. Faculty with expertise in Orthopedic ID supervise fellows and they work with a team of physicians and APPs. First-year fellows are closely supervised by attending physicians. As fellows progress and their ability to assume more responsibility is developed, they begin to take over complete team management.
Community ID Service, Bellevue Medical Center, Madonna Rehabilitation Hospital
• This is predominantly a first-year rotation.
• There will be APPs present on this rotation
• Fellows on Community ID care for patients at a smaller community hospital and a long-term acute care hospital. While there they encounter a mix of traditional General ID problems and patients who have complex medical and ID issues requiring prolonged inpatient care. They work closely with the attending physician of the service and operate with significant autonomy.
Research, Nebraska Medicine
• This rotation occurs during both years of the fellowship.
• The fellow will work with a faculty research mentor.
• Fellows are expected to spend their time on the research rotation answering a specific question or questions. They will spend time working with their selected faculty mentor reviewing the literature, developing a hypothesis, creating a research strategy to evaluate their hypothesis, executing their planned research, analyzing the acquired data, and presenting their work both in written and verbal form. They will be supervised during their project by their selected mentor. Fellows will develop and perform their project with the guidance of their selected mentor with the goal of obtaining the skills to independently pursue research in the future. Also, fellows will meet every 6 months with the research committee who will also monitor fellow progress in their research.
Infection Control/Antimicrobial Stewardship, Nebraska Medicine
• This is a second-year rotation.
• Fellows spend one month receiving training in infection control and antimicrobial stewardship. They will spend time observing and working with the infection control practitioners and directors of healthcare epidemiology and antimicrobial stewardship. They will actively participate in stewardship rounds, develop a small project in these areas, and will take the IDSA/SHEA online course. The ID fellow is supervised at all times by the infection control practitioners with whom they are working and by the directors of healthcare epidemiology and antimicrobial stewardship.
Outpatient, Affiliated Clinics of Nebraska Medicine
• This is a second-year rotation
• Fellow will create an outpatient month elective where he/she rotates to various clinics including STD clinic, travel clinic, specialty infectious diseases clinics (oncology, transplant, NTM, orthopedic), dermatology, wound clinic, viral hepatitis clinic, and cystic fibrosis clinic. The fellow is the first to see the patient in the clinic and is responsible for generating an initial care plan and discussing the case with a faculty member.
Electives
• These are second year rotations
Pediatric ID, Nebraska Medicine and Children’s Hospital
o There may be residents, students, or other fellows on this rotation
o Fellows who desire to improve their clinical expertise in the area of pediatric infectious disease will be allowed to rotate on the Pediatric ID service. This is generally arranged as a 2 week block but could be longer is desired. Fellows are expected to be closely supervised by attending physicians in terms of consults. Dr. Andrea Green-Hines MD is the director of this rotation.
Research Training
I. Program Goals and Objectives
The overall program goal is to provide trainees with the needed competencies to independently conduct biomedical research in infectious diseases. It is expected that all infectious disease fellows at UNMC will participate in a mentored research program to meet this goal.
The UNMC Department of Medicine and Division of Infectious Diseases are fully committed to providing the required resources and research environment for the successful completion of the research portion of their training. Specific program objectives have been established for participating fellows to ensure that trainees gain core competencies in the following areas:
• Principles guiding the conduct of ethical and humane research
• Conduct of systematic literature review in focus area
• Study design
• Protocol development
• Administrative issues including IRB communications
• Data collection and data management
• Basic concepts of statistical analysis
• Data interpretation
• Report generation including abstracts / manuscripts
II. Benchmarks and requirements
a. Selection of Research Mentor(s): Selection of a research mentor is important. Fellows will meet with various ID faculty to discuss possible research projects and interests during the first 4 months of their fellowship. Fellows will also be exposed to research opportunities in the division through research conferences. Fellows will meet with a research committee every 6 months during their fellowship to provide guidance in their ongoing projects. The purpose of this committee is to assist the fellow in successfully choosing, performing and publishing their research. Fellows are expected to choose a specific area of research focus by the end of the first 6 months of the fellowship based on personal interest, faculty availability, and input from the program director and research committee. Each fellow must have a specific faculty mentor for each research project he/she is engaged in.
b. Participation in UNMC CRC research training symposium: The UNMC College of Medicine sponsors an annual one week symposium for fellows and junior faculty. The symposium covers core areas in the conduct of clinical and translational research. Infectious disease fellows will be required to participate in this program during their first year of training.
c. Report submissions: At a minimum, fellows are expected to participate in scholarly activity during the first 2 years of training by one of the following: publication of articles, book chapters, abstracts or case reports in peer-reviewed journals; publication of peer-reviewed performance improvement or education research; peer reviewed funding; peer reviewed abstracts presented at regional, state, or national specialty meetings.
d. Epidemiology: Each fellow will gain proficiency in basic epidemiology and will be required to complete a small research or quality improvement project related to infection control or antimicrobial stewardship.
It is recognized that fellows may participate in more than one study during their training period although they will be solely responsible for the conception and implementation of only one protocol. Participation in additional studies can augment exposure to different areas of research and different research methodologies and will be encouraged.
III. Resources to Support Mentored Research
Resources available to the infectious disease trainee include but are not limited to:
a. Educational resources: Additional educational resources are also available to the fellow including support for specific training activities and corresponding travel Specific requests will be considered by the program director in consultation with the research mentor / trainee. Formal Masters (MPH) training in clinical research, epidemiology, or biostatistics is available through the UNMC School of Public Health.
b. Campus-wide research resources: There are several research resources available on the UNMC campus to support pilot studies or studies conducted by trainees. The UNMC Clinical Research Center (CRC) Research Support Fund provides hospital ‘write-off’ for billable expenses related to studies. Statistical support is available through the UNMC College of Public Health.
IV. Research collaborations: In addition to the resources outlined above, the Division is actively engaged in numerous other collaborative efforts. Members of the UNMC Division of Infectious Diseases actively participate in innovative clinical and basic research in order to prevent, diagnose, and treat infections. Our fellowship program offers bench, epidemiology/outcomes and clinical trials research opportunities to fellows. Areas of research include antimicrobial stewardship, healthcare epidemiology, nosocomial and device related infections, orthopedic infections, tuberculosis, HIV, solid organ transplant, oncology ID, antimicrobial resistance, staphylococcal pathogenesis, microbial biofilms, and biopreparedness. There are multiple ongoing projects in these areas as well as many others. UNMC has a one-of-a-kind “Center for Staphylococcal Research.”
The UNMC HIV Program is as well-known for its research prowess as its clinical care. UNMC is an active participant in the Adult AIDS Clinical Trials Group (AACTG), the largest HIV clinical trials organization in the world, which plays a major role in setting standards of care for HIV infection and opportunistic diseases related to HIV/AIDS in the United States and the developed world.
V. Third year of research: An optional third year of fellowship devoted to research is strongly encouraged to prepare fellows for the rigors of conducting high quality, externally-funded research.
VI. Compliance with UNMC Data Security Policies: Fellows are expected to comply with all UNMC/TNMC computer and patient data security policies.
Evaluations
In order for the training program to assess its ability to meet its goals and objectives, it is essential that the program have an evaluation process, including formative and summative evaluations of the fellows, and an evaluation process of the program and the faculty (see Appendix II for evaluation forms).
I. Formative Evaluation of the Fellows
Formal formative evaluations occur at the completion of any substantive interaction with a specific faculty member or specific rotation. For each clinical rotation, the supervising faculty member will complete an evaluation form. All faculty must complete the form at the completion of the rotation and review their impressions directly with the fellow. All completed evaluation forms are returned to the program director and fellow for review and placed in the fellow’s permanent file.
Most evaluations are completed on New Innovations, and the program director has full access to review evaluations. Additionally, evaluations are printed and maintained in each fellow’s file. If a fellow receives a low score evaluation, the program director and program coordinator are notified by New Innovations. Furthermore, New Innovations will also send notifications about delinquent evaluations. Fellows also have access to view their completed evaluations on New Innovations.
A 360-degree evaluations will be done on each fellow every 6 months. This evaluation will be completed by nursing, ancillary staff, patients, residents and any other staff members that the fellow regularly interacts with. Additionally, fellows will complete an annual self-evaluation.
At least semi-annually, all fellows will confer individually with the program director to review all of their evaluations. This meeting is to provide feedback to the fellow on their performance and to identify areas for professional enhancement. A written summary of this session is placed in the fellow’s permanent file.
II. Clinical Competency Committee
The ACGME requires that clinical competencies committees be used to evaluate fellow progression through the recently published milestones. The role of the UNMC Clinical Competency Committee is to advise and assist the program director regarding fellow performance. Specifically, the Committee will assist and advise the Program Director in decisions regarding:
• Fellow advancement / promotion to next phase of training
• Final competency ratings for graduating fellows
• Initiation of a Performance Improvement Plan for a resident who is underperforming
• Termination or nonrenewal of a resident contract when necessary
Membership: The voting members of the Committee will consist of:
• Program Director – Trevor Van Schooneveld, MD
• Associate Program Director– Andrea Zimmer, MD
• Division Chief - Mark Rupp, MD
• Sara Bares, MD
• Program Coordinator
At least twice yearly each fellow’s performance will be reviewed by the committee. During this process, the committee will systematically review each fellow’s evaluations, adherence to policies and procedures, In-Training Exam Scores, and other available information and advise the Program Director regarding the resident’s development of competence for each ACGME competency domain. This may include recommendations to place the resident on a performance improvement plan consistent with institutional policy. Feedback of this evaluation will be provided to the fellow by the Program Director or the Associate Program Director at their 6-month evaluation.
III. Summative Evaluation of the Fellows
Fellows meet individually with the program director (and/or associate program director) at least semi-annually where feedback on their performance in both a formative and summative fashion is given. Fellows will be provided with copies of all evaluations including 360-degree evaluations, Mini-CEX evaluation, simulation evaluation, resident or peer evaluations, and evaluations completed by faculty members at the completion of each assignment. The results of the CCC discussion will be made known to the fellow and their progress on the ACGME milestones will be discussed and copy of their specific milestones will be provided. A summary evaluation will be provided. Goals for the next 6 months of fellowship will be developed with fellow input.
Any adverse judgments or evaluations regarding the fellow’s level of performance or competence should first be directed to the program director. If the fellow feels that this is not to their satisfaction, then the grievance can be addressed by established institutional policy.
IV. Evaluation of the Faculty, Rotation, and Program
For each clinical rotation, fellows are required to complete and return an evaluation form of the faculty and the rotation. Evaluations are reviewed by the program director and anonymity of the fellow will be maintained by inclusion of resident and non-UNMC fellow evaluations. Annually, a summary evaluation report will be given to every faculty member by the program director. These reports will include a large enough time frame (at least 1 year) and will include resident feedback to ensure anonymity of the fellows.
Fellows and faculty will also complete an annual evaluation of the fellowship program. These evaluations are reviewed by the program director and anonymity of fellows and faculty will be maintained. These surveys will be reviewed at the annual Program Evaluation Committee meeting which includes at least one fellow and discussed there.
The role of the Program Evaluation Committee is to formally and systematically evaluate the curriculum at least annually. Membership of this committee includes the Program Director, Program Coordinator, select faculty and at least one fellow. Specifically, the Committee will assist and advise the Program Director in:
• Planning, developing, implementing, and evaluating the education activities of the program
• Reviewing and making recommendations for revision of competency-based curriculum goals and objectives
• Addressing areas of non-compliance with ACGME/RRC standards
• Reviewing the program annually using evaluations of faculty, fellows, and others, as specified below
• Documenting the results of their review and developing a written plan of action to improve the curriculum (Program Improvement Plan) in at least one area, and delineating how it will be measured and monitored
Conferences, Travel, and Non-Program Employment
As long as funding is available, the program will send fellows to ID WEEK during their first year of fellowship. Subsequent attendance at other conferences is dependent upon fellow interest and research activity. Attendance at ID WEEK during the second and/or third year will be allowed if an abstract or case is submitted and/or accepted for presentation. If fellows would like to attend a different conference in place of ID WEEK that should be discussed with the program director and a similar expectation of submission of an abstract is present. Fellows are strongly encouraged to apply for travel grants available through the sponsoring organizations. If funding is available fellows will also attend the Society for Healthcare Epidemiology of America (SHEA) conference usually during their first year.
Fellows who participate in special research projects may wish to submit and travel to other meetings. Fellows submitting to other conferences where they are planning to present must have their submission reviewed by the program director before they submit. At that time, a plan for travel should be established with the understanding that the fellowship will not generally be supporting their travel. The fellowship may sponsor/support fellow attendance; however, this will be on a case-by-case basis and may be the responsibility of the mentor rather than the fellowship.
Attendance at industry-sponsored conferences, dinners, sporting events, etc. presents the potential for conflict of interest. In general, attendance is discouraged, unless substantial, novel educational material is being presented. Attendance at marketing or promotional conferences is highly discouraged. University funds cannot be used for travel to such events, nor can fellows attend them during official duty hours. An exception to this policy is a conference, or CME course, presented by an academic institution with industry funding as long as there is independence in the choice of speakers and topics. Attendance at these conferences must be approved through the usual vacation requests and educational is not generally approved for such events. Fellows must develop a clear sense of an ethical relationship with industry early in their careers.
In accordance with University policy, no funds are available for certification in areas not covered by the training program.
All travel for business purposes is subject to University regulations. Fellows must submit travel plans to the section education office at least one month in advance of travel. Hotel, airfare, ground transportation, meals, and other expenses are subject to limits imposed by both the University and the availability of funds. Documentation of expenses will be required for reimbursement. It is important to note that travel plans for business purposes that will require no expenses to the University must still be given to the education office one month in advance for authorization. A leave slip must be submitted for the days you will be absent due to conferences. These days will be charged as educational days. The leave slip must be approved by the program director. Advanced notice must be given to HIV clinic and other clinical services to ensure cancellation or coverage plans are implanted.
I. Non-Program Employment (Moonlighting):
The infectious disease fellowship is designed to be a full-time position. Employment outside the fellowship (“moonlighting”) is discouraged and subject to University guidelines. Such activity requires the approval of the Program Director and GME office and must not interfere with clinical or research duties. Before a fellow may participate moonlighting activities, he/she must complete a Record of Outside Employment Form and have it signed by the program director and approved by the UNMC Graduate Medical Education Office. All moonlighting activities are considered part of the 80-hour weekly limit on duty hours.
Once approval is given for moonlighting activities, it is subject to withdrawal if it is determined to interfere with the responsibilities, duties, and/or assignments of the training program. All fellows engaging in outside medical practice must have a full practice license in the state in which they are working. Fellows cannot be required to participate in outside practice. Fellows with a J1 visa are not permitted to engage in outside medical practice.
Professional Liability Insurance:
UNMC provides professional liability insurance, including tail coverage. This policy covers the fellow while providing patient care either as part of the training program or as outside medical practice that has been approved according to the paragraphs above.
Fellowship Space, Equipment, Books
Fellows have their own office space located in SSP 3029 with a dedicated computer. These computers are equipped for video conferencing. Fellows have access to specialty specific reference material through the University library with search capabilities in electronic format. In addition, there is a shared Nebraska Medicine Wellness which is available to residents and fellows of all programs.
Fellows will be provided with a copy of Mandell's Principles and Practice of Infectious Disease at the start of their fellowship. Numerous, additional ID textbooks are available in the fellow office and online through the library.
Each fellow will receive an encrypted USB drive at the start of the fellowship program to store research material and fellow talks. Additional funds for fellow education material may be available and fellows should submit requests to the program director.
Furthermore, fellows have convenient access to laboratory for clinical microbiology which is located on the 3rd floor of the Clarkson tower. Direct and frequent interaction with microbiology laboratory personnel is both readily available and expected.
The Infectious Disease Division, as well as the Department of Internal Medicine, has conference rooms available for teaching purposes. Most of these rooms have a computer and projector to assist in teaching and presentations.
There are two cafeterias and a convenience store located at The Nebraska Medical Center.
Call rooms are not needed for the fellows, but if there is ever a situation where a room is needed, the fellows can have access to rooms in the Lied Transplant Center, located in The Nebraska Medical Center.
ID Call Resident/Fellow Call Schedule Guidance
ACGME work hour prohibit HO-1 home call. Also, HO-1’s must be appropriately supervised which means having staffing immediately available in house. This staffing can be performed by either the fellow or ID staff. Upper level residents and fellows take home call as long as that call is not considered overly burdensome and they receive 4 days off per month. The call plan will be dictated by the number and type of residents assigned to the service and fellow availability.
Attending physicians should attempt to staff all consults on the day they are called if possible. If an attending physician is no longer present the consult must be staffed by phone with the attending physician. These are general guidelines to how call is handled and may be adjusted to best fit resident and fellow availability.
Call Guidelines:
General ID
• Weekend and overnight call is generally split equally between fellow and upper level residents
• HO-1s will take call on the General ID service during the day on weekdays and round on weekends but not be on call overnight
o An attending physician, fellow, or senior resident will always be available on site to supervise HO-1 activities
o Weekday call for HO-1 will be from 7AM-5PM and after 5PM be the fellow or upper level resident responsibility. If neither the fellow nor an upper level resident available, call is handled by an off service fellow or the attending.
o Weekend call for HO-1 will be similar to the “rounding resident”
Weekends:
• Weekend call is shared by the fellow and upper level residents
• Generally 2 house officers (residents or fellow) will be listed on the call schedule for each weekend. One will be designated as “on-call” while the other will be the “rounding resident.”
o On-call resident is on call the entire 24 hour period and listed in PerfectServe
o Rounding resident is expected to come in the morning and see old patients and assist with any new consults. Once these duties are complete they can leave. They will not be listed in PerfectServe. HO-1 can only fulfill the rounding resident roll.
Transplant ID
No fellow on Transplant ID:
• All calls handled by Transplant ID APPs and faculty
UNMC Fellow Transplant Call:
• On call for new consults and current inpatients entire month with following exceptions:
o Duty free 2 weekends per month (Friday 5PM to Mon 8AM)
o Duty free one weeknight (generally Wednesday)
• Fellows may be required to cross cover the general ID service depending on resident compliment
CUMC Fellow Transplant Call:
• CUMC fellows assigned for 2-week block.
• On call for new consults Mon 8AM to Friday 5PM
• Cover one weekend of a two-week rotation as arranged by Transplant service
• Calls generally go to the designated Transplant ID APP or faculty as CUMC fellows do not have access to PerfectServe.
Oncology ID
No fellow on Oncology ID:
• All call duties are handled by Oncology APPs and faculty.
UNMC Fellow on Oncology ID:
• On call for new consults and current inpatients entire month with following exceptions:
o Duty free 2 weekends per month (Friday 5PM to Mon 8AM)
o Duty free one weeknight (generally Wednesday)
• Fellows may be required to cross cover the general ID service depending on resident compliment
CUMC Fellow on Oncology ID:
• CUMC fellows assigned for 2-week block.
• Cover one weekend of a two-week rotation as arranged by Oncology ID service.
• Calls generally go to the designated Oncology ID APP or faculty as CUMC fellows do not have access to PerfectServe.
Orthopedic ID
No fellow on Ortho ID:
• All calls handled by Ortho ID APPs and faculty
UNMC Fellow Ortho Call:
• On call for new consults and current inpatients entire month with following exceptions:
o Duty free 2 weekends per month (Friday 5PM to Mon 8AM)
o Duty free one weeknight (generally Wednesday)
• Fellows may be required to cross cover the general ID service depending on resident availability
Community ID
No fellow on Community ID:
• All calls handled by Community ID APPs and faculty
UNMC Fellow Community ID Call:
• There is no weekend call on Community ID and all calls go to the General ID attending
• Generally on call for new consults and current inpatients entire month. Call duties may be shared with the Community ID APP.
• Fellows may be required to cross cover the general ID service depending on resident availability
ID Call Schedule SOP
Rationale: Optimal patient care requires that referring teams are able to easily identify who is “on-call’ for the various ID services. Call schedules are complex, often subject to change and may include a variety of trainees. To avoid confusion, the SOP below delineates the process for call schedule creation and entry into PerfectServe and specifies who is responsible for these activities. Call schedules which include trainees should take into account the Resident/Fellow ID Call Schedule Guidelines with any exception or adjustment to the guidelines being discussed with Dr Van Schooneveld (or Rupp in his absence).
General Guidelines:
• A specific designee of each service (General, SOT, ONC, Ortho, Community) is responsible for determining who is on the clinical service each month including faculty, mid-levels, and trainees
o Specific trainees assigned to the service will be provided by email to the designee and faculty reviewer of each clinical service by Megan Hoesing at least 15 business days before the start of each month
▪ This will include scheduled time off and clinic schedule for any trainees
o Those making the schedule should take into account any planned absences (vacations, education, etc.)
• Service designees should create the call schedule in an easy to interpret format (eg. calendar grid sheet)
• This schedule must be reviewed by the faculty designee of each service
• The schedule should then be provided to the ID division administrative assistants for entry into Perfect Serve
o It should be turned in at least 5 business days before the start of a new month
• Changes to call schedules should be provided in writing or email to the ID administrative assistants as soon as they are known for entry into PerfectServe
• Fellows should become familiar with how to manipulate PerfectServe
• (Training handouts included in appendix)
GENERAL ID
Responsible for Creating the Call Monthly Schedule: Fellow on service for the month.
Reviews Call Schedule: Dr Van Schooneveld, if unavailable - Dr Rupp
Enters into Perfect Serve: Megan Hoesing (fellows and residents) Debbie Van Cleave, Regina Ueckert or Jessica Quick (faculty)
SOTX
Responsible for Creating the Monthly Call Schedule: Jennifer Hrbek, Adia Sikyta, Cassie Day
Reviews Call Schedule: Dr Florescu, if unavailable - Dr Kalil
Enters into Perfect Serve: Megan Hoesing (fellows); Debbie Van Cleave, Regina Ueckert or Jessica Quick (faculty and APPs)
Oncology
Responsible for Creating the Monthly Call Schedule: Whitney Knuth, Jolene Tijerina, Amanda Bond
Reviews Call Schedule: Dr. Zimmer
Enters into Perfect Serve: Megan Hoesing (fellows); Debbie Van Cleave, Regina Ueckert or Jessica Quick (faculty and APPs)
Ortho
Responsible for Creating the Monthly Call Schedule: Daniel Cramer, Rachel Johnson
Reviews Call Schedule: Dr. Hewlett
Enters into Perfect Serve: Megan Hoesing (fellows); Debbie Van Cleave, Regina Ueckert or Jessica Quick (faculty and APPs)
Community ID
Responsible for Creating the Monthly Call Schedule: Rick Starlin
Reviews Call Schedule: Dr. Hewlett
Enters into Perfect Serve: Megan Hoesing (fellows); Debbie Van Cleave, Regina Ueckert or Jessica Quick (faculty and APPs)
Discipline and Grievances
It is anticipated that all infectious disease fellows will be conscientious and professional, displaying the highest caliber of professional ethics and providing quality medical care in a cost-effective manner to all patients. The infectious disease training program’s faculty is committed to providing a graduate medical education that completely prepares the fellow for a career in our sub-specialty, whether in a private practice, academic, or industry setting. In return, the fellow is expected to commit his/her full professional effort to the program. Failure to perform at a satisfactory level with regard to academic activities, clinical activities, or research will result in disciplinary actions by the program director. Generally, this requires only counseling and the mutual development of a corrective plan by the fellow and director. In more serious cases, it may include, and is not limited to, probation, suspension, non-renewal of contract, and termination.
The University of Nebraska Medical Center Graduate Medical Education Office administers the complete policies on Supervision, Advancement, Evaluation, Discipline, and Grievances. These policies are included in the University of Nebraska Affiliated Hospitals House Staff Manual which the fellow will receive along with the House Officer Agreement.
Duty Hours
All fellows are required to maintain a duty hour log. Duty hours will be continuously monitored by the program director and will also be discussed at the monthly fellowship meeting between the fellows and program director.
I. Duty Hours for Infectious Disease Fellows
a. Duty hours are defined as all clinical and academic activities related to the fellowship program, i.e., patient care (both inpatient and outpatient), administrative duties related to patient care, the provision for transfer of patient care, time spent in-house during call activities, and scheduled academic activities such as conferences. Duty hours do not include reading and preparation time spent away from the duty site.
b. Clinical and educational work hours must be limited to no more than 80 hours per week, averaged over a four-week period, inclusive of all in-house clinical and educational activities, clinical work done from home, and all moonlighting.
c. Fellows will be provided with 1 day in 7 free from all educational and clinical responsibilities, averaged over a 4-week period, inclusive of call. One day is defined as one continuous 24-hour period free from all clinical, educational, and administrative activities.
d. Adequate time for rest and personal activities will be provided.
e. Specific duty hours for Infectious Disease fellows are as follows:
1. Fellows assigned to clinical services should be available from 8:00 am to 6:00 pm, Monday through Friday (including holidays unless fellow has pre-arranged vacation)
2. As part of their training, fellows should learn flexible time-management. Late afternoon consultations or faculty rounds may extend their daily duty hours on a day-to-day basis.
3. When covering clinical services over the weekend, fellows are expected to physically see the patients on their service(s) one or both days, as the clinical situation warrants with the advice of the attending faculty member(s).
II. On-Call Activities
a. As a practical matter, in-house call is not a part of the infectious disease fellowship. As policy, however, continuous on-site duty, including in-house call, will not exceed 24 consecutive hours. Fellows may remain on duty for up to six additional hours to participate in didactic activities, transfer care of patients, conduct outpatient clinics, and maintain continuity of medical and surgical care as defined in the ACGME Specialty and Subspecialty Program Requirements.
b. As policy, no new patients, as defined in the ACGME Specialty and Subspecialty Program Requirements, may be accepted in the circumstance that a fellow has had 24 hours of continuous duty. In practice, this does not occur in the infectious disease fellowship.
c. At-home call (pager call) is defined as call taken from outside the assigned institution.
1. Fellows assigned to the UNMC General ID consultation service share home call with the residents on the service. While most situations will be managed over the telephone, fellows must be able to come into the hospital at any time for patient consultation, if required.
2. Fellows assigned to the UNMC subspecialty consult services are expected to take home call Monday, Tuesday and Thursday overnight and Friday, Saturday and Sundays during their assigned weekend coverage. Wednesday will be free from call.
3. Fellows taking at-home call will be provided with 1 day in 7 completely free from all educational and clinical responsibilities, averaged over a 4-week period.
4. When fellows are called into the hospital from home, the hours they spend in-house are counted toward the 80-hour limit. Additionally, any clinical work done at home which includes using an electronic health record and taking calls from home are included in the 80-hour limit. Reading done in preparation for the following day’s cases, studying, and research done from home do not count toward the 80 hours. Fellows are required to notify the program director if at-home call during a particular week is anticipated to result in more than 80 duty hours.
5. The program director and the faculty will monitor the demands of call duties and make scheduling adjustments as necessary to mitigate excessive service demands and/or fatigue.
III. Institutional Compliance Measures
a. The administration of UNMC has put a high priority on assuring work-hour compliance. If a fellow has concerns about work hours in the infectious disease training program s/he should first bring this to the attention of the program director, section chief, or department chairman. They can also notify the Graduate Medical Education Office by contacting Vicki Hamm (402 559-6329 or vhamm@unmc.edu) or the Associate Dean for Graduate Medical Education, Chandrakanth Are, MD (402 559-7298 or care@unmc.edu). Additional information can be found on the GME website (unmc.edu/GME) by clicking on “Confidential Resident Duty Hours Reporting”.
b. If an infectious disease fellow has concerns about work hours or other aspects of their educational program and feels uncomfortable speaking to any of the individuals described about these concerns, they may access the UNMC Compliance Hotline at 1-866-568-5430. The hotline is operated by a 3rd party compliance hotline service 24 hours a day, 365 days a year. Their concern can be reported anonymously, if they wish, and should include enough detail (i.e. program, rotation, etc.) to allow appropriate investigation and evaluation.
Coverage of Non-Teaching Patients
All patients in the inpatient and outpatient facilities and rotations are potential teaching patients. Because the clinical volume at inpatient and outpatient clinical settings exceeds the involvement of fellows, an effort will be made to especially involve the fellows in patients with the greatest potential educational value to the trainees.
If a patient requests that house officers not be involved in his/her medical care, the patient may be deemed “non-teaching status.” In this case, fellows will not be asked to see this patient except under emergency situations and with prior approval by the fellow’s attending.
Supervision Policy
PURPOSE:
To establish program standards for supervision of fellows to ensure optimal educational effectiveness and compliance with ACGME institutional requirements.
DEFINITIONS:
1. Supervising Physician: A faculty physician
2. Levels of Supervision: Three levels of supervision are defined:
a. Direct: There are 2 types of direct supervision:
i. The supervising physician is physically present with the fellows during the key portion of the patient interaction.
ii. The supervising physician and/or patient is not physically present with the fellow and the supervising physician is concurrently monitoring the patient care through appropriate telecommunication technology
b. Indirect:
i. The supervising physician is not providing physical or concurrent visual or audio supervision but is immediately available to the fellow for guidance and is able to provide direct supervision
c. Oversight:
i. The supervising physician is available to provide review of procedures/encounters with feedback provided after care if delivered.
POLICY:
Supervision by faculty physician/medical staff:
1. At all times and at all training sites, patient care performed by fellows will be under the supervision of a qualified supervising faculty physician with appropriate privileges and credentialed to provide the required level of care. This supervising faculty physician is ultimately responsible and accountable for the patient’s care.
a. The fellow and/or supervising physician must document the supervision in the medical record
b. Information on who the supervising physician is must be available to fellows, faculty members, members of the health care team and patients
2. Telemedicine will be supervised in the same capacity as a clinic visit would be supervised.
3. As fellows progress satisfactorily in their training, they are to be granted graded responsibilities commensurate with their abilities. In this setting, a fellow may provide patient care under the supervision of, but without direct participation by, the attending physician. Under these conditions, the attending physician, although fully responsible for the care of the patient, is considered to be fulfilling an administrative/educational role.
4. The Clinical Competency Committee (CCC) evaluates fellows biannually. As part of this evaluation process, the CCC assesses each fellow’s abilities guided by the Competencies.
a. The CCC assesses individual fellow privilege of progressive authority and responsibly, conditional independence, appropriateness for a supervisory role in patient care, and ultimately graduation to the next PGY level
b. The CCC informs the program director(s) of their recommendations who ultimately evaluates each fellow as guided by the Competencies
5. In a training program, as in any clinical practice, it is incumbent upon the individual physician to acknowledge his/her own limitations in providing patient care and to consult a physician with more expertise when necessary. In all cases, the attending physician is ultimately responsible for the provision of care by trainees and trainees must contact this attending when there is any question about the need for supervision.
6. Procedures may be performed by a fellow in training with varying degrees of supervision based upon their level of experience. It is up to the discretion of each attending physician as to the level of supervision provided.
7. Emergencies: An “emergency” is defined as a situation where immediate care is necessary to preserve the life or to prevent serious impairment of the health of a patient. In such situations, any fellow, assisted by medical center personnel, is permitted to do everything possible to save the life of the patient. The fellow should notify the supervision physician as soon as possible after care is given.
Communication:
1. Fellows and faculty members should communicate with patients their respective roles in the patient’s care
2. Fellows must notify the supervising physician faculty in the following situations, including but not limited to:
a. New patient consultations requiring immediate evaluation
b. Patient admission to the hospital
c. Significant changes in status requiring new diagnostic testing, procedures, or alterations in antimicrobial regimens
d. Medication or other patient care errors requiring intervention
e. Any significant difference of opinion with other faculty physicians providing care for the patient
f. Consultation requests by outside physicians
Progressive Responsibility of Fellows
1. Fellow education is progressively graduated in both experience and responsibility with due attention to the benefit and safety of the patient. Development of mature clinical judgment requires that each fellow be involved in the decision-making process. This process should be individualized commensurate with the clinical circumstance and the abilities of the fellow.
2. Progressive responsibility for “first decision” making prior to faculty involvement is important for the maturation of each fellow, whereas “final decision” making after involvement is the province of the faculty. In the process of allowing a fellow the opportunity to make the “first decision”, the attending physician must ensure that the process does not delay the provision of cost-effective and expeditious care.
3. The responsible faculty member has the final authority for patient care; however, both faculty and fellows at all levels have individual responsibility for their actions in patient care.
4. Senior fellows should serve in a supervisory role of junior fellows in recognition of their progress toward independence, based on the needs of each patient and the skills of the individual fellow.
5. Fellows serve in a supervisory role to residents in recognition of their progress toward independence, based on the needs of each patient and the skills of the individual resident or fellow.
Assessment of Fellow Supervision
1. As part of each rotation evaluation, the fellow will be queried about faculty supervision, including the availability of the faculty member. Any deficiencies will be addressed by the Program Director.
Responsibilities: Ensuring appropriate fellow supervision is the responsibility of the program director, faculty physicians, departmental leadership, and the institution. Specific responsibilities include:
1. Supervising faculty physicians: Supervising faculty physicians are responsible for ensuring patient safety and quality of care. Supervising physicians may not provide direct supervision of all aspects of patient care, but they are ultimately responsible for the care of each patient.
2. Program Directors (PDs):
a. Provide a curriculum, including clinical rotation summaries, delineating fellow responsibilities for patient care, progressive responsibility for patient management, and supervision of fellows over the continuum of the program.
b. Assign progressive authority and responsibility, conditional independence, and a supervisory role in patient care based on specific criteria reviewed by the clinical competency committee for each program, and supervising faculty members for each clinical experience.
c. Review the levels of supervision with fellows, supervising faculty physicians, and appropriate nursing and administrative staff.
d. Provide a specific statement identifying any exceptions for individual fellows to supervising physicians and appropriate nursing and administrative staff, as applicable
3. Graduate Medical Education Committee (GMEC): The GMEC will provide oversight of the appropriateness of supervision through regular review of hospital data, program data, and ACGME data (faculty and fellow surveys) by the Clinical Learning Environment Operations Committee annually,
4. Quality Monitoring: The overall quality of patient care is the collaborative concern of fellows, faculty, nursing staff, and the administration. Clearly defined and carefully reviewed Quality Monitoring should regularly determine that the institutional standards are met.
Procedures: Fellows in Infectious Disease have already completed training in internal medicine. Based upon this they primarily require indirect supervision depending on the clinical circumstance, although depending on the experience of the fellow in the specific situation direct supervision or oversight may be employed.
1. Inpatient Consultations and Continuing Care of Inpatients: For inpatient care, supervising faculty must provide indirect supervision. Supervising faculty must physically meet, examine, and evaluate the patient within 24 hours of a consultation and on a daily basis, including weekends and holidays. Faculty are expected to be personally involved in the ongoing care of the patient and must be identifiable for each resident’s patient care encounter.
2. Outpatient Care: For outpatient care, supervising faculty must provide indirect supervision. Faculty are expected to be personally involved in the ongoing care of the patient and must be identifiable for each resident’s patient care encounter.
3. Routine Bedside and Clinic Procedures: Routine bedside and clinic procedures include: skin biopsies and scrapings, central and peripheral lines, lumbar punctures, thoracentesis, paracentesis, and incision and drainage. Supervision for these activities is dependent on the setting in which they occur and faculty privileges. Documentation standards must follow the setting-specific guidelines.
Microbiology
Description: An understanding and interpretation of microbiology test results is integral to the training of ID fellows. All infectious disease fellows will spend one month during their first year rotating in the clinical microbiology laboratory obtaining hands on experience with in bacteriology, virology, mycology, and parasitology. The primarily director of this rotation is Dr. Paul Fey, but fellows may also work with other faculty members and clinical microbiology fellows. Residents, students, and other trainees may be present in the microbiology lab, but ID fellows will not be responsible for them. Fellows will work directly with and learn from the medical technologists the basic principles and practices in clinical microbiology and the capabilities of the laboratory. The fellow will rotate through the various benches of the laboratory including: set-ups, blood cultures, respiratory, urines, stools, and wound cultures. Their training will also encompass virology, probe testing, mycology, mycobacteria, and serology. Fellows are also expected to participate in microbiology laboratory rounds with the laboratory directors, pathology residents, and clinical microbiology fellows. Current problems, unusual findings, and instructive examples are the basis for discussion at laboratory rounds. Laboratory rounds also include a discussion of the integration of the microbiology laboratory into the health care system and the prevention of system errors. Fellows actively contribute to developing solutions and problem-solving in this arena.
Rotational Goals:
1. Become familiar with basic microbiology diagnostic techniques including specimen processing, Gram staining, pathogen isolation and identification, and susceptibility testing.
2. Become familiar with the methodology of microbial testing including blood, urine, respiratory, stool, and wound cultures
3. Understand the different methods of susceptibility testing and their interpretation
4. Recognize common fungal and mycobacterial pathogens and understand how these organisms are identified.
5. Become familiar with the diagnosis of viruses utilizing various methods (culture, serology, molecular testing)
6. Develop an understand of how a clinical microbiology lab operates and how their services integrate into the care of patients
Rotational Objectives:
1. Become proficient in application of a variety of microbial tests to evaluate bacterial, fungal, viral, and parasitic pathogens including: (Patient care, Medical Knowledge)
a. Interpretation of direct diagnostic tests (Gram stain, immunoflorescence, ELISA, etc.)
b. Culture techniques for various clinical specimens (blood, wound, stool, etc.)
c. Culture techniques for fungal and mycobacterial organisms
d. Recognize the appearance of common organisms on culture (beta-hemolytic streptococci, Streptococcus pneumoniae, Haemophilus species, Staphylococcus aureus, E. coli, Proteus species, and Pseudomonas aeruginosa).
e. Methods of susceptibility testing, the interpretation of the results, and application to specific clinical scenarios
f. Other microbiologic techniques including antigen testing and molecular methods
2. Serve as a role model to residents, medical students, and other medical professionals in professionalism, including timeliness, appropriate communication skills and responsible, ethical, comprehensive care. (Professionalism)
3. Communicate effectively with the microbiology personal the clinical context of the laboratory testing needed and when interacting with medical professionals act as a liaison for the medical technologists communicating the science behind the testing results. (Professionalism, Interpersonal and Communication Skills, Systems Based Practice)
4. Develop an understanding for the role of the microbiology laboratory and testing as it relates to the treatment of infectious disease. This includes appreciating any errors or difficulties in diagnosis or testing that may occur and their impact on treatment decision; developing the ability to evaluate the evidence for implementation of new medical technology including the cost issues; and understanding this information and results are communicated to other medical professionals. (Systems Based Practice, Practice-Based Learning and Improvement, Medical Knowledge, Interpersonal and Communication Skills)
Teaching Methods: Fellows will rotate through the various benches (blood, respiratory, stool, etc.) where they be taught various microbiologic techniques by the laboratory personal in each area. The ID fellow will participate in microbiology rounds with the laboratory team and inpatient ID teams. They will attend the weekly Microbiology management meeting at 230PM on Wednesdays. Fellows are expected to develop and present a brief review of an interesting case or topic at weekly case conference.
It is recommended fellows complete the Coursera online course: Duke University : Tropical Parasitology: Protozoans, Worms, Vectors and Human Disease. Coursera courses are free and instructions on how to complete the course are below.
Go to:
Under the Sessions heading on the right hand side, click on : Join for Free!
Input full name, email and password and click on Sign Up.
After your email address has been confirmed, Click on Courses button.
Click on Tropical Parasitology: Protozoans, Worms, Vectors and Human Diseases .
Click on the Join Free under the Sessions heading.
Click on Go to Course.
Read the Coursera Honor Code and click on I agree.
On the right hand side, click on Course Modules.
You’re now ready to begin.
Evaluation: The clinical microbiology training director will evaluate the progress of the ID fellow at the end of the rotation based on his assessment and feedback from the various areas the fellow has rotated in. Verbal feedback is provided mid-month and verbal feedback and a written evaluation are provided at the end of the month. The goals and objectives are reviewed at the beginning of the rotation. Fellows anonymously evaluate both the rotation and the clinical microbiology training director at the end of the month.
Level of Supervision: Fellows are supervised by the laboratory technologist with whom they work, the clinical microbiology training director, or the laboratory director.
Educational Resources:
1. Henry’s Clinical Diagnosis and Management by Laboratory Methods, 21st edition, 2007 (Section 7 contains material pertaining to medical microbiology)
2. ASM Manual of Clinical Microbiology, 9th edition, 2007 (This manual is contained in 2 volumes and is considered the gold standard for methods in diagnostic microbiology)
3. Koneman’s Color Atlas and Textbook of Diagnostic Microbiology, 6th edition, 2006 (this book contains excellent photographs and is easy to read for a general overview of diagnostic microbiology)
General ID Rotation
Fellow will spend 5-6 months on General ID, primarily during their first year. The general ID team consists of an ID attending, 2-3 internal medicine residents, and may include medical students and pharmacy residents and students. The team rounds daily on patients with a variety of infectious disease issues. Rounds include twice per week sessions in the microbiology lab where specific patient culture data is discussed with the clinical microbiology fellows and laboratory director. The fellow is responsible for evaluating new consultation and daily evaluating patients on the service. The fellow serves as the “team manager” and assigns patients to other physicians for evaluation and presentation to the attending, as well as providing supervision and education to less-experienced physicians/students on the team. Rounds with the consult attending are held daily, at times set by the attending and fellow.
Rotational Goals:
1. Fellows will evaluate patients with acute and chronic infectious diseases across the entire spectrum of the specialty.
2. Fellow will learn the diagnostic and therapeutic approach to these problems.
3. Fellow will learn to communicate recommendations with other health care providers in both written and oral form.
4. Fellows will learn to communicate compassionately and effectively with patients and their families
5. Fellow will learn to facilitate the provision of compassionate and efficient care across the entire spectrum of the health care system.
Rotational Objectives:
1. The ID fellow will be able to formulate a basic approach to the evaluation of acutely ill patients with potential infectious diseases including pertinent history and physical exam, appropriate utilization and interpretation of diagnostic tests (including molecular diagnostic tests), development of a prioritized differential diagnosis based upon history, exam and diagnostic studies, and creation of a treatment plan based upon the above information. (Patient care, Medical Knowledge)
2. Communicate the consultation findings and recommendations both verbally and in written format clearly and appropriately to the patient and other members of the health care team. (Patient care, Professionalism, Interpersonal and Communication Skills, Systems-based Practices)
3. Demonstrate respect, compassion, and integrity towards patients along with sensitivity and responsiveness to patients’ unique experiences and treatment preferences. (Professionalism)
4. Effectively and compassionately interview the patient, family members and staff to formulate a focused clinical question and develop a comprehensive assessment of the pertinent clinical issues (Professionalism, Interpersonal and Communication Skills).
5. Serve as a role model to residents, medical students, and other medical professionals in professionalism, including timeliness, appropriate communication skills and responsible, ethical, comprehensive care. (Professionalism)
6. Communicate with ID team members, the requesting team, the patient and other care providers throughout care of the patient including initial recommendations, modifications in any established plan, and final treatment plans including additional follow up planned. (Professionalism, Interpersonal and Communication Skills, Systems Based Practice)
7. Complete consultation notes within 24 hours of evaluation including diagnoses and recommendations. Complete sign off note including scheduling of outpatient follow up within 48 hours of discharge. (Professionalism, Systems Based Practice)
8. Develop an evidence-based approach to developing a diagnostic and treatment plan through utilization of the medical literature available at UNMC both electronically and in print. Utilize this knowledge to instruct students, residents and other health care professionals about the infectious disease issues relevant to the patient including providing up to date literature. (Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Medical Knowledge)
Teaching Methods: The teaching on this rotation includes a large amount of case-based learning which occurs both at the bedside and in didactics as stimulated by current patient problems. It is expected fellows will independently review topics pertinent to the problems currently being evaluated on the service. Fellows will participate in microbiology rounds which occur twice a week. Daily didactic lectures occur monthly on this rotation and fellows are expected to attend each topic at least once. Topics covered include: hospital-acquired infections, zoonoses, clinical microbiology, opportunistic infections in immunocompromised hosts, antibiotics, bone and joint infections, skin and soft tissue infections, ID emergencies, UTIs, pneumonia, Infections of the CNS, and STDs.
Additional Education Conferences:
1. ID Lectures – occur daily at 830AM except for Thursdays
2. Microbiology Rounds – 2 times per week as scheduled
3. Case Conference – Fellows are expected to attend case conference on Thursdays at 8AM
Evaluation: The attending physician will evaluate the progress of the ID fellow at the end of the rotation. Verbal feedback is provided mid-month and verbal feedback and a written evaluation are provided at the end of the month. Residents on the service will also evaluate the fellows. The goals and objectives are reviewed at the beginning of the rotation. Fellows anonymously evaluate both the rotation and the attending physician at the end of the month.
Call Guidelines:
• Weekend and overnight call is generally split equally between fellow and upper level residents
• HO-1s will take call on the General ID service during the day on weekdays and round on weekends but not be on call overnight
o An attending physician, fellow, or senior resident will always be available on site to supervise HO-1 activities
o Weekday call for HO-1 will be from 7AM-5PM and after 5PM be the fellow or upper level resident responsibility. If neither the fellow nor an upper level resident available, call is handled by an off service fellow or the attending.
o Weekend call for HO-1 will be similar to the “rounding resident”
Weekends:
• Weekend call is shared by the fellow and upper level residents
• Generally 2 house officers (residents or fellow) will be listed on the call schedule for each weekend. One will be designated as “on-call” while the other will be the “rounding resident.”
o On-call resident is on call the entire 24 hour period and listed in PerfectServe
o Rounding resident is expected to come in the morning and see old patients and assist with any new consults. Once these duties are complete they can leave. They will not be listed in PerfectServe. HO-1 can only fulfill the rounding resident roll.
Educational Resources:
1. Principles and Practice of Infectious Disease (Mandell, Douglas, Bennett, 7th ed)
2. IDSA Guidelines at
3. SHEA Guidelines at
4. CDC HICPAC Guidelines at
Transplant Infectious Disease
Description: All infectious disease fellows will rotate on the Transplant ID inpatient service during both their first and second year. They will primarily work with Drs. Andre Kalil, Diana Florescu, and Erica Stohs, but may also work with other faculty members. Residents are occasionally present on the service. The Transplant ID service is focused on the diagnosis, treatment and prevention of infectious diseases in patients undergoing solid organ transplant including the pre-transplant evaluation. Fellows will primarily see patients in the inpatient setting but may also see patients in the outpatient clinic. Fellows will round daily on the service including weekends, but will have 2 weekends free of duty. Call for the transplant ID service will be generally be the responsibility of the fellow while on the service with the exceptions of the 2 weekends free.
Rotational Goals:
1. Fellows will become familiar with the major pathogens and clinical syndromes associated solid organ transplant.
2. Fellows will understand the impact of organ transplantation and immunosuppressive medications on the risk for and treatment of infectious disease
3. Fellows will become familiar with the clinical approach to the pre-transplant evaluation.
4. Fellows will become familiar with the use of antimicrobial prophylaxis in varying groups of solid organ transplant patients.
5. Fellows will develop an approach to diagnosis, treatment and prevention of both viral and fungal infections in organ transplant patients including the role of diagnostic markers and prophylactic, pre-emptive and definitive therapy.
Rotational Objectives:
1. The ID fellow will be able to formulate a basic approach to the evaluation of acutely ill organ transplant patients with potential infectious diseases including pertinent history and physical exam, appropriate utilization and interpretation of diagnostic tests (including molecular diagnostic tests), development of a prioritized differential diagnosis based upon history, exam and diagnostic studies, and creation of a treatment plan based upon the above information. (Patient care, Medical Knowledge)
2. Develop an understanding of the infectious disease issues pertinent to patients undergoing solid organ transplant including (Medical Knowledge):
a. Unique pathophysiology, epidemiology, and risk factors; impact of specific transplant and immunomodulatory agents on infection risk; evaluation and treatment of post-transplant complications; principles of antimicrobial prophylaxis and pre-emptive therapy; evaluation and treatment of opportunistic pathogens including viruses and fungal agents; healthcare-associated infections
3. Communicate the consultation findings and recommendations both verbally and in written format clearly and appropriately to the patient and other members of the health care team. (Patient care, Professionalism, Interpersonal and Communication Skills, Systems-based Practices)
4. Demonstrate respect, compassion, and integrity towards patients along with sensitivity and responsiveness to patients’ unique experiences and treatment preferences. (Professionalism)
5. Effectively and compassionately interview the patient, family members and staff to formulate a focused clinical question and develop a comprehensive assessment of the pertinent clinical issues (Professionalism, Interpersonal and Communication Skills).
6. Serve as a role model to residents, medical students, and other medical professionals in professionalism, including timeliness, appropriate communication skills and responsible, ethical, comprehensive care. (Professionalism)
7. Communicate with ID team members, the requesting team, the patient and other care providers throughout care of the patient including initial recommendations, modifications in any established plan, and final treatment plans including additional follow up planned. (Professionalism, Interpersonal and Communication Skills, Systems Based Practice)
8. Complete consultation notes within 24 hours of evaluation including diagnoses and recommendations. Complete sign off note including scheduling of outpatient follow up within 48 hours of discharge. (Professionalism, Systems Based Practice)
9. Develop an evidence-based approach to developing a diagnostic and treatment plan through utilization of the medical literature available at UNMC both electronically and in print. Utilize this knowledge to instruct students, residents and other health care professionals about the infectious disease issues relevant to the patient including providing up to date literature. (Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Medical Knowledge)
Teaching Methods: The teaching on this rotation is primarily case-based learning which occurs both at the bedside and in didactics as stimulated by current patients. A specific list of topics is covered routinely in more formal didactic discussions including immunosuppressive medications, PTLD, pre-transplant evaluation, etc. Fellows are also expected to independently review topics in the literature pertinent to what is currently being evaluated on the service.
Evaluation: The attending physician will evaluate the progress of the ID fellow at the end of the rotation. Verbal feedback is provided mid-month and verbal feedback and a written evaluation are provided at the end of the month. The goals and objectives are reviewed at the beginning of the rotation. Fellows anonymously evaluate both the rotation and the attending physician at the end of the month.
Level of Supervision: Fellows are directly supervised by the ID attending physician who rounds daily. This attending physician is available 24 hours a day, 7 days per week if issues arise outside of typical rounding hours. The attending physician personally evaluates all new consults after the fellow and discusses treatment plans daily with the fellow. The ID attending is ultimately responsible for the care of the patients.
Call Guidelines:
• On call for new consults and current inpatients entire month with following exceptions:
o Duty free 2 weekends per month (Friday 5PM to Mon 8AM)
o Duty free one weeknight (generally Wednesday)
• Fellows may be required to cross cover the general ID service depending on resident compliment
Educational Resources:
1. IDSA Guidelines ( )
2. Principles and Practice of Infectious Disease (Mandell, Douglas, Bennett, 7th ed)
3. Infections in the Immunosuppressed Patient by PH Chandrasekar
4. Transplant Infections 4th Ed.
Didactic Curriculum: Fellows participate in at least three months of transplant ID. During that time the didactic curriculum outlined below is covered. This is done using article review/discussion and didactics. These sessions are scheduled at the discretion of the rotation and are generally one-on-one discussions.
The areas covered during the rotation are:
Introduction to SOT
• Immunosuppressive Agents
• Risk of Serious Opportunistic Infections After Solid Organ Transplantation: Interleukin-2 Receptor Antagonist Versus Polyclonal Antibodies.
• Interactions Between Anti-Infective Agents and Immunosuppressants in Solid Organ Transplantation
• Fluoride Excess and Periostitis in Transplant Patients Receiving Long-Term Voriconazole Therapy
• Longitudinal Assessment of Posttransplant Immune Status
• Can Immune Cell Function Assay Identify Patients at Risk of Infection or Rejection? A Meta-Analysis
• What is the Impact of Hypogammagolobulinemia on the Rate of Infections and Survival in Solid Organ Transplantation?
Cytomeglovirus in Solid Organ Transplantation (CMV)
• CMV:Prevention, Diagnosis and Therapy
• Updated international Consensus Guidelines on the Management of Cytomegalovirus in Solid-Organ Transplantation
• A Direct and Indirect Comparison Meta-Analysis on the Efficacy of Cytomeglovirus Preventive Strategies in Solid Organ Transplantation
• Effectiveness of Valganciclovir 900 mg versus 450 for Cytomeglovirus Prophylaxis in Transplantation: Direct and indirect treatment Comparison Meta Analysis
• Valganciclovir for Cytomegalovirus Prevention in Solid Organ Transplant Patients: An Evidence-Based Reassessment of Safety and Efficacy
Candida
• Candida Infections in Solid Organ Transplantation
• Performance of Candida Real-time Polymerase Chain Reaction, Glucan Assay, and Blood Cultures in the Diagnosis of Invasive Candidiasis
Fungal Infections
• Cryptococcosis in Solid Organ Transplant Recipients: Current State-of-the-Science
• Immune Reconstitution Inflammatory Syndrome in non-HIV Immunocompromised Patients
• Aspergillosis in Solid Organ Transplant
• Endemic Fungal Infections in Solid Organ Transplantation
• Emerging Fungal Infections in Solid Organ Transplantation
Screening & Vaccinations
• Screening of Donor and Recipient in Solid Organ Transplantation
• Vaccination in Solid Organ Transplantation
• 2013 IDSA Clinical Practice Guideline for Vaccination of the Immunocompromised Host
Oncology Infectious Disease
Description: All infectious disease fellows will rotate on Oncology ID during both first and second year. Dr. Andrea Zimmer is the primary attending for this rotation, but fellows may also work with a variety of ID faculty members. Internal medicine and pharmacy residents are occasionally assigned to this service. The Oncology ID service is focused on the diagnosis, treatment and prevention of infectious diseases in patients being treated for malignancies including hematopoietic stem cell transplant, solid tumor therapy, and surgical therapy for cancer. Fellows will primarily see patients in the inpatient setting but may also attend clinic. Fellows will round daily on the service including weekends but will have 2 weekends free of any call duties. Call for the oncology ID service will be the responsibility of the fellow while on the service with the exceptions of the 2 weekends free and Wednesday nights.
Rotational Goals:
1. Fellows will become familiar with the major pathogens and clinical infectious syndromes associated with various cancers and cancer therapies.
2. Fellows will understand the impact of specific oncologic therapies, prolonged neutropenia and GVHD on risk for and treatment of infectious disease.
3. Fellows will gain understanding of and clinical approach to fever and neutropenia in cancer patients.
4. Fellows will become familiar with the use of antimicrobial prophylaxis in varying subsets of cancer patients.
5. Fellows will develop an approach to diagnosis, treatment and prevention of fungal infections in cancer patients including the role of diagnostic markers and prophylactic, pre-emptive and definitive therapy.
6. Fellows will understand the etiologies and management of catheter-related infections in cancer patients.
Rotational Objectives:
1. The ID fellow will be able to formulate a basic approach to the evaluation of acutely ill oncology patients with potential infectious diseases including pertinent history and physical exam, appropriate utilization and interpretation of diagnostic tests (including molecular diagnostic tests), development of a prioritized differential diagnosis based upon history, exam and diagnostic studies, and creation of a treatment plan based upon the above information. (Patient care, Medical Knowledge)
2. Develop an understanding of the infectious disease issues pertinent to oncology patients including (Medical Knowledge):
a. Unique pathophysiology, epidemiology, and risk factors; impact of specific chemotherapy, stem cell regimen, and graft-verses-host disease on infection risk; evaluation and treatment of febrile neutropenia, principles of antimicrobial prophylaxis and pre-emptive therapy; evaluation and treatment of opportunistic pathogens including viruses and fungal agents; healthcare-associated infections
3. Communicate the consultation findings and recommendations both verbally and in written format clearly and appropriately to the patient and other members of the health care team. (Patient care, Professionalism, Interpersonal and Communication Skills, Systems-based Practices)
4. Demonstrate respect, compassion, and integrity towards patients along with sensitivity and responsiveness to patients’ unique experiences and treatment preferences. (Professionalism)
5. Effectively and compassionately interview the patient, family members and staff to formulate a focused clinical question and develop a comprehensive assessment of the pertinent clinical issues (Professionalism, Interpersonal and Communication Skills).
6. Serve as a role model to residents, medical students, and other medical professionals in professionalism, including timeliness, appropriate communication skills and responsible, ethical, comprehensive care. (Professionalism)
7. Communicate with ID team members, the requesting team, the patient and other care providers throughout care of the patient including initial recommendations, modifications in any established plan, and final treatment plans including additional follow up planned. (Professionalism, Interpersonal and Communication Skills, Systems Based Practice)
8. Complete consultation notes within 24 hours of evaluation including diagnoses and recommendations. Complete sign off note including scheduling of outpatient follow up within 48 hours of discharge. (Professionalism, Systems Based Practice)
9. Develop an evidence-based approach to developing a diagnostic and treatment plan through utilization of the medical literature available at UNMC both electronically and in print. Utilize this knowledge to instruct students, residents and other health care professionals about the infectious disease issues relevant to the patient including providing up to date literature. (Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Medical Knowledge)
Teaching Methods: The teaching on this rotation is primarily case-based learning which occurs both at the bedside and in didactics as stimulated by current patients. Fellows are expected to independently review topics in the literature pertinent to what is currently being evaluated on the service. A curriculum of Oncology ID related topics is also covered via lecture and selected reading over the course of 2 or more rotations as outlined below.
Call Guideline:
• On call for new consults and current inpatients entire month with following exceptions:
o Duty free 2 weekends per month (Friday 5PM to Mon 8AM)
o Duty free one weeknight (generally Wednesday)
• Fellows may be required to cross cover the general ID service depending on resident compliment
Evaluation: The attending physician will evaluate the progress of the ID fellow at the end of the rotation. Verbal feedback is provided mid-month and verbal feedback and a written evaluation are provided at the end of the month. Use of the mini-CEX is encouraged. The goals and objectives are reviewed at the beginning of the rotation. Fellows anonymously evaluate both the rotation and the attending physician at the end of the month.
Level of Supervision: Fellows are directly supervised by the ID attending physician who rounds daily. This attending physician is available 24 hours a day, 7 days per week if issues arise outside of typical rounding hours. The attending physician personally evaluates all new consults after the fellow and discusses treatment plans daily with the fellow. The ID attending is ultimately responsible for the care of the patients.
Educational Resources:
1. IDSA Guidelines ( )
2. Principles and Practice of Infectious Disease (Mandell, Douglas, Bennett, 8th ed)
3. Infections in the Immunosuppressed Patient by PH Chandrasekar
4. Transplant Infections 4th Ed.
5. NCCN Guidelines: Prevention and Treatment of Cancer Related Infections
Lectures and Reading: Topics below will be covered during the months on the Onc ID rotation.
Topic 1: Febrile Neutropenia
• Reading:
o Mandell’s Prophylaxis and Empirical Therapy of Infection in Cancer Patients
o IDSA Guidelines Freifeld
o Infections in the Immunosuppressed Patient; p3-5, p28-32, p63-68
• Lecture: Febrile neutropenia
Topic 2: HSCT basics
• Reading:
o Mandell’s Infections in Recipients of Hematopoietic Cell Transplantation
o Transplant Infections Chapter 1 “Intro to HSCT”
o NCCN Guidelines Baden
o Infections in the Immunosuppressed Patient p215-216,
o AST Handbook p4-5, 8
• Lecture: Overview of HSCT, Infections unique to HSCT
Topic 3: Invasive fungal infections
• Reading:
o Mandell’s Introduction to Mycoses, Aspergillus species
o Definitions of IFI and Revised Definitions
o Infections in the Immunosuppressed Patient; p35-44, 51- 55, 75-79, 93-98, 112-122, 219-223, 267-268
• Lecture: Invasive fungal infections, diagnosis and treatment
Topic 4: CMV, other herpesviruses in allo-HSCT recipients
• Reading
o Infections in the Immunosuppressed Patient p215-216, 224-225, 249-250, 262-266, 269-270
o Transplant Infections “CMV Infection After Stem Cell Transplantation”, “Herpes Simplex and VZV Infection after Hematopoietic Stem Cell Transplantation” “Human Herpesvirus 6A, 6B, 7 and 8 Infections after HSCT”
• Lecture CMV and herpesviruses
Topic 5: Prevention of infection in hematologic malignancies and post-HSCT
• Reading
o Transplant Infections “Risks and Epidemiology of Infections After Hematopoietic Stem Cell Transplantation”, “Vaccination of Transplant Recipients” (only HSCT portion)
o ASBMT Guidelines Tomblyn, ECIL Guidelines
o Infections in the Immunosuppressed Patient p260-261
• Lecture: Prophylaxis and Vaccination in Hematologic Malignancies and HSCT
Topic 6: Viral respiratory infections
• Reading
o Transplant Infections “Respiratory Syncytial Virus and Human Metapneumovirus Infection”, Influenza and Parainfluenza Infection in HSCT”, “Adenovirus”
o Infections in the Immunosuppressed Patient p 70-74, 229-231, 236-241
• Lecture: Viral respiratory infections
Orthopedic ID Rotation
Fellow will spend at least two months on the Orthopedic ID service during the two years of their fellowship. The Ortho ID team consists of an ID attending and 2 APPs, with Orthopedic interns assigned to the rotation 5 months per year. The Ortho ID service is focused on the diagnosis and treatment of infectious diseases in patients with orthopedic problems including prosthetic joint infections, complex osteomyelitis, and other infectious complications of orthopedic surgery. The team rounds daily on patients with a variety of infectious disease issues. Fellows will primarily see patients in the inpatient setting, but will also attend ortho ID clinic if available. Fellows will round daily on the service including weekends, but will have 2 weekends free of any call duties. Call for the Ortho ID service will be the responsibility of the fellow while on the service with the exceptions of the 2 weekends free and Wednesday nights.
Rotational Goals:
1. Fellows will become familiar with the major pathogens, clinical infectious syndromes associated with and diagnostic approach to bone and joint infections including hardware-related infections.
2. Fellows will gain understanding of the clinical approach to the management and prevention of prosthetic joint infections, osteomyelitis, native joint septic arthritis and complicated skin/soft tissue infections.
3. Fellows will learn the importance of surgical intervention for bone and joint infections, including the utility and indications of various surgical procedures.
4. Fellows will learn the importance of outpatient antibiotic therapy and the associated clinical monitoring in patients with bone and joint infections.
5. Fellow will learn to communicate recommendations with surgical teams in both written and oral form.
6. Fellows will learn to communicate compassionately and effectively with patients and their families
7. Fellow will learn to facilitate the provision of compassionate and efficient care across the entire spectrum of the health care system.
Rotational Objectives:
1. The ID fellow will be able to formulate a basic approach to the evaluation of acutely ill patients with potential infectious diseases including pertinent history and physical exam, appropriate utilization and interpretation of diagnostic tests (including molecular diagnostic tests), development of a prioritized differential diagnosis based upon history, exam and diagnostic studies, and creation of a treatment plan based upon the above information. (Patient care, Medical Knowledge)
2. Develop an understanding of the infectious disease issues pertinent to orthopedic patients including (Medical Knowledge):
a. Unique pathophysiology, epidemiology, and risk factors associated with various bone and joint infections; utility of diagnostic studies for bone and joint infections; clinical presentation of various bone and joint infections; inpatient antibiotic management of bone and joint infections, including choice of empiric vs targeted therapy; surgical approaches to bone and joint infections; outpatient antibiotic management, including duration of therapy considerations, oral antibiotic step down therapy and chronic suppressive therapy (when appropriate) clinical monitoring for adverse events, laboratory monitoring, and patient follow-up.
3. Communicate the consultation findings and recommendations both verbally and in written format clearly and appropriately to the patient and other members of the health care team. (Patient care, Professionalism, Interpersonal and Communication Skills, Systems-based Practices)
4. Demonstrate respect, compassion, and integrity towards patients along with sensitivity and responsiveness to patients’ unique experiences and treatment preferences. (Professionalism)
5. Effectively and compassionately interview the patient, family members and staff to formulate a focused clinical question and develop a comprehensive assessment of the pertinent clinical issues (Professionalism, Interpersonal and Communication Skills).
6. Serve as a role model to residents, medical students, and other medical professionals in professionalism, including timeliness, appropriate communication skills and responsible, ethical, comprehensive care. (Professionalism)
7. Communicate with ID team members, the requesting team, the patient and other care providers throughout care of the patient including initial recommendations, modifications in any established plan, and final treatment plans including additional follow up planned. (Professionalism, Interpersonal and Communication Skills, Systems Based Practice)
8. Complete consultation notes within 24 hours of evaluation including diagnoses and recommendations. Complete sign off note including scheduling of outpatient follow up within 48 hours of discharge. (Professionalism, Systems Based Practice)
9. Develop an evidence-based approach to developing a diagnostic and treatment plan through utilization of the medical literature available at UNMC both electronically and in print. Utilize this knowledge to instruct students, residents and other health care professionals about the infectious disease issues relevant to the patient including providing up to date literature. (Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Medical Knowledge)
Teaching Methods: The teaching on this rotation is primarily case-based learning which occurs both at the bedside and in didactics as stimulated by current patients. Fellows are expected to independently review topics in the literature pertinent to what is currently being evaluated on the service. A curriculum of Ortho ID related topics is also covered via lecture and selected reading over the course of 2 or more rotations as outlined below.
Call Guideline:
• On call for new consults and current inpatients entire month with following exceptions:
o Duty free 2 weekends per month (Friday 5PM to Mon 8AM)
o Duty free one weeknight (generally Wednesday)
• Fellows may be required to cross cover the general ID service depending on resident availability
Additional Education Activities:
• Fellows on the Ortho ID rotation should attend the Bone and Joint Infection and Skin and Soft Tissue lectures provided monthly to the ID inpatient team.
• Fellows should also arrange an OR visit to observe a surgical procedure. Please discuss with the Ortho ID Attending physician on-service or Dr. Hewlett to arrange.
• Fellows will also complete a brief QI project focusing on either orthopedic ID or Outpatient Antimicrobial Therapy (OPAT). Examples include defining OPAT lab monitoring, reviewing surgical prophylaxis options for a new procedure, evaluating a portion of the OPAT process, developing guidelines related a specific medication, infection, or pathogen, etc.
Evaluation: The attending physician will evaluate the progress of the ID fellow at the end of the rotation. Verbal feedback is provided mid-month and verbal feedback and a written evaluation are provided at the end of the month. Use of the mini-CEX is encouraged. The goals and objectives are reviewed at the beginning of the rotation. Fellows anonymously evaluate both the rotation and the attending physician at the end of the month.
Level of Supervision: Fellows are directly supervised by the ID attending physician who rounds daily. This attending physician is available 24 hours a day, 7 days per week if issues arise outside of typical rounding hours. The attending physician personally evaluates all new consults after the fellow and discusses treatment plans daily with the fellow. The ID attending is ultimately responsible for the care of the patients.
Educational Resources:
1. Principles and Practice of Infectious Disease (Mandell, Douglas, Bennett, 7th ed)
2. IDSA Guidelines at
Community ID Rotation
Fellow may rotate on the Community ID rotation during either their first or second year. The Community ID team consists of an ID attending, 1 nurse practitioner, and may include medical students or residents. The team rounds daily on patients with a variety of infectious disease issues. The fellow is responsible for evaluating new consultation and daily evaluating patients on the service. Rounds with the consult attending are held daily, at times set by the attending and fellow. The rotation includes both Bellevue Medical Center and Madonna Rehabilitation Hospital which is a long-term acute care facility.
Rotational Goals:
1. Fellows will evaluate patients with acute and chronic infectious diseases across the entire spectrum of the specialty.
2. Fellow will learn the diagnostic and therapeutic approach to these problems.
3. Fellow will learn to communicate recommendations with other health care providers in both written and oral form.
4. Fellow will learn to facilitate the provision of care within the entire spectrum of the health care system.
5. Fellows will develop an understanding of different models of medical practice.
Rotational Objectives:
1. The ID fellow will be able to formulate a basic approach to the evaluation of acutely ill patients with potential infectious diseases including pertinent history and physical exam, appropriate utilization and interpretation of diagnostic tests (including molecular diagnostic tests), development of a prioritized differential diagnosis based upon history, exam and diagnostic studies, and creation of a treatment plan based upon the above information. (Patient care, Medical Knowledge)
2. Communicate the consultation findings and recommendations both verbally and in written format clearly and appropriately to the patient and other members of the health care team. (Patient care, Professionalism, Interpersonal and Communication Skills, Systems-based Practices)
3. Demonstrate respect, compassion, and integrity towards patients along with sensitivity and responsiveness to patients’ unique experiences and treatment preferences. (Professionalism)
4. Effectively and compassionately interview the patient, family members and staff to formulate a focused clinical question and develop a comprehensive assessment of the pertinent clinical issues (Professionalism, Interpersonal and Communication Skills).
5. Serve as a role model to residents, medical students, and other medical professionals in professionalism, including timeliness, appropriate communication skills and responsible, ethical, comprehensive care. (Professionalism)
6. Communicate with ID team members, the requesting team, the patient and other care providers throughout care of the patient including initial recommendations, modifications in any established plan, and final treatment plans including additional follow up planned. (Professionalism, Interpersonal and Communication Skills, Systems Based Practice)
7. Complete consultation notes within 24 hours of evaluation including diagnoses and recommendations. Complete sign off note including scheduling of outpatient follow up within 48 hours of discharge. (Professionalism, Systems Based Practice)
8. Develop an evidence-based approach to developing a diagnostic and treatment plan through utilization of the medical literature available at UNMC both electronically and in print. Utilize this knowledge to instruct students, residents and other health care professionals about the infectious disease issues relevant to the patient including providing up to date literature. (Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Medical Knowledge)
Teaching Methods: The teaching on this rotation includes a large amount of case-based learning which occurs both at the bedside and in didactics as stimulated by current patient problems. It is expected fellows will independently review topics pertinent to the problems currently being evaluated on the service.
Additional Education Conferences: None
Evaluation: The attending physician will evaluate the progress of the ID fellow at the end of the rotation. Verbal feedback is provided mid-month and verbal feedback and a written evaluation are provided at the end of the month. Residents on the service will also evaluate the fellows. The goals and objectives are reviewed at the beginning of the rotation. Fellows anonymously evaluate both the rotation and the attending physician at the end of the month.
Call Guidelines:
• There is no weekend call on Community ID and all calls go to the General ID attending
• Generally on call for new consults and current inpatients entire month. Call duties may be shared with the Community ID APP.
• Fellows may be required to cross cover the general ID service depending on resident availability
Educational Resources:
1. Principles and Practice of Infectious Disease (Mandell, Douglas, Bennett, 7th ed)
2. IDSA Guidelines at
3. SHEA Guidelines at
Research Rotation
Fellows will spend at least 6 months on the research rotation. This begins with two month during the first year, but is primarily during their second year. Fellows may stay for a third year of training primarily in research. They will spend time working with their selected faculty mentor or mentors reviewing the literature, developing a hypothesis, creating a research strategy to evaluate their hypothesis, executing their planned research, analyzing the acquired data, and presenting their work both in written and verbal form. Fellows are directed to choose a specific area with well-defined hypotheses, objectives, and end-points. Mentors are chosen on the basis of the projects proposed, funding, productivity, and ability to teach and support the fellow. Fellows will be supervised during their project by their selected mentor(s). Fellows will develop and perform their project with the goal of obtaining the skills needed to independently pursue research in the future. Fellows are expected to present their research proposal and outcomes at the research conference.
A research committee is available to advise fellows on research activities. To familiarize fellows with research opportunities available in the ID Division the program coordinator will arrange meetings of the fellows with various groups of ID physicians where they can explore research opportunities available. When this is complete they will meet with the research committee (typically Nov-Dec of year 1). At that time fellows will be expected to have a proposal for what they would like to pursue as a research project. The committee will discuss this with them and provide feedback with a goal of improving the focus, efficiency, and effectiveness of subsequent research efforts. Fellows will meet with the research committee again at the start of year 2 to evaluate progress and provide further feedback. Fellows will be expected to present their research at the ID Division Research Conference during their second year.
Rotational Goals:
1. Fellows will develop an understanding of the fundamentals of research including basics of research design, data analysis (biostatistics), public policy, economics, health education, designing trials, recruiting subjects, responsible use of informed consent, standards of ethical conduct of research, clinical epidemiology, and outcomes analysis.
2. Fellows will gain hands-on experience with conducting a clinical research project including research design (where feasible), data analysis, subject recruitment, data collection, data analysis, and manuscript preparation.
3. Fellows will develop an understanding of the principles of grant and paper writing and obtain the skills needed to critically assess basic and clinical research literature
4. Fellows will obtain sufficient exposure to research to allow them to make an informed decision about pursuing a career involving research.
5. Fellows will become a co-author on a published manuscript or abstract, or present research at a national meeting.
Rotational Objectives:
1. Fellows will utilize their knowledge of clinical care to develop a research project which addresses a recognized deficit in knowledge. They will then develop a research project which may lead to improvements in patient care. They will do this using (Patient care, Medical Knowledge, Practice-Based Learning and Improvement)
2. Develop an in-depth understanding of the medical literature and laboratory techniques related to their area of research (Medical knowledge)
3. Communicate their research findings verbally and in written from clearly, concisely, and accurately to other physicians. (Professionalism, Interpersonal and Communication Skills, Systems-based Practices)
4. Demonstrate an understanding of the responsibilities and ethical standards required for research. (Professionalism, Systems Based Practice)
5. Serve as a role model to residents, medical students, and other medical professionals in professionalism, including timeliness, appropriate communication skills and responsible, ethical, behavior. (Professionalism)
Teaching Methods: Teaching will be accomplished primarily through the interaction of the fellow with their mentor. Much of the learning will be through independent review of the topic in question with input from the mentor. First year fellows will also attend the Clinical Research Symposium which is aimed at giving fellows a broad overview of the clinical research process, including study design, statistical design and analysis, ethical issues, and the Institutional Review Board application policy and procedures.
Additional Education Conferences: Clinical Research Symposium
General Expectations: Under the supervision of their mentor fellows are expected to:
1. Develop a research question and hypothesis based on a thorough review of the literature
2. Create a research strategy to evaluate their hypothesis including a research protocol and IRB if necessary
3. Execute their planned research through data acquisition and recoding
4. Analyze the acquired data in collaboration with experts in statistical analysis
5. Present their work both in written (abstract or manuscript) and verbal form (Divisional Research Conference)
Evaluation: Fellows will be evaluated by their primary mentor(s) every 2 research months. Verbal feedback is provided at least monthly and a written evaluation are provided at the end of every 2 months of research. The goals and objectives are reviewed at the beginning of the rotation. Fellows evaluate both the rotation and the mentor physician(s) at the end of two months of research. Fellows will also be evaluated on their presentation at the research conference.
Educational Resources:
1. CITI Training
2. UNMC IRB Website unmc.edu/irb/
Infection Control/Antimicrobial Stewardship Rotation
All infectious disease fellows will spend one month during their second year working with the Healthcare Epidemiology and Antimicrobial Stewardship groups at the Nebraska Medical Center. They will specifically work with Dr. Mark Rupp, the director of Healthcare Epidemiology, and Dr. Trevor Van Schooneveld, the director of Antimicrobial Stewardship. The department of Healthcare Epidemiology is actively involved in the monitoring, reporting, and control of epidemiologically significant pathogens; the development and promotion of evidence based approaches to infection prevention; and the development and promotion of methods to decrease healthcare-associated infections. The Antimicrobial Stewardship program is actively engaged in promoting the appropriate use of antimicrobials using a variety of methods including audit and feedback, education, and clinical pathways. Fellows will have the opportunity to be involved in both of the areas and learn the principles of infection control and outbreak investigation, the requirements of public reporting, and methods for improving antimicrobial use.
Rotational Goals:
1. Fellows will gain an understanding of the organization and function of a hospital infection control department including its role in data acquisition and reporting, outbreak investigation, and quality improvement
2. Fellows will appreciate the role the infection control and antimicrobial stewardship play in improving the care of hospitalized patients
3. Fellows will develop familiarity with the principles of outbreak investigations and the tools used in these investigations
4. Fellows will become familiar with the principles of antimicrobial stewardship and the tools used to improve antimicrobial use
Rotational Objectives:
1. Achieve an understanding of the organization of an infection control department and antimicrobial stewardship program, including the role of infection preventionist, hospital epidemiologist, stewardship pharmacist, and stewardship medical director (Systems-based practice)
2. Develop and understanding of how microbiologic and infection control data is acquired, organized, analyzed, interpreted, reported, and to whom it is reported (Medical Knowledge, Systems-based practice)
3. Achieve familiarity with the principles of outbreak investigation and the tools available to perform an epidemiological investigations including genetic analysis (Medical Knowledge, Systems-based practice, Interpersonal and Communication Skills, Professionalism)
4. Understand the mechanism of spread of antimicrobial resistance and methods used prevent healthcare-associated infections (Medical knowledge)
5. Become familiar with tools used to assess the quality of medical care, their application in the hospital, and the influence of regulatory bodies on infection control and stewardship (Medical knowledge, Systems-based practice, Practice-based learning and improvement)
6. Develop understanding of the clinical significance of antimicrobial resistance, the importance of antimicrobial stewardship, the methods used to improve antimicrobial use, and how these methods are implemented and measured (Medical knowledge, Systems-based practice, Interpersonal and communication skills)
7. Utilized knowledge of infectious diseases and antimicrobial stewardship to communicate evaluate antibiotic use and make appropriate stewardship interventions (Patent Care, Medical knowledge, Professionalism, Interpersonal and Communication Skills, Systems-based Practices, Practice-based learning and improvement)
Teaching Methods: The fellow will spend time observing and interacting with the infection control practitioners learning their various jobs and activities. They will participate in any meetings that are educationally valuable. A schedule of infection control experiences will be arranged by the manager of infection control. Fellows will participate in antimicrobial stewardship rounds. This will be done in EPIC and patients reviewed will be discussed with antimicrobial stewardship supervisor before communicating recommendations. Fellows will be expected to complete the Stanford Antimicrobial Stewardship Course. It is expected fellows will develop and present a small project in the area of infection control and antimicrobial stewardship. These can vary but may include write up of an outbreak investigation, development of institutional guidelines, review of a medically pertinent topic, or the creation of patient educational materials. Multiple didactic lectures on a variety of infection control and antimicrobial stewardship topics will be presented during the rotation.
Lecture Topics: Please work with Sandy to arrange time for these lectures with various faculty
1. Antimicrobial Stewardship Overview - Van
2. HAI Prevention - Rupp
3. Central line-associated Blood Stream Infections - Rupp
4. Procalcitonin - Van
5. PK-PD - Bergman
6. Stewardship Metrics - Bergman
7. Antifungal stewardship - Stohs
8. Stewardship in Ambulatory Settings - Marcelin
9. Stewardship in LTCF - Ashraf
10. VAE/VAP Prevention - Cawcutt
Education Conferences:
1. Attend weekly Healthcare Epidemiology (Tues 830AM) and Antimicrobial Stewardship meetings (Wed 9AM)
2. Attend monthly Infection Control Committee and HAI review
3. Attend monthly Healthcare Epidemiology/Stewardship Journal Club
4. Attend other regularly scheduled or ad hoc meetings attended by members of the Healthcare Epidemiology Department or Antimicrobial Stewardship personal
Evaluation: The director of Healthcare Epidemiology will evaluate the progress of the ID fellow at the end of the rotation with input from the Antimicrobial Stewardship director and the infection control practitioners who assisted in proving training. Verbal feedback is provided mid-month and verbal feedback and a written evaluation are provided at the end of the month. The goals and objectives are reviewed at the beginning of the rotation.
Educational Resources:
1. Stanford Antimicrobial Stewardship Course at
You will need to create a new Stanford Medicine account at:
and then enroll in the course at
(scroll to bottom of page and look for )
Click here for the details -> , which is also available at Stanford Medicine.
2. IDSA/SHEA Infection Control Course at
3. Antifungal Education at
4. Review Knowledge, Skills, and Competencies for IC and ASP from SHEA.
5. Hospital Epidemiology and Infection Control (Mayhall, 4th ed)
6. Practical Healthcare Epidemiology (Lautenbach, 4rd ed)
7. SHEA Guidelines at
8. CDC HICPAC Guidelines at
Outpatient Infectious Disease
Description: All infectious disease fellows will spend one month during their second year on the Outpatient ID rotation. This rotation will provide experience in treatment of viral hepatitis, subspecialty ID (oncology, transplant, orthopedic, non-tuberculous mycobacteria), travel medicine, sexually transmitted disease, wound care, dermatology, and other areas depending on fellow interest. They will work with a variety of faculty members including Drs. Mark Mailliard, Alison Freifeld, and Angela Hewlett but may also work with other faculty members. Fellows will see patients in a variety of clinical settings, which may include the Durham Outpatient Center, various NM clinics, and Douglas County Hospital. Fellows will receive a schedule outlining their rotational schedule at the beginning of the month and are expected to attend all scheduled clinics. They will evaluate patients in various clinics and present to the attending of each clinic.
Rotational Goals:
1. Fellows will become familiar with the epidemiology, diagnosis, clinical manifestations, and treatment of the various hepatitis viruses.
2. Fellows will be able to recommend a treatment regimen for patients with chronic hepatitis C infection.
3. Fellows will become familiar with the evaluation and appropriate preventative measures for travels
4. Fellows will develop an approach to a patient with a suspected sexually transmitted infection
5. Fellows will be able to evaluate, diagnose and develop a treatment plan for patients with complicated bone and joint infections
6. Fellows will become familiar with various methods and products used for complicated wound management.
Rotational Objectives:
1. The ID fellow will develop a basic approach to patients presenting with evidence of infection with chronic viral hepatitis, complicated bone and joint infections, complex wounds, and sexually transmitted disease including obtaining pertinent history and physical exam, appropriate utilization and interpretation of diagnostic tests (including molecular diagnostic tests), development of a prioritized differential diagnosis based upon history, exam and diagnostic studies, and creation of a treatment plan based upon the above information. (Patient care, Medical Knowledge)
2. Develop an understanding of the specific needs of travelers including pre-travel advice, vaccination, risk avoidance strategies, and evaluation of patients who present with illness after travel. Communicate customized pre-travel advice to patients. (Patient care, Medical Knowledge, Interpersonal and Communication Skills):
3. Communicate the consultation findings and recommendations both verbally and in written format clearly and appropriately to the patient and other members of the health care team. (Patient care, Professionalism, Interpersonal and Communication Skills, Systems-based Practices)
4. Demonstrate respect, compassion, and integrity towards patients along with sensitivity and responsiveness to patients’ unique experiences and treatment preferences, particularly in the area of sexually transmitted diseases. (Professionalism)
5. Effectively and compassionately interview the patient, family members and staff to formulate a focused clinical question and develop a comprehensive assessment of the pertinent clinical issues (Professionalism, Interpersonal and Communication Skills).
6. Serve as a role model to residents, medical students, and other medical professionals in professionalism, including timeliness, appropriate communication skills and responsible, ethical, comprehensive care. (Professionalism)
7. Complete consultation notes within 24 hours of evaluation including diagnoses and recommendations. (Professionalism, Systems Based Practice)
8. Develop an evidence-based approach to developing a diagnostic and treatment plan through utilization of the medical literature available at UNMC both electronically and in print. Utilize this knowledge to instruct students, residents and other health care professionals about the infectious disease issues relevant to the patient including providing up to date literature. (Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Medical Knowledge)
Teaching Methods: The teaching on this rotation is primarily case-based learning which occurs both at the bedside and in didactics as stimulated by current patient problems. It is expected fellows will independently review topics pertinent to the problems currently being evaluated on the service. Fellows are expected to complete the on-line IDSA Hepatitis C Curriculum and view the Hepatitis C Knowledge Network Lectures.
Evaluation: Clinic physicians who regularly work with the fellow will be asked to provide evaluations. Verbal feedback is provided mid-month and verbal feedback and a written evaluation are provided at the end of the month. The goals and objectives are reviewed at the beginning of the rotation. Fellows anonymously evaluate both the rotation and the attending physicians at the end of the month.
Level of Supervision: Fellows are directly supervised by the attending physician who is present in the clinic. This attending physician is available while the clinic is in progress and by pager if issues arise outside of typical clinic hours. The attending physician personally evaluates all new consults after the fellow and discusses treatment plans daily with the fellow. The attending physician is ultimately responsible for the care of the patients.
Educational Resources:
1. IDSA Guidelines ( )
2. American Association for Study of Liver Diseases Guidelines Hepatitis B ()
3. AASLD and IDSA Hepatitis C Guidelines ()
4. Principles and Practice of Infectious Disease (Mandell, Douglas, Bennett, 7th ed)
5. CDC Yellow Book ()
6. IDSA Hepatitis C Curriculum – on IDSA website. ()
7. IDSA Hepatitis C Knowledge Network Webinar Series – on IDSA website. Series of on-line lectures. Review during rotation. ()
8. Diagnosis and Treatment of Non-tuberculous Mycobacteria
9. Review CF Guidelines:
a. Mogayzel PJ, Naureckas ET, Robinson KA, et al. Cystic Fibrosis Pulmonary Guidelines: Chronic Medications for Maintenance of Lung Health. Am J Resp Crit Care. 2013;187;680-90.
b. Flume PA, Mogayzel PJ, Robinson KA, et al. Cystic Fibrosis Pulmonary Guidelines: Treatment of Pulmonary Exacerbations. Am J Resp Crit Care. 2009;180:802-8.
c. Floto RA, Oliveir KN, Saiman L, et al. US Cystic Fibrosis Foundation and European Cystic Fibrosis Society consensus recommendations for the management of non-tuberculous mycobacteria in individuals with cystic fibrosis. Thorax. 2016;71:i1-i22.
List of Clinics can participate in:
• Orthopedic ID, Oncology ID, Transplant ID, NTM, Travel – available weekly
• CF Clinic – once
• Wound Care Clinic – once
• STD Clinic – 2-3 times
• Viral Hepatitis Clinic – weekly
• General ID New Consult and faculty clinics – if available
Example Schedule:
| |Monday |Tuesday |Wednesday |Thursday |Friday |
|AM |HIV Clinic |Hepatitis Clinic |Transplant Clinic |Ortho ID |NTM Clinic |
|PM | CF Clinic or Derm |Wound Clinic or Derm |Oncology ID or Travel |STD Clinic | |
Contact Information:
CF Clinic: Jill Fliege, 402-559-9101, UNMC Internal Medicine Clinic
Hepatitis Clinic: Lynne Roh, 402-559-4356, Gastro and Hep. Clinic, with Dr. Mailliard, UNMC Internal Medicine Clinic
Wound clinic: Deb Kozeny, NP, 402-552-3932, pager 888-1104. UT 3250A. Call 552-3932 to confirm that day.
Travel clinic: ID Clinic, various staff
Oncology Clinic: Dr. Andrea Zimmer, pager 888-1614. 3rd floor of the Lied, Cowdry Cancer Center. Contact Dr. Zimmer to get patient list prior to clinic.
Ortho ID clinic: Dr Nicolas Cortes-Penfield, 5th Floor DOC
Transplant ID Clinic: Dr Erica Stohs, 5th Floor DOC
NTM Clinic: Dr Van Schooneveld and Starlin, 5th Floor DOC
Douglas County STD Clinic: Shannon Stafford, shannon.stafford@douglascounty-, ph: 402-444-3588. Address: 1111 S. 41st St. off of Pacific Street.
Douglas County STD Clinic: from UNMC: Out of parking garage head East on Emile Street. Turn right onto 42nd street. Turn left on Pacific Street. Turn right on 41st Str
Pediatric Infectious Disease
Description: Fellows have the opportunity to spend one month on the pediatric ID rotation. This rotation is an elective rotation during the second year. Depending on interest fellows may elect to spend more time on the pediatric ID rotation. They will primarily work with Drs. Kari Simonsen, Jessica Snowden, and Shirley Delair, but may also work with other faculty members. Residents and pediatric ID fellows are usually present on the service. The Pediatric ID service is focused on the diagnosis, treatment and prevention of infectious diseases in children. Fellows will primarily see patients in the inpatient setting, but may also see outpatients. The rotation occurs at both TNMC and Children’s Hospital. Fellows will round daily on the service.
Rotational Goals:
1. Fellows will evaluate patients with acute and chronic infectious diseases in pediatric patients.
2. Fellow will learn the diagnostic and therapeutic approach to these problems.
3. Fellows will understand the unique epidemiology, risk factors, presentations, and treatment issues relevant to pediatric infectious disease
4. Fellow will learn to communicate recommendations with other health care providers in both written and oral form.
5. Fellow will learn to facilitate the provision of care within the entire spectrum of the health care system.
Rotational Objectives:
1. The ID fellow will be able to formulate a basic approach to the evaluation of acutely ill pediatric patients with potential infectious diseases including pertinent history and physical exam, appropriate utilization and interpretation of diagnostic tests (including molecular diagnostic tests), development of a prioritized differential diagnosis based upon history, exam and diagnostic studies, and creation of a treatment plan based upon the above information. (Patient care, Medical Knowledge)
2. Develop an understanding of the infectious disease issues pertinent to pediatric patients including (Medical Knowledge):
a. Unique aspects of disease presentation and treatment, diseases primary seen in children, and disease prevention in pediatrics including vaccinations
3. Communicate the consultation findings and recommendations both verbally and in written format clearly and appropriately to the patient and other members of the health care team. (Patient care, Professionalism, Interpersonal and Communication Skills, Systems-based Practices)
4. Demonstrate respect, compassion, and integrity towards patients along with sensitivity and responsiveness to patient and families unique experiences and treatment preferences. (Professionalism)
5. Effectively and compassionately interview the patient, family members and staff to formulate a focused clinical question and develop a comprehensive assessment of the pertinent clinical issues (Professionalism, Interpersonal and Communication Skills).
6. Serve as a role model to residents, medical students, and other medical professionals in professionalism, including timeliness, appropriate communication skills and responsible, ethical, comprehensive care. (Professionalism)
7. Communicate with ID team members, the requesting team, the patient and other care providers throughout care of the patient including initial recommendations, modifications in any established plan, and final treatment plans including additional follow up planned. (Professionalism, Interpersonal and Communication Skills, Systems Based Practice)
8. Complete consultation notes within 24 hours of evaluation including diagnoses and recommendations. (Professionalism, Systems Based Practice)
9. Develop an evidence-based approach to developing a diagnostic and treatment plan through utilization of the medical literature available at UNMC both electronically and in print. Utilize this knowledge to instruct students, residents and other health care professionals about the infectious disease issues relevant to the patient including providing up to date literature. (Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Medical Knowledge)
Teaching Methods: The teaching on this rotation is primarily case-based learning which occurs both at the bedside and in didactics as stimulated by current patients. Fellows are also expected to independently review topics in the literature pertinent to what is currently being evaluated on the service.
Evaluation: The attending physician will evaluate the progress of the ID fellow at the end of the rotation. Verbal feedback is provided mid-month and verbal feedback and a written evaluation are provided at the end of the month. The goals and objectives are reviewed at the beginning of the rotation. Fellows anonymously evaluate both the rotation and the attending physician at the end of the month.
Level of Supervision: Fellows are directly supervised by the ID attending physician who rounds daily. This attending physician is available 24 hours a day, 7 days per week if issues arise outside of typical rounding hours. The attending physician personally evaluates all new consults after the fellow and discusses treatment plans daily with the fellow. The ID attending is ultimately responsible for the care of the patients.
Educational Resources:
1. IDSA Guidelines ( )
2. Principles and Practice of Infectious Disease (Mandell, Douglas, Bennett, 7th ed)
3. Red Book (American Academy of Pediatrics, 28th ed)
General ID Clinic
Fellows will attend the general ID clinic on the 5th floor of the Durham Outpatient Center (DOC) on Wednesday mornings. The clinic evaluates patients referred by other providers for evaluation of infectious disease related problems along with follow up of patients seen in the hospital by the general ID service. The fellow is expected to evaluate patients independently and present the patients to the attending physician who is ultimately responsible for any treatment decisions. The attending physician is available on site Wednesday mornings and by phone or pager at other times during the week. Any questions or issues which arise outside of usual clinic hours should be discussed with the clinic attending. Fellows are expected to participate in the monitoring and management of their patients on outpatient parenteral antimicrobial therapy which includes taking phone calls from home health care agencies.
Rotational Goals:
1. Fellows will evaluate patients with acute and chronic infectious diseases in the outpatient setting.
2. Fellow will learn the diagnostic and therapeutic approach to these problems.
3. Fellows will learn the natural course of infectious diseases.
4. Fellow will learn to communicate recommendations with other health care providers in both written and oral form.
5. Fellow will learn to facilitate the provision of care within the outpatient setting including use and monitoring of outpatient parenteral antimicrobial therapy.
Rotational Objectives:
1. The ID fellow will be able to formulate a basic approach to the evaluation of patients potential infectious diseases in the outpatient setting including pertinent history and physical exam, appropriate utilization and interpretation of diagnostic tests (including molecular diagnostic tests), development of a prioritized differential diagnosis based upon history, exam and diagnostic studies, and creation of a treatment plan based upon the above information. (Patient care, Medical Knowledge)
2. Communicate the consultation findings and recommendations both verbally and in written format clearly and appropriately to the patient and other members of the health care team. (Patient care, Professionalism, Interpersonal and Communication Skills, Systems-based Practices)
3. Interact with home health services and if needed the health department in the management of specific infectious diseases including but not limited to outpatient antibiotic therapy. (Professionalism, Systems Based Practice)
4. Demonstrate respect, compassion, and integrity towards patients along with sensitivity and responsiveness to patients’ unique experiences and treatment preferences. (Professionalism)
5. Effectively and compassionately interview the patient, family members and staff to formulate a focused clinical question and develop a comprehensive assessment of the pertinent clinical issues (Professionalism, Interpersonal and Communication Skills).
6. Serve as a role model to residents, medical students, and other medical professionals in professionalism, including timeliness, appropriate communication skills and responsible, ethical, comprehensive care. (Professionalism)
7. Complete consultation notes within 24 hours of evaluation including diagnoses and recommendations. (Professionalism, Systems Based Practice)
8. Develop an evidence-based approach to developing a diagnostic and treatment plan through utilization of the medical literature available at UNMC both electronically and in print. Utilize this knowledge to instruct students, residents and other health care professionals about the infectious disease issues relevant to the patient including providing up to date literature. (Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Medical Knowledge)
Teaching Methods: The teaching on this rotation is primarily case-based learning which occurs both at the bedside and in didactics as stimulated by current patient problems. It is expected fellows will independently review topics pertinent to the problems currently being evaluated on the service.
Evaluation: Fellows will be evaluated every 3 months by the two physicians who have supervised them the most during that time period. The goals and objectives are reviewed at the beginning of the rotation. At 6 months a 360 degree evaluation by the clinic staff and patients will be completed. Fellows anonymously evaluate both the rotation and the attending physicians every 3 months.
Level of Supervision: Fellows are directly supervised by the ID attending physician during the clinic time. This physician is available outside of clinic hours by phone or pager. The attending physician personally evaluates all patients after the fellow and discusses treatment plans with the fellow. The ID attending is ultimately responsible for the care of the patients.
Educational Resources:
1. Principles and Practice of Infectious Disease (Mandell, Douglas, Bennett, 7th ed)
2. IDSA Guidelines at
a. Tice AD, Rehm SJ, Dalovisio JR, et al. Practice guidelines for outpatient parental antimicrobial therapy. Clin Infect Dis. 2004;38:1651-72.
3. CDC HICPAC Guidelines at
HIV Clinic
Description: Fellows will participate in the HIV clinic for the entire 2 years of their fellowship. The UNMC HIV clinic is a multi-disciplinary clinic with physicians, nurse practitioners, nurses, social workers, and a specialized pharmacist focused on providing comprehensive care to those with HIV/AIDS. Fellows will be assigned a panel of at least 20 patients living with HIV (PLWH) with the goal of following those patients throughout the duration of their fellowship. Fellows will be supervised by either Dr. Bares, Dr. Fadul, Dr. Marcelin, or Dr. Swindells, who are experts in HIV care. The dedicated Fellows’ clinics will take place on Mondays and Fridays as assigned. Residents and students may also participate in the clinic at times. The clinic is located in the Specialty Care Center near the corner of 52nd St and Leavenworth St (804 S. 52nd St).
Rotational Goals:
1. Fellows will learn to evaluate and treat PLWH in all aspects of their care.
2. Fellows will become familiar the diagnosis, treatment and prevention of opportunistic infections in PLWH.
3. Fellows will recognize and be able to treat non-infectious complications of HIV and its treatment.
4. Fellows will be able to diagnose and manage co-infections, such as hepatitis B and C.
5. Fellows will become well versed in antiretroviral medications including their indications and side effects and management of virologic failure.
6. Fellows will be familiar with the unique aspects of women’s health care in HIV, including pregnancy-related issues.
7. Fellows will develop understanding of the local, state and federal resources available to help provide care and social resources for PLWH.
8. Fellows will understand how to provide medical care to PLWH using non-judgmental approaches in a vulnerable and culturally diverse patient population.
Rotational Objectives:
1. The ID fellow will be able to formulate a comprehensive approach to the evaluation of PLWH including pertinent history and physical exam, appropriate utilization and interpretation of diagnostic tests (including molecular diagnostic tests), and development of a treatment plan based upon the above information. (Patient care, Medical Knowledge)
2. Fellows will develop an understanding of the outpatient management of PLWH: (Patient care, Medical Knowledge)
a. Pathogenesis, diagnosis and staging of HIV disease
b. Determining when to initiate antiretroviral therapy and which agents to use
c. Use of resistance testing and selection of subsequent regimens
d. Treatment and prophylaxis for opportunistic infections
e. General primary care for HIV-infected patients
f. Management of the non-infectious complications of HIV and its treatment
g. Diagnosis and management of co-infections such as hepatitis B & C
h. HIV in women and women's health, including pregnancy-related issues
3. Communicate findings and recommendations both verbally and in written format clearly and appropriately to the patient and other pertinent members of the health care team. (Patient care, Professionalism, Interpersonal and Communication Skills, Systems-based Practices)
4. Interact with home health services, the health department, and other assistance agencies which may assist in providing care to PLWH. (Patient care, Professionalism, Systems Based Practice)
5. Demonstrate respect, compassion, and integrity towards patients along with sensitivity and responsiveness to patients’ unique experiences and treatment preferences. (Professionalism)
6. Effectively and compassionately interview the patient, family members and staff to formulate a focused clinical question and develop a comprehensive assessment of the pertinent clinical issues (Professionalism, Interpersonal and Communication Skills).
7. Serve as a role model to residents, medical students, and other medical professionals in professionalism, including timeliness, appropriate communication skills and responsible, ethical, comprehensive care. (Professionalism)
8. Complete notes within 24 hours of evaluation including diagnoses and recommendations. (Professionalism, Systems Based Practice)
9. Develop an evidence-based approach to developing a diagnostic and treatment plan through utilization of the medical literature available at UNMC both electronically and in print. Utilize this knowledge to instruct students, residents and other health care professionals about the infectious disease issues relevant to the patient including providing up to date literature. (Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Medical Knowledge)
Teaching Methods: The teaching on this rotation is primarily case-based learning which occurs both in the clinic and in didactic sessions. As time allows, more formal didactic teaching will occur. Lectures on HIV management are also part of the core fellow curriculum and occur every other week. It is expected that fellows will independently review topics pertinent to the patients they are managing at any given time.
Evaluation: Fellows will be evaluated every 3 months by the HIV attending physicians. At 6 months a 360 degree evaluation by the clinic staff and patients will be completed. Fellows anonymously evaluate both the rotation and the attending physicians every 3 months. Fellows will also have a Clinical Observation Checklist (mini-CEX) performed at least once per year. The goals and objectives are reviewed at the beginning of the rotation.
Level of Supervision: Fellows are directly supervised by the HIV attending physician during the clinic time. This physician is available outside of clinic hours by phone or pager. If this specific attending is not available, an on-call physician is available 24 hours a day to address any questions that arise. The attending physician personally evaluates all patients after the fellow and discusses treatment plans with the fellow. The ID attending is ultimately responsible for the care of the patients.
Fellow Responsibilities:
• Clinic attendance is a top priority and should only be missed under extenuating circumstances. Please contact Deanna Hansen (402-559-5392 or dmhansen@unmc.edu) no later than 1 month in advance if you will be unable to attend.
• Clinic starts at 8:30am. Promptness is essential to an efficient clinic.
• Volume: 1st year fellows will be expected to see at least 4 patients (including 1 new)/clinic. 2nd year fellows will be expected to see 4-6 patients (including 1 new)/clinic.
• Lab/imaging results: Fellows will be responsible for reviewing all basic lab (CBC, CMET) results within 24 hours. The remaining lab results including HIV viral loads should be reviewed within 1 week. All abnormal results should be reviewed with the attending who saw the patient with the fellow. Fellows are responsible for ensuring that the patients are contacted with the appropriate guidance regarding their lab results.
• Clinic notes: All notes should be completed within 24 hours of the patient visit.
• Documentation: All telephone encounters with patients should be documented in EPIC and cc’d to the attending.
Educational Resources:
1. DHHS AIDS Treatment Guidelines (aidsinfo.guidelines/)
2. International Antiviral Society-USA Guidelines ()
3. AIDS Education and Training Centers (aids-)
4. UCSF Clinical Consultation Center ()
5. Principles and Practice of Infectious Disease (Mandell, Douglas, Bennett, 7th ed)
6. IDSA Guidelines ( )
7. UNMC Resources (unmc.edu/intmed/id/provider_resources)
Itemized Goals and Objectives:
• Perform comprehensive continuity care for patients living with HIV
• Perform comprehensive initial evaluation of a newly-diagnosed patient with HIV
• Order HIV-focused labs and other routine tests
• Offer appropriate primary care to patients living with HIV (age-specific tests, immunizations, assessments, care, screening for TB, HBV, HCV, and other STIs)
• Report and interpret lab values
• Prevent, diagnose and provide treatment for opportunistic infections (OIs)
• Teach patient about HIV treatment options
• Initiate antiretroviral therapy (ART)
• Identify and prevent drug-drug interactions that could result from treatment of other acute and chronic medical conditions
• Recognize and manage adverse effects and metabolic complications of ART, including drug toxicities, changes in glucose metabolism, renal dysfunction, coronary artery disease, and lipid abnormalities
• Assess for mental health and substance abuse comorbidities and offer treatment and/or referral to care when appropriate
• Assess need for and assist with planning for contraception and /or conception
• Order and interpret resistance labs tests
• Modify ART based on resistance testing
HIV Clinic Performance Improvement Chart Reviews for Fellows
In addition to the appropriate medical knowledge, competency in systems-based practice and practice-based learning are increasingly important to the physician of the future. To that end, we would like all fellows to perform peer chart reviews to evaluate competency and quality of care delivery for PLWH followed in UNMC’s HIV clinic. This activity will allow fellows to “monitor their practice with a goal for improvement (Milestone 13)” while they also “learn and improve via performance audit and feedback (Milestone 14,15).”
When: Twice yearly (October and April)
How: Faculty attending will select 10 patients for each fellow to review with collection of the following measures:
1. Documentation of ART adherence
2. Documentation of employment status
3. Documentation of sexual history
4. STI screening
5. Annual lipids
6. Documentation of immunization status
7. Zoster vaccine administration
8. HPV vaccine administration
9. Bone density screening
10. Documentation of delivery of lab results (either by phone or mail) within 2 weeks of visit (or of patient preference not to receive lab results)
A REDCap database will be created to log in and to and review the results of the chart review. Abstracted results will be reviewed and feedback will be provided by HIV attending (Sara Bares).
Appendix I
HIV and Core Curriculum Topic List
Core Curriculum Topics:
Antibiotics #1 (Beta-lactams)
Antibiotics #2 (FQ, AG, macrolides, vanco/dapto)
Antibiotics #3 (Tetra, sulfa, anaerobic agents, antifungals)
Evaluation of the febrile patient, fever and rash and FUO
Skin/Soft Tissue Infections
Sepsis
ID Emergencies
Intro to Geriatrics and Infections in LTCF
UTIs
Dimorphic Fungi (histo, blasto, etc)
Non-tuberculosis Mycobacterium Diseases and Nocardia
Malaria
Tickborne and Rickettsia Disease
Lower Respiratory Tract Infection
Immunodeficiency
Cardiovascular Infections – Endocarditis and cardiac device infections
Staphylococcal Infections (S. aureus and Coag-neg Staph)
Potozoa and Parasites II (Helminths)
Gram-positive Mechanisms of Resistance
Gram-negative Mechanisms of Resistance
Career Options in ID and Practice Models
STDs and Infections of Reproductive Organs
STDs and Infections of Reproductive Organs II
Gastrointestinal Infections and Foodborne Disease
Bioterrorism Agents
Herpes Viruses – Other Herpes Viruses
Pharmacokinetics/Pharmacodynamics Applied
Tuberculosis
Intra-abdominal Infections
CNS Infections – Meningitis/Brain Abscess/Encephalitis
Transplant Infectious Disease #1
Transplant Infectious Disease #2
Transplant Infectious Disease #3
Zoonoses
Osteomyelitis/Diabetic Foot Ulcers/Prosthetic Joint Infection
Other viruses-Mumps/Rubella/Measles, Parvo, Filoviruses, Bunyaviridae
Other Mycobacterial Diseases/Nocardia
Herpes Viruses – CMV
Travel Medicine and Fever in the Returned Traveler
Arthropod-borne diseases of the tropics
Viral Hepatitis – Hep A/B/C/D/E
Upper Respiratory Tract Infection
Catheter-Related BSI and Other HAI’s (CAUTI, SSI, VAP)
Potozoe and Parasites I (Amebae, Leishmania, Trypanosomiasis, Toxo)
Clostridium difficile infection
Immunomodulatory Agents and Associated Infections
Respiratory Viruses and Influenza
Appendix II
ACGME Milestones for Infectious Disease Training
Appendix III –
ACGME Program Requirements for Infectious Disease Fellowship
Appendix IV – Evaluations
➢ Evaluation of Fellow at End of Rotation
➢ Faculty Evaluation of Research Fellow
➢ Evaluation of Attending Physician
➢ Evaluation of Research Faculty
➢ Evaluation of Rotation
➢ Clinic Evaluation
➢ Evaluation of Clinic Faculty
➢ Self-evaluation
➢ Program Evaluation
➢ Evaluation of Fellow by Resident
➢ Six-Month Consultation Evaluation with Program Director
➢ Systems Based Practice Improvement Project Evaluation
➢ 360 Degree Evaluation: Nursing Staff
➢ 360 Degree Evaluation: Patient Evaluation
➢ Milestones
Fellow Acknowledgement
I have received and read a copy of the training program handbook, including curriculum, for subspecialty training in Infectious Diseases at the University of Nebraska Medical Center.
Fellow Signature Date
Fellow Name Printed
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