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Infectious Diseases
Fellowship
2010/2011
1
INFECTIOUS DISEASE FELLOWSHIP
INTRODUCTION
Infectious Diseases remain a major cause of morbidity and mortality. New organisms have been
emerging, older pathogens re-emerging and the specter of bioterrorism requires a broad range of
knowledge. The fellowship program’s purpose is to train the Infectious Disease specialist to
treat and manage patients with Infectious diseases in a changing world.
The Infectious Disease Medicine division is proud to welcome you into our fellowship training
program. Enclosed in this notebook you will find the outline of your 2-year curriculum and
general guidelines for your entire fellowship program.
It is expected that each fellow attend all conferences that are listed on the monthly-published
calendar. Twice yearly individual evaluations of fellow performance will be conducted by the
program director. You will also be expected to evaluate the faculty and the training program.
Over the 2-year period of training, fellows will be expected to have increasing responsibility for
patient care and involvement in administrative tasks.
Infectious Disease Fellows are expected to exhibit the highest level of professionalism at all
times.
Research is a core component to the training program. Each fellow must identify a research
mentor early in the program and develop a substantive research project. A careful evaluation
process will also guide the research aspect of the program.
Please review the entire contents of this notebook and refer to it as needed throughout your
training.
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FELLOW SUPERVISION POLICY
Infectious Diseases Fellowship
The Program Director, with the assistance of attending physicians, assures that fellows are
appropriately supervised. Fellows are permitted to take on progressively greater responsibility
throughout the course of the fellowship, consistent with individual growth in clinical experience,
judgment, knowledge, and technical skill. Fellows are supervised by attending physicians so that
the fellows assume progressively increasing responsibility according to their level of education,
ability, and experience.
The Program Director, with the assistance of attending physicians, will assess fellows’
competence as the basis for determining the minimum level of supervision required for different
activities. The objective criteria used to evaluate the fellow’s progressive ability, and which will
be consistently applied, is contained in evaluation forms; program director review of fellow
competency / feedback form; procedure logs; Competency-based curriculum and objectives. This
assessment includes the evaluation of the fellow’s technical, patient management, and
communication skills and capacity to perform as required. The Program Director communicates
the assessment of the fellow’s competence to the fellow and supervising attending physician at
least annually and when significant progress or deficiencies are noted.
On-call schedules for attending physicians shall provide for supervision, that is readily available
to a fellow, on duty 24 hours per day, 7 days per week. Under circumstances in which urgent
judgments by highly experienced physicians are typically required, attending physicians must be
immediately available on site at all times. Under other circumstances, attending physicians can
provide adequate supervision off site as long as their physical presence within a reasonable time
can be assured in case of need. The Program Director assures that a schedule with the name and
contact number of the responsible attending physician is available at all times to program
fellows.
All patients seen by a fellow on an outpatient basis must be seen by, discussed with, or reviewed
by the responsible attending physician
An attending physician is responsible for and actively involved in the care provided to each
patient, both inpatient and outpatient.
An attending physician directs the care of each patient and provides the appropriate level of
supervision for a fellow, based on the nature of the patient's condition, the likelihood of major
changes in the management plan, the complexity of care, and level of education, ability,
experience, and judgment of the fellow being supervised.
The attending physician, in consultation with the program director, accords a fellow progressive
responsibility for the care of the patient, based on the fellow’s clinical experience, judgment,
knowledge, technical skill, and capacity to function.
The attending physician advises the program director if he/she believes a change in the level of
the fellow’s responsibility and supervision should be considered. The overriding consideration
must be the safe and effective care of the patient that is the personal responsibility of the
attending physician.
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The attending physician fosters an environment that encourages questions and requests for
support or supervision from the fellow, and encourages the fellow to call or inform the attending
physician of significant or serious patient conditions or significant changes in patient condition.
The fellow must be aware of his/her level of training, his/her specific clinical experience,
judgment, knowledge, and technical skill, and any associated limitations. The fellow must not
independently perform procedures or treatments, or management plans that he/she is
unauthorized to perform or lacks the skill and training to perform.
The fellow is responsible for communicating to the attending physician any significant issues
regarding patient care.
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Duty Hours
Resident duty hours are governed by ACGME guidelines and are monitored by the Graduate
Medical Education Committee via its Duty Hours Subcommittee and individual programs. All
efforts should be made to maximize educational opportunities while minimizing fatigue and
service requirements via the individual training programs and the Duty Hours Sub-Committee,
the GMEC is responsible for monitoring resident duty hours.
All schedules for the fellows are designed in a yearly format, taking into consideration all the
work hour rules. The schedule is posted in advance on a web based program (Amion.com). Any
necessary schedule changes are posted immediately to Amion.com – this program is designed to
stay within all duty hour rules. To ensure the fellow is in compliance with all duty hours
regulations, he or she will be responsible for entering their hours daily on the duty hours module
of a web based product: E Value. E-Value is set up to send email reminders to the fellows if
they do not log their hours. The program will also notify the Program Director of any duty hours
violations, or of any fellows not reporting their hours. Any duty hours violations will be reported
to the Program Director and the Program Director will work with the fellow to correct the issues
involved
Moonlighting Policy
The Internal Medicine Department of UCSF Fresno and the UCSF Fresno Infectious Diseases
Fellowship endorses the ACGME and the UCSF Fresno GMEC policy on Moonlighting.
The Moonlighting Policy, which my also be found in the UCSF Fresno Resident handbook, is as
follows:
The term “resident” denotes all levels of trainees in the UCSF Fresno Medical Education
programs.
(The department office has these forms)
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Vacation Policy
Fellows are entitled to 3 weeks of vacation and 1 week of continuing medical education activity
per year.
It is requested that the fellows work out their plans with each other regarding coverage and
present their requests to the Program Director.
NAME:___________________________________________DATE___________
DATES REQUESTED_______________________________________________
NAME OF CONFERENCE____________________________________________
ROTATION________________________________________________________
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We take the issue of fellow stress very seriously. We discuss these issues with the
fellows at orientation, and address it in our lecture series throughout the year. Fellows
are able to access (free of charge) our Employee Assistance Program, and both health
plans offered have covered services for mental or emotional issues. The Program
Director and the faculty monitor fellows for unusual behavior that could signal
impairment. In addition, UCSF Fresno has the Impaired Residents/ Fellow Policy listed
below:
Policy:
Impairment of performance by resident physicians places patients at risk. Impairment may result
from depression or other mental health/behavioral disorders, physical conditions, medical
illnesses, and substance abuse and subsequent chemical dependency. Impairment in resident
physicians will be recognized and managed as a medical/behavioral illness. This concept of
impairment allows for diagnosis, opportunity for treatment, and, with a successful recovery, an
opportunity to return to training in an appropriate capacity. This policy is written to ensure
optimal patient care, excellence in medical education, and to prevent or eliminate, to the extent
possible, impaired resident physicians.
3. To the extent that its resources allow, the UCSF Fresno Wellness Committee will
facilitate education, preliminary assessment, diagnostic evaluation, and work with the
State Diversion Program.
Procedure:
Diagnosis of Impairment
The following are signs and symptoms of impairment. Isolated instances of any of these signs
and symptoms may not impair ability to perform adequately, but if they are noted on a continual
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basis or if multiple signs are observed, any individual action may be at risk. Warning signs and
symptoms of impaired functioning may include:
1. Physical signs such as fatigue, deterioration in personal hygiene and appearance, multiple
physical complaints, accidents, eating disorders.
2. Disturbances in personal and professional relationships.
3. Social withdrawal and isolation from peers, inappropriate behavior in the professional
setting, unpredictable behavior, increased argumentativeness, and aggressive behavior.
4. Changes in professional behavior patterns such as unexplained absences, tardiness,
decreasing quality and interest in work, and inadequate professional performance.
5. Drug use indicators such as excessive agitation or edginess, dilated or pinpoint pupils,
noticeable odor of alcohol or cannabis.
Access and Reporting Process
1. If a resident physician is observed to be impaired/disabled while engaged in the
performance of his/her duties, the course of action shall be as follows The observer shall
report his/her concern immediately to a responsible supervisor, and ultimately to the
Program Director.
2. The Program Director will notify the HR Manager who will assemble the Wellness
Committee if needed. If further evaluation is thought to be warranted, the resident will
be sent for an evaluation by the addiction specialist for Fresno County. The addiction
specialist will report to the State Medical Board should that be necessary. The diversion
services of the Board will arrange appropriate treatment and monitor resident compliance.
3. The Program Director and the HR Manager will discuss the resident’s options regarding
any leave of absence and/or suspension from the Medical Education Program in
accordance with the UCSF Fresno Due Process Policy. If a leave of absence is indicated,
the resident will be informed of the decision to require a LOA as soon as possible.
4. The need for reporting to the State of California Licensing Board will be made with
consultation with the Board and University Legal Counsel and the evaluating physician.
5. Should the evaluating physician recommend a level of treatment that can be addressed
locally, the HR Manager will assist the resident in obtaining local mental health/treatment
services.
6. Should a resident about whom the concern has been expressed be determined not to be
impaired, any mention of the concern will be removed from his/her file and the individual
will be allowed to return to the Medical Education program without prejudice.
7. Appropriate and complete documentation of the events shall be performed.
Follow-up
The HR Manager will serve as liaison with the Diversion Board. When it is determined by the
Board that the resident is ready to re-enter the Medical Education Program, the HR Manager will
assist the resident in the re-entry to the Medical Education Program.
Prevention and Education Services
1. Each year during New House staff Orientation, an educational component addressing
Resident Physician Impairment policies and services will be presented.
2. Seminars addressing the Impaired Physician will be presented at least yearly in the UCSF
Fresno Wednesday Special Lecture series. This lecture series is open to all housestaff
and faculty.
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Daily rounds
CRMC
ROTATION Monday Tuesday Wednesday Thursday Friday
Pgy 5 ID Clinic HIV clinic
Pgy 4 ID Clinic HIV clinic Hep clinic
Lecture noon noon noon noon noon
Grand HIV Case Conf ID case conf ID Core Lecture UCSF 301
Rounds UMC – 12-1 Rm 333 Rm 301 Board Review
Rounds
CRMC - daily
VA
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Evaluations:
Fellows;
We follow similar policies already in effect for the Internal Medicine Residency Program. We
utilize a web based evaluation program called E-Value. Fellows will be evaluated on each
rotation by the faculty, and fellows will evaluate their attending each rotation. Peer evaluations
are also sent out to fellows, both fellow to fellow and resident to fellow. Nursing personnel also
use E-Value to evaluate fellows. All evaluations are based on the core competencies. The
evaluations are sent out by email, with reminders until the evaluations are complete. The system
also has “on the fly” evaluations which allow for concern or praise cards of either fellows or
faculty. These evaluations go directly to the Program Director. The system is also set up to send
a notice immediately both to the fellow’s mentor and Program Director if a fellow receives a less
than satisfactory score in any area of his / her evaluation. The participating hospitals send out
patient evaluations, and this information is shared on a regular basis with the Program Director.
The fellows meet as a group with the Fellowship Program Director every 4 months and as
needed. During those meetings all aspects of the fellowship program are open for discussion and
critical review is encouraged. Problems delineated from those discussions are then addressed by
the Program Director until they are resolved satisfactorily.
Two times per year, the Fellowship Program Director meets with each individual fellow and
solicits from the fellow their observations and recommendations for improvements in the
program.
Issues which require general consideration are presented at the Division’s Bi-monthly Faculty
Meeting for discussion by the entire Division faculty.
Conference attendance is expected to be 100%, with vacations as the only excuse to not attend.
Attendance record is kept in the Fellowship office.
Faculty;
At least annually, the program must evaluate faculty performance as it relates to the educational
program.
These evaluations should include a review of the faculty’s clinical teaching abilities,
commitment to the educational program, clinical knowledge, professionalism, and scholarly
activities.
The evaluation must include at lest annual written confidential evaluations by fellows. Fellows
should evaluate the faculty’s effectiveness as teacher, the effectiveness of rotation or assignment
in achieving the goals and objectives identified in the curriculum for that rotation.
The fellows must have the opportunity to assess formally the effectiveness of ambulatory
teaching on an ongoing basis.
16
GRADED RESPONSIBILITY
Fellows are assigned incrementally increasing responsibility and independence during their
training appropriate for their demonstrated level of competency and professional development
(as assessed by the supervising physicians), according to a three-tiered format as shown below.
17
ROTATION TEMPLATES - CONSULTS
First year
Second year
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Duration ½ day sessions Average patients
Name of Experience ID (months) per week seen per session
Special Services Clinic (HIV) CRMC 18 1 6
½ day Average
Duration sessions patients seen
Name of Experience ID (months) per week per session
ID Clinic CRMC 18 1 12
ID Clinic VA 5 1 5
ID Clinic (elective) CHILDRENS 1 1 10
ID Clinic (elective) KAISER 1 1 12
CORE CURRICULUM
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REQUIRED CLINICAL COMPETENCIES IN INFECTIOUS DISEASES
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Teaching conferences
Fellows are expected to present at the weekly Case Management conference as
well as the monthly Journal Club and M & M., and the weekly ID Core
conference, Chest conference, and Medicine Grand Rounds.
100% attendance is expected, vacation being the only excuse for absence.
Core Curriculum:
Conferences are held once each week, discussing each topic, one time per year.
1. The febrile patient
2. URI
3. Pleuropulmonary Infections
4. Urinary Tract Infections
5. Intra-Abdominal Infection
6. Cardiovascular Infection
7. Central Nervous System Infection
8. Skin and Soft Tissue Infection
9. Infections Related to Trauma(including bites and burns)
10. GI Infections and food poisoning
11. Bone and Joint Infections (including Prosthetic device and joint infections)
12. Infections of Reproductive Organs
13. Sexually Transmitted Diseases
14. Infections of the Eye
15. Viral hepatitis
16. Sepsis Syndromes
17. Nosocomial Infections
18. HIV Infections and its Complications
19. Infections in Neuropenic Hosts
20. Infections in Patients with Leukemia and Lymphoma
21. Infections in Marrow Transplant Patients
22. Infections in Solid Organ Transplants
23. Infections in Geriatric Patients
24. Infections in Travelers
25. Infections in Parenteral Drug Users
26. Antimicrobial Therapy – (7 sub topics)
27. Bioterrorism
28. Catheter Related Infections
29. Emerging infectious diseases and pathogens
30. Fungal Infections (7 sub topics)
31. Anaerobic infections
32. Anthrax
33. Helicobacter pylori
34. herpes viruses
35. Immunizations
36. infection control
37. influenza
38. lyme disease
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ROTATION SPECIFIC CURRICULUM
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Name of rotation: General ID Consultation Service
Division: Infectious Diseases Average Number of Months
Fellows at Hospital
Course Director: Robert Libke, M.D.
F1 F2 F3
Site(s):Fresno-CRMC 6 6
The infectious diseases consult team includes the ID attending physician, 1 to 3 residents and medical
students, an ID pharmacist and pharmacy resident and students. The general infectious diseases
consultative service at the CRMC sees a mix of both primary and tertiary care patients with a variety of
acute and chronic infectious disease problems, both in the intensive care units and on the general
medical/surgical wards. Approximately 60% of all consults are men and 40% are women. Our fellows
will see an average of 50 to 60 consultations per month covering patients across a wide range of services
including Medicine, HIV, Surgery, post transplant medicine, Neurosurgery, Ophthalmology, Ob-Gyn,
ENT, etc., as well as patients with varying degrees of severity of illness including intensive care patients.
Common presentations include: fever of unknown origin, bacteremia, infectious endocarditis, pneumonia,
empyema, meningitis, brain abscess, osteomyelitis, and urinary tract infections, to name a few. Emphasis
will be placed on generating a strong database including history, physical examination and laboratory
values including microbiology, antibiotic levels, and radiology. These data will be used to make initial
treatment plans and subsequent day-to-day treatment decisions.
CRMC has a large full-service microbiology lab. The fellows will have frequent interaction with
the microbiology laboratory personnel through their clinical rotations and the clinical
microbiology rounds, which occur almost daily. All first year fellows spend several days during
the 2 week orientation learning the basics of the clinical microbiology laboratory. Subsequently
through the rest of the year, all fellows on clinical rotations have clinical microbiology rounds
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almost daily in the microbiology lab. These rounds include acquiring knowledge of all aspects of
microbiology including: basic culture techniques, other diagnostic techniques, and appropriate
cost-effective utilization of the microbiology lab.
Fellow responsibilities:
a. The fellow will develop the on-call schedule for him/herself and for the rotating residents
Patient Care
1. Develop expertise in the epidemiology as well as in the clinical and microbiological diagnosis of
infectious diseases.
2. Read and interpret gram stains, AFB smears, fungal stains, and understand the general
principles of obtaining and interpreting microbiologic cultures and sensitivity reports.
3. Develop expertise in the management of infectious diseases.
4. Understand and utilize the principles of anti-infective management to maximize treatment
effectiveness while at the same time minimizing side effects, preventing emergence of resistant
pathogens, and promoting cost effectiveness.
Medical Knowledge
1. Discuss the major classes of antibiotics, their appropriate use, and important side effects.
2. Demonstrates knowledge of the application of microbiologic laboratory tests and their clinical
application
3. Discuss differential diagnoses for common infectious disease problems encountered in the large referral
hospital setting
73
4. Demonstrates knowledge of the pharmacology, spectrum of activity, toxicities, limitations and drug
interactions of antimicrobials utilized in treating infections, including an understanding of the
mechanisms of resistance.
5. Discuss the epidemiology and pathophysiology of common infectious diseases encountered in the
referral hospital setting.
6. Discuss the issues surrounding indications for testing, appropriate laboratory tests, and pre- and post-
test counseling for communicable infectious diseases such as TB, HIV and other sexually transmitted
diseases.
7. Discuss the basic principles guiding hospital epidemiology and infection control in the referral hospital
setting.
Practice-Based Learning
1. Perform literature searches, read textbooks and journal articles pertinent to the infectious diseases’
cases that are being seen on service.
Interpersonal and Communication Skills – See Core Competencies
1. Examines personal attitudes toward sexuality, intravenous drug abuse, cultural differences,
communicable diseases and death.
2. Recognizes the importance of quality-of-life issues.
3. Demonstrates compassion and objectivity when dealing with patients who have a chronic and
potentially life-threatening illness.
4. Appreciates the importance of support from family members and others.
5. Awareness of community and cultural attitudes toward the illness and the need for confidentiality
Professionalism – See Core Competencies
System-Based Practice – See Core Competencies
1. Practice cost-effective health care and resource allocation that does not compromise quality of care.
2. Advocate for quality patient care and assist patients in dealing with system complexities.
3. Apply principles of infection control and hospital epidemiology to the inpatient units
74
Fellows are expected to attend the following conferences while on this rotation. This is in addition to
attending/patient care rounds as outline above under fellow responsibilities.
Rev. 5/09
75
Name of rotation: General ID Consultation Average Number of Months
Service Fellows at Hospital
Division: Infectious Diseases F1 F2 F3
Site(s): Fresno VA
3 4 Required
Course Director:, Shobha Sharma, D.O.
Elective
Duration of rotation: [x] one month
VACCHCS serves veterans throughout Central California. It has 53 acute care beds with 12 ICU -
telemetry beds and 60 geriatrics extended care unit beds. On Average 30-50 inpatient infectious disease
consultation are provided per month. The inpatient ID consultative service includes patients from a
number of services including Medicine, Surgery (general surgery, orthopedics, urology, etc), and
intensive care. Patients are seen with a variety of presentations including bacteremia, infectious
endocarditis, pneumonia, empyema, meningitis, brain abscess, osteomyelitis, and urinary tract infections.
Infectious diseases more commonly seen in the veteran population and especially those in the geriatric
unit will be emphasized.
While at the VACCHCS, the fellows will have an opportunity to participate in quality improvement
measures related to infection control issues such as wound infection, ventilator associated pneumonia and
methicillin resistant Staph aureus. In addition, efforts to improve outcomes in community acquired
pneumonia and antibiotic use will be part of the experience.
The Fresno VACCHCS has an active outpatient program, including an ambulatory infectious diseases
program that will provide experience for the fellows during the rotations at the medical center. The
ambulatory experience will include providing medical care to veterans with a variety of acute and chronic
infectious diseases, diabetic complications, and other immune-compromising settings.
There are on-site microbiology and pathology labs which process cultures and biopsy specimens. Fellows
will have the chance to interact closely with microbiology and pathology staff.
Fellow responsibilities:
a) The fellow will perform all of the Infectious Diseases consultations requested.
b) The fellow will present cases to the faculty physician on clinical rounds
c) Interesting cases from the VA should be incorporated into the weekly case
conference.
d) The fellow will review all laboratory results and work with the attending physician to
appropriately act to provide patient care.
e) The fellow will take call two of the four weekends per block making certain to
maintain 1 day off in every 7 averaged over 30 days.
All objectives pertain to first and second year fellows (PGY-4,5). It is expected that the
achievement and mastery of these objectives will occur over multiple rotations.
Patient Care
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1. Develop expertise in the epidemiology as well as in the clinical and microbiological diagnosis of
infectious diseases.
2. Read and interpret gram stains, AFB smears, fungal stains, and understand the general
principles of obtaining and interpreting microbiologic cultures and sensitivity reports.
3. Develop expertise in the management of infectious diseases.
4. Understand and utilize the principles of anti-infective management to maximize treatment
effectiveness while at the same time minimizing side effects, preventing emergence of resistant
pathogens, promoting cost effectiveness.
Medical Knowledge
1. Discuss the major classes of antibiotics, their appropriate use, and important side effects.
2. Demonstrates knowledge of the application of microbiologic laboratory tests and their clinical
application
3. Discuss differential diagnoses for common infectious disease problems encountered in the large referral
hospital setting
4. Demonstrates knowledge of the pharmacology, spectrum of activity, toxicities, limitations and drug
interactions of antimicrobials utilized in treating infections, including an understanding of the
mechanisms of resistance.
5. Discuss the epidemiology and pathophysiology of common infectious diseases encountered in the
referral hospital setting.
6. Discuss the issues surrounding indications for testing, appropriate laboratory tests, and pre- and post-
test counseling for communicable infectious diseases such as TB, HIV and other sexually transmitted
diseases.
7. Discuss the basic principles guiding hospital epidemiology and infection control in the referral hospital
setting.
Practice-Based Learning
1. Perform literature searches, read textbooks and journal articles pertinent to the infectious disease cases
that are being seen on service.
Interpersonal and Communication Skills – See master list for these competencies.
1. Examines personal attitudes toward sexuality, intravenous drug abuse, cultural differences,
communicable diseases and death.
2. Recognizes the importance of quality-of-life issues.
3. Demonstrates compassion and objectivity when dealing with patients who have a chronic and
potentially life-threatening illness.
4. Appreciates the importance of support from family members and others.
5. Awareness of community and cultural attitudes toward the illness and the need for confidentiality
Professionalism – See master list for these competencies.
System-Based Practice
1. Practice cost-effective health care and resource allocation that does not compromise
quality of care.
2. Advocate for quality patient care and assist patients in dealing with system complexities.
3. Apply principles of infection control and hospital epidemiology to the Fresno VA inpatient units
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[x] Handouts on relevant topics [x] Articles from the literature
[x] Other: Small group discussion of prepared [x] Case studies
cases
Rev 5//09
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Name of rotation: Pediatric Infectious Diseases Consultation Service
Division: Infectious Diseases
Site(s): Children’s Hospital of Central California, Madera, CA
Course Directors: David Pugash, M.D. & James McCarty, M.D.
The Children’s Hospital of Central California has 255 beds. On average 25-30 inpatient infectious disease
consultations are provided per month. The fellowship elective rotation at Children’s Hospital of Central
California will include both inpatient and outpatient experiences. The fellows will experience the practice
of the specialty of Pediatric Infectious Diseases in a medical center that serves both as a primary care
facility and as a referral center for the care of children.
The inpatient ID consultative service includes patients from a number of services including pediatric
medicine, cardiology, surgery (general surgery, orthopedics, urology, etc), intensive care, oncology and
neurologic services. Patients are seen with an array of acute and chronic infections. Infectious diseases
more commonly seen in the pediatric population and especially those related to immunologic and genetic
disorders will be emphasized. Educational experiences in dealing with viral illness and prevention of
infectious illnesses by vaccination will be prominent during this rotation.
The Pediatric Infectious Diseases rotation includes an active ambulatory pediatric infectious disease
experience for the fellows during their time at that medical center. The clinic experience will include
providing medical care to children with HIV disease and with a mixture of acute and chronic infectious
diseases such as coccidioidomycosis, osteomyelitis, infections in compromised pediatric hosts, and a
variety of viral illnesses.
Fellow responsibilities:
f) The fellow will perform all of the Infectious Diseases consultations requested.
g) The fellow will present cases to the faculty physician on clinical rounds
h) Interesting cases from the Children’s Hospital should be incorporated into the weekly
case conference.
i) The fellow will review all laboratory results and work with the attending physician to
appropriately act to provide patient care.
All objectives pertain to first and second year fellows (PGY-4,5). It is expected that the
achievement and mastery of these objectives will occur over multiple rotations.
Patient Care
1. Develop knowledge in the epidemiology as well as in the clinical and microbiological diagnosis of
pediatric infectious diseases.
2. Read and interpret gram stains, AFB smears, fungal stains, and understand the general
principles of obtaining and interpreting microbiologic cultures and sensitivity reports.
3. Develop knowledge in the management of pediatric infectious diseases.
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4. Understand and utilize the principles of anti-infective management in pediatric patients to maximize
treatment effectiveness while at the same time minimizing side effects, preventing emergence of resistant
pathogens, promoting cost effectiveness.
Medical Knowledge
1. Discuss the major classes of antibiotics, their appropriate use, and important side effects.
2. Demonstrates knowledge of the application of microbiologic laboratory tests and their clinical
application
3. Discuss differential diagnoses for common pediatric infectious disease problems encountered in the
large referral hospital setting
4. Demonstrates knowledge of the pharmacology, spectrum of activity, toxicities, limitations and drug
interactions of antimicrobials utilized in treating infections, including an understanding of the
mechanisms of resistance.
5. Discuss the epidemiology and pathophysiology of common pediatric infectious diseases encountered in
the referral hospital setting.
6. Discuss the issues surrounding indications for testing, appropriate laboratory tests, and pre- and post-
test counseling for communicable infectious diseases such as TB and HIV.
7. Discuss the basic principles guiding hospital epidemiology and infection control in the referral hospital
setting.
Practice-Based Learning
1. Perform literature searches, read textbooks and journal articles pertinent to the pediatric infectious
disease cases that are being seen on service.
Interpersonal and Communication Skills – See master list for these competencies.
1. Examines personal attitudes toward sexuality, intravenous drug abuse, cultural differences,
communicable diseases and death.
2. Recognizes the importance of quality-of-life issues.
3. Demonstrates compassion and objectivity when dealing with patients who have a chronic and
potentially life-threatening illness.
4. Appreciates the importance of support from family members and others.
5. Awareness of community and cultural attitudes toward the illness and the need for confidentiality
Professionalism – See master list for these competencies.
System-Based Practice
1. Practice cost-effective health care and resource allocation that does not compromise
quality of care.
2. Advocate for quality patient care and assist patients in dealing with system complexities.
3. Apply principles of infection control and hospital epidemiology to the Children’s Hospital inpatient
units
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[x ] Evaluation of attending teaching skills and other attributes
[x ] Rotation assessment by fellow
[x ] Observation of fellow's clinical competency
[x ] Observation of fellow's leadership and teaching skills
[x ] Review of the fellow's history/physical exam, progress notes and documentation
of procedures in the chart
[x ] Fellow's attendance of rounds and conferences monitored
[ ] Other: ________________________
Rev: 5/09
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Name of rotation: General Infectious Diseases Service
Division: Infectious Diseases
Course Director: Dee A. Lacy, MD, Ph.D.
Site(s): Kaiser Permanente Fresno Medical Center
The Infectious Disease Fellows will provide first contact for requested consultations and will be supervised
by Board Certified Infectious Disease faculty members who are experienced Kaiser medical staff
physicians. Emphasis will be placed on generating a strong database including history, physical
examination and laboratory values including microbiology, antibiotic levels, and radiology. These data
will be used to make initial treatment plans and subsequent day-to-day treatment decisions.
The Fellows will also have a rich ambulatory experience with an opportunity to see, again on a first contact
basis, a variety of infectious disease problems in a busy Infectious Diseases Clinic. The patients include
those with fungal infections (especially coccidioidomycosis), HIV infection, osteomyelitis, mycobacterial
infections, and chronic pulmonary infections.
The Fellows will have an opportunity to participate in a mix of quality improvement activities in the
Kaiser system, including infection control and epidemiology with monitoring of ventilator associated
pneumonia, as well as surgical site , blood stream and urinary tract infections. They will also participate
in antibiotic use and monitoring and the surveillance of daily microbiologic reports.
Fellow responsibilities:
j) The fellow will perform all of the Infectious Diseases consultations requested.
k) The fellow will present cases to the faculty physician on clinical rounds
l) Interesting cases from the Kaiser Hospital should be incorporated into the weekly
case conference.
m) The fellow will review all laboratory results and work with the attending physician to
appropriately act to provide patient care.
All objectives pertain to first and second year fellows (PGY-4,5). It is expected that the
achievement and mastery of these objectives will occur over multiple rotations.
Patient Care
1. Develop expertise in the epidemiology as well as in the clinical and microbiological diagnosis of
infectious diseases.
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2. Read and interpret gram stains, AFB smears, fungal stains, and understand the general
principles of obtaining and interpreting microbiologic cultures and sensitivity reports.
3. Develop expertise in the management of infectious diseases.
4. Understand and utilize the principles of anti-infective management to maximize treatment
effectiveness while at the same time minimizing side effects, preventing emergence of resistant
pathogens, promoting cost effectiveness.
Medical Knowledge
1. Discuss the major classes of antibiotics, their appropriate use, and important side effects.
2. Demonstrates knowledge of the application of microbiologic laboratory tests and their clinical
application
3. Discuss differential diagnoses for common infectious disease problems encountered in the large referral
hospital setting
4. Demonstrates knowledge of the pharmacology, spectrum of activity, toxicities, limitations and drug
interactions of antimicrobials utilized in treating infections, including an understanding of the
mechanisms of resistance.
5. Discuss the epidemiology and pathophysiology of common infectious diseases encountered in the
referral hospital setting.
6. Discuss the issues surrounding indications for testing, appropriate laboratory tests, and pre- and post-
test counseling for communicable infectious diseases such as TB, HIV and other sexually transmitted
diseases.
7. Discuss the basic principles guiding hospital epidemiology and infection control in the referral hospital
setting.
Practice-Based Learning
1. Perform literature searches, read textbooks and journal articles pertinent to the infectious disease cases
that are being seen on service.
Interpersonal and Communication Skills – See master list for these competencies.
1. Examines personal attitudes toward sexuality, intravenous drug abuse, cultural differences,
communicable diseases and death.
2. Recognizes the importance of quality-of-life issues.
3. Demonstrates compassion and objectivity when dealing with patients who have a chronic and
potentially life-threatening illness.
4. Appreciates the importance of support from family members and others.
5. Awareness of community and cultural attitudes toward the illness and the need for confidentiality
Professionalism – See master list for these competencies.
System-Based Practice
1. Practice cost-effective health care and resource allocation that does not compromise
quality of care.
2. Advocate for quality patient care and assist patients in dealing with system complexities.
3. Apply principles of infection control and hospital epidemiology to the Kaiser Hospital inpatient units
83
cases
Rev. 5/09
84
Name of rotation: Transplant Infectious Diseases Service
Division: Infectious Diseases
Site(s): University of California, San Francisco Moffitt Hospital
Course Director: Peter Chin-Hong, MD
Fellow responsibilities:
a. The patients to be managed on the transplantation service include solid organ and bone
marrow transplants.
b. The fellow receives the calls for consultations and he/she will then evaluate the patient.
c. The patient will be presented to the transplant attending for teaching and review of the
plan of management.
d. The fellow will then be involved in the discussions with the primary service regarding the
final plan of action.
e. The fellows will participate in ID transplant rotation conferences
f. Interesting cases from the San Francisco Moffitt Hospital should be incorporated into the
weekly case conference.
g. The fellow will take call two of the four weekends per block making certain to maintain 1
day off in every 7 averaged over 30 days.
All objectives pertain to first and second year fellows (PGY-4,5). It is expected that the
achievement and mastery of these objectives will occur over multiple rotations.
Patient Care
1. Develop expertise in the epidemiology as well as in the clinical and microbiological diagnosis of
infectious diseases in immunosuppressed patients.
2. Read and interpret gram stains, AFB smears, fungal stains, and understand the general
principles of obtaining and interpreting microbiologic cultures and sensitivity reports.
3. Develop expertise in the management of transplant infectious diseases.
85
4. Understand and utilize the principles of anti-infective management to maximize treatment
effectiveness while at the same time minimizing side effects, preventing emergence of resistant
pathogens, and promoting cost effectiveness.
Medical Knowledge
1. Discuss the major classes of antibiotics, their appropriate use, and important side effects.
2. Demonstrates knowledge of the application of microbiologic laboratory tests and their clinical
application in transplant patients.
3. Discuss differential diagnoses for transplant-related infectious disease problems encountered in
the large referral hospital setting
4. Demonstrates knowledge of the pharmacology, spectrum of activity, toxicities and limitations of
antimicrobials utilized in treating infections, including an understanding of the mechanisms of
resistance.
5. Understand adverse reactions and drug-to-drug interactions of commonly used post-transplant
immuosuppressive agents
6. Discuss the epidemiology and pathophysiology of common transplant-related infectious diseases
encountered in the referral hospital setting.
7. Discuss the basic principles guiding hospital epidemiology and infection control in the referral
hospital setting.
Practice-Based Learning
1. Perform literature searches, read textbooks and journal articles pertinent to the infectious disease cases
that are being seen on service.
Interpersonal and Communication Skills – See master list for these competencies.
1. Examines personal attitudes toward sexuality, intravenous drug abuse, cultural differences,
communicable diseases and death.
2. Recognizes the importance of quality-of-life issues.
3. Demonstrates compassion and objectivity when dealing with patients who have a chronic and
potentially life-threatening illness.
4. Appreciates the importance of support from family members and others.
5. Awareness of community and cultural attitudes toward the illness and the need for confidentiality
Professionalism – See master list for these competencies.
System-Based Practice
1. Examines personal attitudes toward sexuality, intravenous drug abuse, cultural differences,
communicable diseases and death.
2. Recognizes the importance of quality-of-life issues.
3. Demonstrates compassion and objectivity when dealing with patients who have a chronic and
potentially life-threatening illness.
4. Appreciates the importance of support from family members and others.
5. Awareness of community and cultural attitudes toward the illness and the need for confidentiality
quality of care.
2. Advocate for quality patient care and assist patients in dealing with system complexities.
3. Apply principles of infection control and hospital epidemiology to the Fresno VA inpatient units
86
[x] Handouts on relevant topics [x] Articles from the literature
[x] Other: Small group discussion of prepared [x] Case studies
cases
We will need to get the conf schedule @ San Francisco Moffitt Hospital
87
Name of rotation: Special Services Clinic (HIV) Division: Infectious Diseases
88
1. Develop and maintain a willingness to learn from errors.
2. Locate, appraise and assimilate evidence from scientific studies related to their patients’ health
problems.
Interpersonal and Communication Skills
1. Demonstrate the ability to create and maintain a therapeutic relationship with patients and
families.
2. Communicate effectively and respectfully with the referring physician and other members of the health
care team.
System-Based Practice
1. Demonstrate commitment to the practice of cost-effective medical care.
2. Anticipate problems patients/care givers may face in negotiating the health care system and
advocate on the patient’s behalf.
3. Identify and work with other health care professionals and organizations that may assist in a
patient’s care.
4. Partner with members of the health-care team to manage complex patient issues.
89
[x ] Individual instruction of procedures [x ] Review of diagnostic studies,
[ ] Other: ________________________ including radiology
Rev. 5/09
90
General Clinic Organization, HIV
Scheduling:
General stuff:
--Clinic starts at 8:30 (first patient is scheduled at 8:15 and should be registered, vital signs done
by 8:30).
--after having their vital signs done, patients wait in the clinic waiting room. When you are ready
to see the patient, get them from the waiting room, introduce yourself if they do not already
know who you are, and take them to the exam room you will be using.
--If the patient is not in the waiting room they may be meeting with their case manager
somewhere. Unless you are very short of time, try not to interrupt their meeting but wait until the
case manager finishes and then go get the patient from the waiting room. The case managers try
to work around the provider’s schedule, so this doesn’t happen often.
--when you are done seeing the patient, send them back to the waiting room. That’s where their
case manager will look for them and that’s where the nursing staff will look for them if they need
any vaccines/injections etc.
--It’s fine to use the computers in the exam room, but make sure to close windows etc. if patients
can view the screen so as to protect other patient’s confidentiality. If you are using the computer
in the exam room be very careful about leaving patients alone in the room when you are not there
(i.e. don’t). You can click on the encentuate icon in the lower right corner of the toolbar to close
all windows and lock the computer if you need to.
Scheduling:
--New patients and your own patients will be added to your schedule without contacting you if
there is an available appointment.
--Case managers will check with you first prior to adding on any: same-day add-on
appointments, overbooked patients, or to have you see another provider’s patient.
--If you do not have an appointment slot available, case managers will contact you to get your
OK for your patient to see another provider (vs. waiting to be seen by you if that’s a reasonable
alternative).
--Canceling clinics/vacation dates: please give six weeks notice to cancel a clinic date. If you
need to cancel a clinic with less than six weeks notice then provide an alternate clinic session for
the patients to be moved to. Email all schedule change requests to Karla
(kvilla@communitymedical.org) and me as well.
Paper flow:
--We do not use the med sheet in the medical paper chart. Instead we print out the active
medications at each appointment, the provider signs off on that list, and the front desk staff adds
that current med list to the paper chart.
--Labtracker IS NOT the official medical record, so anything that needs to be in the medical
record has to be printed out and sent off for filing….
--return the billing sheet, order sheet (either orders on the progress note or the separate sheet with
instructions), labsheet, and prescriptions to the front desk staff. They will give everything to the
patient when they give them their next appointment date.
Labtracker:
(Detailed instructions regarding how to do these things are attached below)
--Prescriptions: ALL prescriptions need to be entered in labtracker. This includes rx’s such as
narcotics that have to be written by hand
--clinic visit notes: you can type these in labtracker OR write your note by hand and enter a 2-3
sentence summary in labtracker so that covering providers/case managers know what’s going on
--health maintenance: this screen also has to be updated. Case managers also help update these
fields, but ultimately it’s the primary provider’s responsibility to document that health
maintenance has been completed. Our performance reporting to the federal gov’t is extracted
91
automatically from the health maintenance screen so it’s critical this be updated: writing that
something was done in your progress note isn’t enough.
Health Maintenance:
As we are the patient’s primary care provider, all recommended health maintenance for all
conditions/age/sex that’s indicated should of course be done. Specific to HIV, the things we care
about are:
--Baseline labs get done (including hep serologies, lipids, repeat HIV ab test if not in chart, u/a,
gc/Chlamydia, toxo IgG, cmv ab, cd4/hiv vl)
--PAP Smears: at least yearly
--PPD or quantiferon yearly
--VDRL q 6 months
--Adherence counseling
--assessment of drug use, risk assessment/prevention/safe sex
If you want to know if your patient is due for anything, click on the “decision support” box that
is on the main patient screen when you first select your patient from the active patient list. (note:
check with the patient before ordering anything. Sometimes it will say a ppd is due, but actually
they have had a +PPD in the past and they really just need questioning re if they have
symptoms/signs of active tb as their particular yearly tb screening)
The specific health maintenance outcomes that we monitor at present and our minimum
acceptable levels are:
PPD: at least 40% of active patients should be up to date (last ppd within 12 mo)
PAP: at least 40% of active patients should be up to date (last pap within 12 mo)
RPR: at least 50% of active patients should be up to date (last vdrl within 12 mo)
Conferences:
Each Tuesday at noon we have the clinic case conference. The first Tuesday of the month we go
over patients in the MediCal Waiver/CMP intensive case management program. The other
Tuesdays we go over the previous week’s patients that came to clinic. Each week we also try and
go over new patients that will be coming in the next week, and any inpatients on the HIV service.
The primary purpose of this conference is to coordinate care between the various providers, case
managers, and clinic staff.
The current format is for the casemanager to present first, then the physician or psychiatrist. It’s
helpful for people to know a few basic things about where you patient is at clinically, where they
are going and any new/unusual issues that came up. For example: “has a low cd4 count but is
planning to begin arv’s at their next visit. They were hospt for pcp but currently they feel fine…”
LabTracker Orientation:
Entering Medications:
1. Find patient in patient list, select patient
2. click on “medication” tab, med list should appear (note you can select “all meds” or “active
meds” and various other options from the combo box near the top of the med list)
3. to add a new medication click on “new med”
3a. search for the med in the search box, click on the name once it appears
92
3b. enter a dose in the first box (has to include a number)
3c. select a dosing interval (i.e “bid”) in the next box
3d. click on done
Inactivating a medication:
Just enter a date in the “end date” window for that medication. You can enter a reason if you feel
like it in the next box over…
Health Maintenance:
This section is kind of a pain, but here are some tips:
If a test already has info recorded (i.e. a ppd was done 16 months ago), just click on the box in
the “click for more dates” column and go with whatever it asks for in the next window.
If no info has ever been entered for that test, if you click on that box, you will get a message
about “adding a new test”. That doesn’t mean adding a new test to labtracker, it just means that
you are adding new test info for that patient! So click on the “new test/imm” box near the top left
and select a test that is already on the list in the window that will appear. Do not click on the
“new test” option at that point as that option is for adding a completely new test that labtracker
has never heard of before...
Visits:
Often by the time you get around to writing your note, the front desk staff will have already
entered the visit date and possibly visit type/provider info. If not, here’s what needs to be
entered:
Go to the “Visits” tab (top right area when you have selected a patient),
Click on “new visit date” and enter a date
Click on “visit type” and select “routine clinic visit”
Select your name under “provider”
Enter a time, length of visit (ballpark), and select “attended”
If you asked the patient about adherence, click on the “y” box over on the left under adherence
and fill in that pop up window.
Once you have done the above, you can either write a quick summary in the “visit comments”
box (2-3 sentences) and initial that (and write a regular progress note by hand), OR, click on
“edit soap” and write your note in labtracker (easier than it sounds once you figure out how to
enter them). If you write your note in labtracker you need to print it out and sign it to go off to
the paper chart.
93
LabTracker Orientation:
Entering Medications:
1. Find patient in patient list, select patient
2. click on “medication” tab, med list should appear (note you can select “all meds” or “active
meds” and various other options from the combo box near the top of the med list)
3. to add a new medication click on “new med”
3a. search for the med in the search box, click on the name once it appears
3b. enter a dose in the first box (has to include a number)
3c. select a dosing interval (i.e “bid”) in the next box
3d. click on done
Inactivating a medication:
Just enter a date in the “end date” window for that medication. You can enter a reason if you feel
like it in the next box over…
Health Maintenance:
This section is kind of a pain, but here are some tips:
If a test already has info recorded (i.e. a ppd was done 16 months ago), just click on the box in
the “click for more dates” column and go with whatever it asks for in the next window.
If no info has ever been entered for that test, if you click on that box, you will get a message
about “adding a new test”. That doesn’t mean adding a new test to labtracker, it just means that
you are adding new test info for that patient! So click on the “new test/imm” box near the top left
and select a test that is already on the list in the window that will appear. Do not click on the
“new test” option at that point as that option is for adding a completely new test that labtracker
has never heard of before...
Visits:
Often by the time you get around to writing your note, the front desk staff will have already
entered the visit date and possibly visit type/provider info. If not, here’s what needs to be
entered:
Go to the “Visits” tab (top right area when you have selected a patient),
Click on “new visit date” and enter a date
94
Click on “visit type” and select “routine clinic visit”
Select your name under “provider”
Enter a time, length of visit (ballpark), and select “attended”
If you asked the patient about adherence, click on the “y” box over on the left under adherence
and fill in that pop up window.
Once you have done the above, you can either write a quick summary in the “visit comments”
box (2-3 sentences) and initial that (and write a regular progress note by hand), OR, click on
“edit soap” and write your note in labtracker (easier than it sounds once you figure out how to
enter them). If you write your note in labtracker you need to print it out and sign it to go off to
the paper chart.
95
Name of rotation: Infectious Diseases Outpatient Clinic
Division: Infectious Diseases
Fellow responsibilities:
a) The fellow will see and evaluate patients referred to the clinic for consultation.
b) The fellow will present the patients to the faculty physician to develop the plan for
management.
c) The fellow will review the laboratory and radiology results returned to the clinic that are not
on the EMR and address those results that require immediate action while forwarding others
to the appropriate provider.
d) The fellow will be responsible for prescription refills for their own patients and if there is no
assigned attending physician. The one exception is pain medications and other controlled
substances.
e) The fellow will be primarily responsible for answering phone consultations by outside
physicians and discuss them with the attending physician as required.
Rev: 5/09
98
Research
In the Second year of the fellowship, the majority of the time will be spent in Research
As research director for the internal medicine residency program, Dr. Simon Paul has been very
involved in teaching research methods. In the year 2008, we began an interactive research design
workshop for fellows in specialty training; this course is required for infectious disease fellows.
This research course assists fellows in developing their research projects by providing training in
research design, data analysis and statistics and also by providing exposure to basic science
methodologies. The bi-monthly course also provides a forum for fellows in training to present
their ongoing research projects.
Our program has developed a broad range of research interests that will provide a foundation for
fellows in infectious disease to gain research training. Dr. Simon Paul is the Principal
Investigator of an NIHfunded study using exercise testing and isotopic tracers to study the
effects of antiretroviral therapy on glucose and lactate metabolism. He plans to go forward with
this methodology in the future to study more broadly the effects of infections on metabolism and
mitochondrial function. Dr. Paul has also served as the local PI for an NIH funded multi-center
study validating in Spanish an adolescent risk for HIV infection survey. In addition Dr. Paul has
received funding to establish an internet based patient education center in the HIV clinic and is
currently mentoring internal medicine residents studying the effectiveness of this approach.
Our HIV program also served as a site for the CPCRA SMART study of structured treatment
interruptions for antiretroviral therapy and has participated in several industry-funded clinical
trials, thus providing opportunities for fellows training in infectious disease to participate in
multi-center clinical trials.
Fungal meningitis is also an area of active investigation. Dr. Paul has also collaborated with Dr.
Roger Mortimer in a study of risk factors for cryptococcal meningitis in HIV infected patients.
Dr. Robert Libke is studying the epidemiology of coccidioidal meningitis and Dr. Tanya
Warwick of neurology is studying the use of transcranial doppler for prediction of complications
of fungal meningitis.
99
weekly HCV clinic and participate in evaluating and initiating HCV treatment as outlined in
these studies.
Participating Institutions:
1.Community Regional Medical Center: (CRMC)
Site Director, Robert Libke, M.D.
2823 Fresno Street – Main Campus
See page 57 for Specific Rotation Information
Cedar Campus
Site Director, HIV, Simon Paul, M.D.
445 South Cedar - Clinic Campus
See page 76 for Specific Rotation Information
100
Faculty requirements:
In addition to the program director, each program must have two key clinical faculty. Key
clinical faculty are attending physicians who dedicate, on average, 10 hours per week throughout
the year to the training program.
In addition to the responsibilities of all individual faculty, the key clinical faculty with the
Program director, are responsible for the planning implementation, monitoring and evaluation of
the fellows’ clinical and research training.
Some members of the faculty should also demonstrate scholarship by one or more of the
following:
1. peer-reviewed funding
2. publication of original research or review articles in peer reviewed journals or
chapters in textbooks.
3. publication or presentation of case reports or clinical series at local, regional, or
national professional and scientific society meetings; or,
4. participate in national committees or educational organizations.
5. faculty should encourage and support fellows in scholarly activities.
At each participating site, there must be a sufficient number of faculty with documented
qualifications to instruct and supervise all fellows at that location. They must:
1. devote sufficient time to the educational program to fulfill their supervisory and
Teaching responsibilities and to demonstrate strong interest in the education
2. administer and maintain an educational environment conductive to educating the
Fellows
The nonphysician faculty must have appropriate qualifications in their field and hold appropriate
institutional appointments.
The faculty must establish and maintain an environment of inquiry and scholarship with an
active research component.
The faculty must regularly participate in organized clinical discussions, rounds, journal clubs and
conferences.
101
Facilities and Resources
The institution and the program must jointly ensure the availability of adequate resources
for fellow education, as defined in the specialty program requirements.
Fellows must have clinical experiences in efficient, effective ambulatory and inpatient care
settings.
There must be space and equipment for the educational program, including meeting rooms,
classrooms, examination rooms, computers, visual and other educational aids, and work/study
space.
Fellows must have lounge and food facilities during assigned duty hours.
Medical Records:
Clinical records that document both inpatient and ambulatory care must be readily
available at all times.
Patient Population:
The inpatient and ambulatory care population must provide experience with patients
whose illnesses are encompassed by, and help to define, the fellowship.
There must be patients of both sexes with a broad age range, including geriatric patients.
Support Services:
Administrative support must include adequate secretarial and administrative staff and
technology to support the program director.
102
39. malaria
40. parasites
41. parvovirus
42. rabies
43. SARS
44. Septic Shock
45. Small Pox
46. Zoonosis
20
Curriculum for Fellowship Training in Clinical Infectious Diseases
UCSF-Fresno MEP
Educational Purpose
Infectious Diseases remain a major cause of morbidity and mortality. In addition, new
organisms have been emerging, older pathogens have been re-emerging and the specter of
bioterrorism requires a broad range of knowledge for physicians practicing clinical infectious
diseases. The purpose of the fellowship program at UCSF-Fresno is to broadly train our fellows
to treat and manage patients with infectious diseases in a changing world. The fellows serve as
consultants in the hospital as well as in the outpatient setting. For patients with HIV, hepatitis C
and other chronic infections, the fellows follow the patients longitudinally and commonly serve
as the primary care providers. Upon completion of training the fellows are required to be
competent specialists in our field. Demonstration of competency will be evaluated by using the
following competencies.
Core Competencies
1. Patient Care
a. Clinical skills needed to achieve competency include: ability to obtain an accurate
history focusing on the issues of particular interest to infectious diseases and
perform a complete and accurate physical exam. The fellow must also
demonstrate the ability to accurately review medical records.
b. Patient management skills are necessary to achieve competency. The skills to be
evaluated are: the ability to synthesize patient data and the literature to come to an
accurate differential diagnosis, demonstration of sound clinical judgment,
appropriately use antimicrobial agents and other approaches to therapy, and
incorporation of the patient preferences into the final plan.
2. Medical Knowledge
a. The fellow must demonstrate a mastery of the literature in Infectious Diseases.
b. Understanding etiologic agents and the pathogenesis of diseases is a required skill
to achieve competency.
c. The appropriate use of antimicrobial agents is an important skill that must be
mastered.
d. Access and critically evaluate the medical literature. This will demonstrate
evidence of independent scholarship.
e. Apply an open minded and analytical approach to acquiring new knowledge.
23
CORE CURRICULUM
CORE COMPETENCIES
5. Professionalism
a. The fellow is expected to demonstrate respect, compassion and integrity when
working with patients and families.
b. The fellow is expected to demonstrate respect and integrity with fellow physicians
and healthcare providers.
c. The fellow is required to adhere to HIPAA standards for patient confidentiality.
d. The fellow is expected to adhere to principles of scientific and academic integrity.
e. The fellow should demonstrate the ability to recognize and identify deficiencies in
peer performance in a constructive manner.
f. The fellow must take responsibility for providing quality patient care.
g. The fellow must acknowledge mistakes without being defensive.
6. System-Based Practice
a. Be able to work at all medical facilities understanding the systems available for
patient care.
b. Identify the infectious diseases that are reportable to state and county health
departments.
c. Work within regional and national medical systems to deliver optimal medical
care.
d. Participate in quality improvement activities to optimize patient care.
e. Maintain credentials to be an active member of the medical staff.
f. If performing clinical research, maintain certification to achieve the expected
completion of the clinical projects.
g. Appropriate use of on-line resources to access information.
24
CORE CURRICULUM
Teaching Methods
The primary method of teaching is at the patient’s bedside. The fellow evaluates the
patient and the faculty member supervises and helps direct the clinical practice. A basic science
series, journal club, case conference, and core curriculum lectures provide didactic teaching.
The fellows participate in these conferences by providing some of the teaching through their
reading and evaluation of the literature. Self-directed learning by reading textbooks and current
literature is an expectation.
List of Rotations
x Inpatient Consultation Service at Fresno Community Regional Medical Center
x Inpatient Consultation Service at the Fresno VA Hospital
x Outpatient ID Clinic at Community Regional Medical Centers, Cedar campus
x Outpatient (Continuity) Clinic at Special services Clinic (HIV) Community Regional
Medical Centers, Cedar campus
x Infectious Diseases Outpatient Clinic at the Fresno VA Hospital
x Clinical Microbiology Rotation at Community Regional Medical Centers, Infection
Control at Community Regional Medical Centers
x Research
x Inpatient Transplant Infectious Diseases Services at UCSF Campus
x Inpatient Consultation Service, Kaiser Hospital, Fresno (Elective)
x Inpatient Consultation Service, Children’s Hospital, Fresno (Elective)
25
CORE CURRICULUM
The fellow will be provided 2 weekends free from clinical service while on the 4-week
consultation service block so that there is one day off in every seven averaged over 30
days. The fellow will also work no more than 80 hours in a week and there will be a
minimum of 10 hours off between shifts The fellow must inform the program director
regarding any schedule change.
b. The fellow will perform all of the Infectious Diseases consultations requested.
c. The fellow will present cases to the faculty physician on clinical rounds
26
CORE CURRICULUM
RESPONSIBILITIES OF FELLOW
d. Interesting cases from the VA should be incorporated into the weekly case
conferences.
e. The fellow will review all laboratory results and work with the attending
physician to appropriately act to provide patient care.
f. The fellow will take call 2 of the 4 weekends per block making certain to
maintain 1 day off in every 7 averaged over 30 days.
5. Special Services Clinic (HIV) Community Regional Medical Centers, Cedar campus
There will be one clinic per week for the 24 months of the fellowship program in
order to provide continuity of care.
a. The fellow will see and evaluate patients sent to Special Services Clinic. This
clinic will serve as the continuity clinic. There may also be consultations
performed.
b. The fellow will present all patients to the attending physician for teaching and
development of a plan of management.
c. The fellow is responsible for following up labs and phone calls for their patients.
They will also provide prescription refills for their patients.
d. The fellow is responsible for all paperwork for their patients including Ryan
White forms.
27
CORE CURRICULUM
RESPONSIBILITIES OF FELLOW
8. Infection Control
a. Due to time constraints it is often difficult for the fellow to spend much time at
CRMC in Infection Control. Therefore, all fellows are sent to the CDC/SHEA
Infection Control training course.
b. At CRMC the fellow on the consultation service is expected to help with
tuberculosis management by evaluating patients regarding necessity for isolation.
c. The fellow on the consultation service is responsible for addressing bloodborne
pathogen exposures on off-hours (5:00 PM through 7:00 AM).
1. The faculty is assigned to the Inpatient Consultation Service in 4-week blocks. Some
of the faculty are also assigned to one Infectious Diseases Clinic at CRMC.
Responsibility as the teaching attending at CRMC-HIV clinic is shared by faculty
assigned to Special Services Clinic.
2. The faculty member is expected to be present for rounds on the consultation service
and in the clinic to staff the patients.
3. On the consultation service the faculty member is expected to perform teaching
rounds daily.
4. In the clinic the faculty member is expected to see and evaluate all of the fellows
patients and participate in the development of a plan of action (Please see the Graded
Responsibility Document).
5. The faculty member is expected to provide an environment conducive to learning.
6. The faculty member is expected to respond to questions appropriately.
28
CORE CURRICULUM
9. The faculty member must provide written evaluations at the end of each rotation for
the consultation service and quarterly evaluations for the clinic rotations using E-
value.
2. Understand the rationale for selection and use of antimicrobials on the CRMC
hospital formulary
i. Select antibiotics and usual dosing regimens based on the hospital
formulary
ii. Learn how to interpret the antibiogram in the selection of empiric and
directed antimicrobial therapy.
29
CORE CURRICULUM
CONSULTATION SERVICE
3. Antibacterials
Competency Requirement Fellows will participate in the approval restricted
antibacterials in accordance with institutional
formulary and guidelines as well as approve restricted
antibacterials appropriate to specific ID indications.
Competency Measurement Fellows will review approval of restricted
antibacterials with the attending on the ID Consult
Service.
References x Mandell, et al. Principles and practices of
Infectious Diseases, 6th Ed.
x Guidelines: Antimicrobial Stewardship
x CID 2007; 44: 159-77.
x PNAS 1999; 96: 1152-56
x CID 2005; 41: 435-40.
x CID 2005; 41: 441-9
x AJIC 2006; 34; S64-73.
x Steven J. Brickner. J. Med. Chem., 2008, 51
(7),1981–90
31
D. KarageorgopoulosJournal of Antimicrobial
Chemotherapy 2008 62(1):45-55
CORE CURRICULUM
ANTIBACTERIALS
b. Understand the concept of an antibiotic formulary and
appropriate use of medications within it’s context.
c. Penicillins
¾ Understand the difference between the agents in this class.
d. Cephalosporins
¾ Understand the differences and similarities between the
cephalosporins including spectrum of activity and toxicities.
o 1st generation-cefazolin
o 2nd generation-cefotetan, cefoxitin, cefuroxime
o 3rd generation-cefotaxime, ceftriaxone, ceftazidime
32
o 4th generation-cefepime
e. Monobactams
¾ Understand the role of aztreonam in the treatment of gram-
negative bacterial infections.
¾ Understand the nature of cross-reaction regarding beta-lactam
allergies.
f. Carbapenems
¾ Understand the mechanism of action, antibacterial spectrum, basic
pharmacology and adverse reactions of the members of this group
of drugs.
¾ Differentiate imipenem, meropenem, doripenem and ertapenem and
identify the role each plays in the treatment of infectious diseases.
g. Glycopeptides - vancomycin
¾ Understand mechanism of action, antibacterial spectrum, and
mechanisms of resistance. Additionally understand the pathogens
that are resistant to vancomycin including VRE and VRSA.
¾ Learn the appropriate manner of dosing this medication
understanding the monitoring of blood concentrations and interaction
of these parameters with toxicity and efficacy.
¾ Management of drug toxicities
h. Streptogramins
¾ Understand mechanism of action, antibacterial spectrum, and
mechanisms of resistance.
CORE CURRICULUM
ANTIBACTERIALS
k. Aminoglycosides
¾ Gentamicin, tobramycin, streptomycin, and amikacin
¾ Learn the spectrum of these antibiotics for gram-negative
infections and their use for synergy in the treatment of serious
gram-positive bacterial infections.
33
¾ Knowledge of basic pharmacokinetics and pharmacodynamics to
direct the appropriate dosing schedules
¾ Understanding the appropriate monitoring of patients receiving
treatment with these medications
l. Tetracycline, Glycylcyclines and Chloramphenicol
¾ Learn mechanism of action, basic pharmacology, and relevant
toxicity issues. Learn the appropriate use of these drugs in
pregnancy, children and unusual infections.
¾ Tetracycline, doxycycline, minocycline, tigecycline and
chloramphenicol
m. Macrolides and Clindamycin
¾ Learn mechanism of action, antibacterial spectrum, therapeutic
uses, toxicity and issues of resistance.
o In particular, understand the role of the D-test in identifying
inducible MLS resistance via the ermB gene.
¾ Erythromycin, clarithromycin, azithromycin, clindamycin
n. Fluoroquinolones
¾ Learn mechanism of action, drug spectrum, drug interactions and
therapeutic uses of this class of drug.
o Understand the difference in spectrum with the traditional
fluoroquinolones like ciprofloxacin and the respiratory
fluoroquinolones like moxifloxacin.
o Understand the role in treatment of mycobacterial
infections.
CORE CURRICULUM
ANTIBACTERIALS
q. Other antimicrobials
34
¾ Understand the “niche” for other antimicrobials used in inpatient
infectious diseases setting
o
o Metronidazole
o
o Nitrofurantoin
o Topical antibiotics
r. Antimycobacterials – see tuberculosis and other mycobacterial
pathogens
s. Antibiotics and pregnancy
¾ Know the drugs that would be contraindicated for treatment of
infections in pregnant women.
¾ Understand the pharmacokinetics of antimicrobials in pregnant
women.
t. Antimicrobial Resistance
- Develop an understanding of methods to limit development of
resistant pathogens by understanding mechanisms of resistance
- Understand the relevance of resistance in clinical practice.
- Comprehend the mechanisms of resistance
¾ Enzymatic inhibition
¾ i.e. Beta-lactamasesBypass of
antibiotic inhibition
¾ Membrane permeability
¾ Promotion of antibiotic efflux
CORE CURRICULUM
ANTIFUNGALS
4. Antifungals (systemic)
CORE CURRICULUM
1. Meningitis
a. Recognize clinical presentation of acute meningitis. Understand
causative agents, diagnostic tools available and treatment.
¾ Causative agents include bacterial, viral, fungal, rickettsiae,
spirochetes, protozoa, other pathogens, and non- infectious causes.
¾ Diagnosis - Interpretation of the CSF cell formula, cultures, and
serologic evaluation.
36
2. Encephalitis, myelitis, and neuritis.
a. Understand clinical presentation of these syndromes.
b. Learn the relevant laboratory workup to define an etiologic
diagnosis.
c. Understand the most common causes of these syndromes including
enterovirus, tick-borne pathogens, and mosquito-borne pathogens
including West Nile Virus, mumps, and herpes viruses.
d. Understand therapeutic strategies for the management of these
patients.
3. Brain Abscess
a. Understand basic epidemiology.
b. Know the causative agents and clinical manifestations.
¾ Bacterial- i.e. Streptococcus anginosus group, Bacteroides sp. and
mixed infections
¾ Fungal including Candida sp., Aspergillus sp. and Zygomycetes
¾ Protozoan/helminthic-i.e. Toxoplasmosis
c. Diagnosis and management
¾ CT vs. MRI vs. SPECT
¾ Appropriate surgical intervention
¾ Brain abscess and HIV infection
d. Antimicrobial Therapy
¾ Empiric vs. culture driven
¾ Duration of therapy
CORE CURRICULUM
MAJOR CLINICAL SYNDROMES
4. Sepsis
a. Recognize clinical and physiologic manifestations of sepsis.
b. Learn a thoughtful approach to discovering cause of the sepsis
syndrome.
c. Understand the appropriate use of antimicrobials in the septic
patient.
d. Learn the use of adjunctive therapies in the patient with sepsis.
5. Enteric Infections
a. Acute diarrhea
¾ Understand concept of noninflammatory, inflammatory and
invasive diarrhea.
¾ Understand common causes of enteric infections.
o Bacterial causes of diarrhea including E. coli 0157:H7,
Salmonella, Shigella and Campylobacter
o The role of antimicrobial use with O1 57:H7 and the
development of HUS.
o
Antibiotic associated diarrhea including C. difficile
associated diarrhea
o
Viral causes of diarrhea
¾ Develop a systemic approach to all patients with enteric infections.
¾ Understand prevention and control of infections.
o Public health implications
CORE CURRICULUM
MAJOR CLINICAL SYNDROMES
b. Chronic Diarrhea
¾ Develop an approach for the diagnosis and management of patients
with chronic diarrhea.
38
antimicrobial therapy and the appropriate
drugs of choice for the different pathogens.
Reference Zar FA, et al. Clin Infect Dis. 2007;
45(3):302-7.
Am J Gastroenterol 2009; 104:S10–S16
Aliment Pharmacol Ther 30, 187–196
Current Opinion in Gastroenterology: 2009
Volume 25 - Issue 1 - p 1-7
CORE CURRICULUM
39
MAJOR CLINICAL SYNDROMES
7. Pneumonia
Competency Requirement Fellows will diagnose and manage difficult cases of
pneumonia on the ID consult services.
Competency Measurement Fellows will see cases of pneumonia due to various
pathogens during fellowship. They will demonstrate
expertise by the antimicrobial choices and duration of
therapy recommended. The fellow must manage
CAP, VAP and pneumonia in compromised hosts.
References CID 1999; 29: 745-58
CID 2007; 44: 769-74
CID 2001; 33: 615-21
Critical Care Medicine. 36(1):1-7, January 2008
Critical Care 2008, 12:R56
Cochrane Database of Systematic Reviews 2009, Issue
4. Art. No.: CD002109
40
a. Understand the epidemiology in relation to etiologic agents and
risk factors
b. Learn to perform a physical exam to identify the clinical
manifestations of disease
c. Learn the utility and limitations of various diagnostic tests
including echocardiogram.
CORE CURRICULUM
MAJOR CLINICAL SYNDROMES
41
9. Bone and Joint Infections
a. Infectious Arthritis
¾ Understand the different mechanisms of pathogenesis of infectious
arthritis
¾ Recognize the important historical clues to etiology, physical exam
and laboratory findings of infectious arthritis
¾ Recognize the various etiologies of infectious arthritis: bacterial,
viral, mycobacterial
¾ Understand the role of surgical and medical management in
treatment of patients.
b. Osteomyelitis and Prosthetic Joint Infections
¾ Understand the pathogenesis of osteomyelitis
CORE CURRICULUM
MAJOR CLINICAL SYNDROMES
1. Bacteria
a. Staphylococcus aureus
¾ Learn how the organism is identified in the Microbiology Laboratory by
morphology, biochemical and other tests.
¾ Understand the epidemiology and pathogenesis of different clinical
syndromes caused by S. aureus, especially ones listed below
o Localized infection
o Localized infection with diffuse skin rash
o Bacteremia and endocarditis
o Toxic Shock Syndrome
o Osteomyelitis, septic arthritis, and pyomyositis
o Staphylococcal food poisoning
¾ Understand the treatment using the most active drug based on
susceptibility of methicillin-susceptible (MSSA), methicillin-resistant
CORE CURRICULUM
MANAGEMENT OF SPECIFIC MICROBES
b. Enterococcus species
44
¾ Learn to identify by morphology and biochemical tests
¾ Understand the pathogenesis of the different manifestations of infection
¾ Understand the risk factors for colonization or infection with vancomycin-
resistant enterococci (VRE)
¾ Develop knowledge of different antibiotics used for treatment and
understand when treatment is necessary
c. Pseudomonas aeruginosa
¾ Understand basic microbiology, epidemiology and pathogenesis of this
organism.
¾ Know classic clinical manifestations of syndromes caused by this
organism, host factors that put patients at risk, and treatment.
o Infections of interest include endocarditis, hospital acquired
pneumonia, ear infections, respiratory tract infections in patients
with cystic fibrosis.
CORE CURRICULUM
MANAGEMENT OF SPECIFIC MICROBES
45
resistant organisms including Pseudomonas
aeruginosa
Competency Measurement Competency will be measured by
observations on rounds and evaluation.
Also presentations at Case Conference
and the Basic Science Conference will
demonstrate competency.
Epidemiol. 2006;27:889-92.
References
Paterson DL, Bonomo RA. Clin Microbiol
Rev. 2005 Oct;18(4):657-86.
2. Fungi
a. Candida species
¾ Understand microbiology, pathogenesis, and pathologic findings.
¾ Learn spectrum of clinical manifestations.
o Thrush, esophagitis, cutaneous syndromes, fungemia and deep
organ manifestations.
o Know appropriate management of infections with Candida sp. as
determined by cultures of blood or sterile body fluids.
x Endocarditis, line infections and peritonitis
o Understand relationship between different species particularly the
non-albicans candida and antifungal agents.
Competency Requirement Fellow will be required to demonstrate the
knowledge of diagnosis and management of candidal
infections
Competency Measurement The fellow will be evaluated while on clinical service
using e-value. Antifungal therapy for candidal
infections is part of the antimicrobial approval
process.
CORE CURRICULUM
MANAGEMENT OF SPECIFIC MICROBES
2007;20:133-63.
46
Medical Mycology June 2007, 45, 321_346
CID 2007;44:402–409
Drugs, Volume 67, Number 2, 2007 , pp. 269-
298(30)
Infection 2008; 36: 296–313
d. Zygomycetes
¾ Understand the ecology and epidemiology of different species of
Zygomycetes.
¾ Understand the risk factors for infection with these organisms.
¾ Understand the different clinical manifestations and pathogenesis of
infection
o Rhinocerebral
o Pulmonary
47
CORE CURRICULUM
MANAGEMENT OF SPECIFIC MICROBES
FUNGI
o Cutaneous
o Gastrointestinal
o Central nervous system
¾ Be able to identify hyphae by microscopy. Differentiate Zygomycetes
from other groups of fungi such as Aspergillus
¾ Understand the importance of surgical vs. medical treatment in the
management of infected patients.
¾ Understand the antifungal agents with activity against these moulds.
o Amphotericin B and lipid formulations
o Posaconazole
3. Viruses
a. Enterovirus
¾ Understand different species of enterovirus.
48
o Poliovirus, coxsackievirus, echoviruses and other enterovirus species
such as 71.
CORE CURRICULUM
MANAGEMENT OF SPECIFIC MICROBES
VIRUSES
49
CORE CURRICULUM
MANAGEMENT OF SPECIFIC MICROBES
2008;46:732-40.
84.
approaches.
50
CORE CURRICULUM
MANAGEMENT OF SPECIFIC
BIOTERRORISM
organisms.
52.
2002;346:1300-8.
51
e. Develop knowledge about role of resistance testing, interpretation of genotypic
and phenotypic resistance tests
f. Develop the knowledge of tropism testing for the use of CCR5 inhibitors and the
role of HLA B5701 testing for prevention of abacavir hypersensitivity reactions.
g. Develop knowledge about the clinical presentation, diagnosis and treatment of
opportunistic infections
CORE CURRICULUM
INFECTIOUS DISEASES AMBULATORY CLINIC OBJECTIVES
52
a. Understand the epidemiology of infective endocarditis, including prosthetic valve
endocarditis, including the common microorganisms involved in this infectious
disease
b. Develop knowledge about the natural history, pathophysiology, diagnosis, clinical
management and antimicrobial treatment of bacterial endocarditis
c. Understand the role of cardiac valve replacement in the management of infective
endocarditis
CORE CURRICULUM
TRAVELERS’ HEALTH
CORE CURRICULUM
TRAVELERS’ HEALTH
8. Tuberculosis
a. Understand the epidemiology of tuberculosis
b. Understand the pathogenesis, clinical stages (latent versus active disease) and
clinical manifestations of tuberculosis. Understand the role of screening for the
diagnosis of tuberculosis, including interpretation of PPD skin test and interferon J
induction assays.
d. Become familiar with the IDSA/ATS/CDC guidelines on the diagnosis and treatment of
latent and active tuberculosis
e Become familiar with the role of the microbiology laboratory in the diagnosis,
susceptibility testing and follow-up of patients with tuberculosis
f. Become familiar with the use of antimicrobial therapy in the management of latent and
active tuberculosis
i. First line vs. second/third line agents
ii. Common side effects of antituberculous agents
iii. Periodic laboratory tests and clinical exams used to monitor for toxicity of
antituberculous therapy
55
m. Become facile with the communication skills required to manage patients
receiving this treatment modality, including collaboration with the pharmacy,
home health agency and referring physician
11. Chronic fatigue syndrome (CFS)
n. Understand the IDSA/ACP clinical practice guidelines for diagnosing and
managing CFS
o. Know the differential diagnosis of CFS
p. Become familiar with commonly indicated referrals for specialty evaluation in
patients with CFS, including Psychiatry and Rheumatology
q. Develop communication skills required in long-term management of CFS patients
CORE CURRICULUM
MANAGEMENT OF SPECIFIC MICROBES
CHRONIC FATIGUE
HIV
F. Curriculum for The Treatment of Patients Infected With The Human Immunodeficiency
Virus (HIV)
Table of Contents
Virology
Epidemiology
Approach to the HIV positive patient
Preventive medical care
Management of other sexually transmitted diseases
Clinical Manifestations of HIV/AIDS
Anti-retroviral Therapy
Issues of adherence
Prophylaxis against opportunistic infections
Resistance testing
Therapeutic drug monitoring
Pharmacodynamics and pharmacokinetic
56
HIV and Hepatitis C co-infection
HIV and Hepatitis B co-infection
Virology
Nomenclature
Direct cell killing
Anti-genetic diversity
Receptor signaling theory
TH1 – TH2 Switch
Viral load and replication kinetics
Concept of long term non-progressors
Concept of virologic controllers
CORE CURRICULUM
HIV
Chemokines as receptor antagonists
Mucosal Immunity
Immune Activation
Epidemiology
Demographic trends
Prevalence
x USA Trends and prevalence
x California Trends and prevalence
x Global prevalence
x Geographic distribution of hiv-1 and hiv-2 infection
x Clades & Distribution
Vaccines
x Pneumococcal vaccine, hepatitis A and B vaccines, influenza vaccines, Tdap
x STD Screening: RPR, and urine tests for C. trachomatis and Neisseria
gonorrhoeae, Q12 mo
Pap smears
PPD tests
Routine dental – Q12 mo.
57
Mammograms, Colorectal CA Screening;
x Ophthalmology in selected populationDiabetes mellitus
CD4 counts FHOOVPP3
Mental Health Issues
x Depression
x Bi-polar Disorder
x Addiction
CORE CURRICULUM
SEXUALLY TRANSMITTED DISEASES
x Fungal infections
o Candidiasis
o Cryptococcosis
o Histoplasmosis
o Coccidioidomycosis
o Penicillium marneffei
CORE CURRICULUM
CLINICAL MANIFESTATIONS OF HIV/AIDS
Neuropathy
x Distal symmetrical Polyneuropathy
x Acute and chronic inflammatory Demyelinating polyneuropathy [AIDP/CIDP]
x CMV polyradiculopathy
Anti-retroviral Therapy
x Mechanisms of action
x Treatment theory
x When to start
x Treatment sequencing
x Treatment naïve patients
x Second Regimen patient
x Treatment experienced patient
x Salvage Therapy
x Acute and long term side-effects of antiretroviral therapy
o NRTI associated
Lipodystrophy
Lactic acidosis,
Neuromuscular weakness syndrome,
Nonalcoholic steatohepatitis
Antiretroviral therapy -induced pancreatitis
Antiretroviral therapy induced peripheral neuropathy
x NNRTI-induced
Hepatotoxicity
Rash
x Special consideration to specific medications:
o Abacavir hypersensitivity syndrome, role of HLA B5701
o Zidovudine associated anemia [acute and latent]
o Stavudine, didanosine, and zalcitabine.
Peripheral neuropathy
Pancreatitis
o Indinavir
59
Retinoid-like cutaneous side effects
o Indinavir and atazanavir – hyperbilirubinemia, nephrolithiasis
o Efavirenz - central nervous system toxicity
CORE CURRICULUM
ANTI-RETROVIAL THERAPY
x When to start
x Medication options and their side-effects
x When to discontinue
Issues of adherence
x Understanding factors that influence medication compliance
o Positive
o Negative
o Counseling patient’s on adherence
Resistance testing
x Understanding currently available resistance assays –
o Proper use, strengths, and limitations;
o Utility of resistance testing in selecting a drug regimen
Treatment naïve
Treatment experienced
Salvage therapy
Competency Requirement The fellow is expected to manage patients with HIV infection
in the inpatient setting and provide continuity care in the
outpatient setting.
Competency Measurement The fellow will be evaluated on the management of patients
through interaction with faculty (e-value or mini-CEX)
References Clin Infect Dis 2004; 39:609–29
MMWR 2002; 51(RR-8)
http://aidsinfo.nih.gov/contentfiles/AdultandAdolescentGL.pdf
Antiviral Research 85 (2010) 241–244
Current Infect Dis Report Volume 11, Number 4 / July, 2009
CORE CURRICULUM
TRANSPLANTATION INFECTIOUS DISEASES
61
Competency Measurement Fellows will manage infectious
complications in patients with solid organ
transplantation
References Infect Dis Clin North Am. 2001;15:901-52
Clin Liver Dis. 2000;4:657-73
62
Competency Requirements The fellow will become knowledgeable
regarding the appropriate use of the
microbiology laboratory and the
interpretation of data provided.
Competency Measurements The fellow will be evaluated by the
preceptor of the microbiology rotation.
Additionally, knowledge will be evaluated
on the clinical service.
References Curr Clin Top Infect Dis. 2001;21:172-89
CORE CURRICULUM
INFECTION CONTROL
63
Competency Requirement The fellow will become knowledgeable in
epidemiology practice.
approvals.
64
INTERDEPARTMENTAL RELATIONSHIPS
The ID Program Director reports directly to the Program Director of the Department of
Medicine. The status of clinical services, research programs, faculty development including
promotion and educational activities are reviewed on a regular basis.
The overall performance of the trainees in ID Medicine is reported to the Program Director of the
Department of Medicine on an annual basis. He/She is required to sign all forms indicating
satisfactory performance, completion of training, and eligibility for subspecialty certification. All
offers of appointment for new trainees are issued jointly by the Program Director of Medicine as
well as the ID Medicine program director. The Chairman of Medicine is directly involved in
faculty performance evaluations, advancement and assignment of responsibilities. Trainees in ID
Medicine participate in developing written evaluations of medical residents and students who
have served with them on the ID consultation and clinic.
Policy outlining lines of responsibility between Infectious Diseases residents and Internal
medicine residents
Our policy follows the guidelines established in the UCSF Fresno GMEC policy regarding
resident supervision. When an internal medicine resident is on the infectious diseases elective
he/she will perform the initial consultation and write the preliminary note. The ID fellow will
advise and educate prior to presentation to the attending physician. When the number of cases
increase, the fellow will also perform initial consultations. Should a patient require a procedure,
it is the fellow’s responsibility to obtain informed consent and perform the procedure. When
appropriate, the resident may do the procedure under the fellow’s supervision. The attending
physician will supervise any procedure the fellow is not qualified to perform independently.
6
Leave Policy for Residents/Fellows
Policy: UCSF Fresno supports a work and training environment that offers solutions to the
complex issues individuals face in balancing their work and family commitments. For this
reason UCSF Fresno has adopted the following guidelines regarding leave time for residents,
including leaves of absence. Any leaves of absence identified as a part of the UCSF Fresno
Academic Due Process policy are not covered under this policy.
Specialty Board requirements and RRC requirements should be reviewed prior to granting any
leave by the program director and resident to assure the resident is familiar with the possibility of
having to make up time away from training. Absences/Leaves (including Sick Leave) from the
training program may jeopardize the resident’s approval of credit for training; or additional
training may be required by the specialty Board/RRC. If extended leave results in the
requirement for additional training in order to satisfy specialty Board requirements or RRC
requirements, financial support for the additional training time must be determined when
arrangements are made for the leave and the makeup activity.
At the time each trainee requests a leave of absence, the terms will be put in writing and
signed by the Program Director and the trainee. The trainee will be informed of what
effect the leave will have on the completion of training. A copy of the written consent will
then be sent along with the Personnel Action Form (PAF) to the UCSF Fresno Office of
Medical Education.
Any consecutive leave beyond four (4) calendar months needs to be reviewed and
approved by the Associate Dean.
All leave time is subject to UCSF Fresno department and/or program approval. Paid leave will
be based on the normal academic year. If a resident begins training outside of the normal
academic year, vacation, sick and educational leave will be prorated from the beginning of the
training year to the end of the normal academic year on June 30th. A summary of the leave
policies referred to within this document include:
PAID LEAVE
Vacation/Educational Leave – Leave that is used at the resident’s discretion with program
approval.
Sick Leave – Leave that is used in the event of personal illness or injury; or illness, injury
or death of an immediate family member.
Short Term Military Leave
Jury Duty
Bereavement (sick leave)
UNPAID LEAVE
Medical Leave – leave without pay for illness, including any pregnancy related illness
(includes CFRA & FMLA)
Personal Leave – Leave without pay for any reason.
Extended Term Military Leave
VACATION LEAVE
Vacation leave with compensation shall be fifteen (15) days per academic year. In addition to
any department regulations concerning vacations, all vacation time must be scheduled with the
prior approval of the designated department faculty member and/or Program Director. As a
7
general rule, vacation time does not carry forward from year to year and must be scheduled and
taken in the same academic year the vacation is earned.
EDUCATIONAL LEAVE
Educational leave with compensation shall be five (5) days per academic year. To the extent that
a resident's department does not include educational leave as a portion of the annual vacation
leave, each resident is entitled to use the department educational leave days consistent with the
policies and procedures of the department. Educational time does not carry forward from year to
year and must be scheduled and taken in the same academic year the educational leave is earned.
SICK LEAVE
Sick leave with compensation shall be twelve (12) days per academic year for personal illness,
bereavement or disability. In addition, any remaining educational or vacation leave may be used
to cover illness or disabilities that exceed twelve (12) days of sick leave. Any incidents of sick
leave over 3 consecutive calendar days may require medical certification from the resident’s
health care provider. Programs must notify HR if a resident is on sick leave for 3 consecutive
calendar days or more so that they will receive Family and Medical Leave information that
describes rules and regulations under the policy. Sick leave does not carry forward from year to
year and must be taken in the same academic year the sick leave is earned.
Upon the death of an immediate family member (parent, spouse, child, grandparent,
grandchild, sister, brother, mother-in-law, father-in-law, or domestic partner w/affidavit on
file w/UCSF Fresno Human Resources Office), residents may request up to 3 days of
bereavement in the form of sick leave to make arrangements and/or attend the funeral.
Residents must discuss the amount and any additional time needed with their Chief and/or
Program Director.
DISABILITY BENEFITS
Please note that residents are not eligible for, nor covered by the state of California for short-
term disability insurance. However, residents enrolled in the UCSF Housestaff Benefits Plan are
entitled to disability coverage following 30 consecutive days of “total disability.” For more
information, please contact UCSF Fresno Human Resources at (559) 499-6416.
PREGNANCY-RELATED DISABILITY
The California Family Rights Act allows for an additional twelve (12) workweeks of leave after
the birth of a child for pregnancy-related disability. This leave is in addition to the (12)
workweeks of Family and Medical Leave in a twelve-month period. The resident may elect to
use accrued sick leave, vacation leave and educational leave to remain on full pay status for the
initial period of the leave. The total duration of the maternity disability leave (paid and unpaid)
may not exceed 24 calendar weeks.
PATERNITY LEAVE
Paternity leave is covered under the Family and Medical Leave Act (FMLA). Residents
employed by UCSF Fresno for one year, who have worked 1,250 hours in the previous 12
8
months, and have a qualifying status change, are eligible for Family Medical Leave. Residents
who do not qualify for paternity leave may request an unpaid personal leave of absence from
their program. Approvals are subject to the requirements of applicable law, the program, the
appropriate specialty Board and the RRC. If UCSF Fresno employs both parents, UCSF Fresno
reserves the right, if consistent with system-wide University policy, to limit employees to a
combined total of 12 weeks of family leave.
If the event necessitating the leave is based on the expected birth, placement for adoption or
foster care, or planned medical treatment for a serious health condition, the resident must provide
at least 30 days advance notice before leave is to begin. If 30 days notice is not practicable,
notice must be given as soon as practicable. A resident’s request for a leave of absence must be
in writing.
JURY DUTY
A resident called to Jury Duty or to Grand Jury Duty will not suffer a loss of regular pay for
those days when one would otherwise be scheduled to perform their resident duties. A resident is
obligated to keep their department, and appropriate rotation service supervisor apprised of the
status once a jury summons has been received. Only the court pursuant to the procedure outlined
in the Jury Summons Notice can grant deferment or excused absence from jury service.
Deferment or excused absence is generally not granted for inconvenience but may be granted for
reasons of personal health or undue hardship, as determined by the court on a case-by-case basis.
MILITARY LEAVE
Residents are eligible for up to thirty (30) days of military leave with pay while engaged in the
performance of military duty. All benefit coverage will continue during paid military leave.
Absence from the training program to meet military service obligations must be with the
approval of the program director and/or department.
PERSONAL LEAVE
A resident may request from his/her program a personal leave of absence in order to attend to
personal matters of a serious, time consuming nature or if other leaves of absence are not
available. Requests must be in writing. A personal leave, if granted, is unpaid and may follow
the required use of any remaining unused vacation and/or educational leave. The total duration
of the personal leave (including paid and unpaid time) may not exceed four (4) calendar months.
Approval of a personal leave of absence is subject to the needs of the program in addition to the
requirements of the appropriate specialty Board and RRC.
DURATION OF LEAVE
The total length of any leave (paid and unpaid together) may not exceed four (4) calendar months
unless expressly extended in writing by the Program Director with acknowledgement and
approval of the Associate Dean. Consecutive leaves of absences cannot be granted for more than
one (1) year in duration.
9
coverage (University’s contribution plus the resident premium contribution, if applicable) on a
monthly basis.
Premium payments must be made payable to the “UC Regents” and delivered or mailed to:
UCSF Fresno
Attention: Human Resources
155 N. Fresno Street
Fresno, CA 93701
Any payment covering insurance benefits must be received on the first of the month in which the
coverage is applicable. Late payments will initiate termination of benefits and COBRA
Continuation Coverage information will be forwarded to residents’ address of record. Group
coverage may be continued under COBRA benefits for up to 18 months.
(Original signed Policy is available in the UCSF Fresno Office of Medical Education)
10
ACGME Program Requirements for Graduate Medical Education
in Infectious Diseases
I. Institutions
One sponsoring institution must assume the ultimate responsibility for the
program, as described in the Institutional Requirements, and this
responsibility extends to fellow assignments at all participating sites.
The sponsoring institution and program must ensure that the program
director has sufficient protected time and financial support for his or her
educational and administrative responsibilities to the program.
Infectious Diseases 1
number of accredited training years in the program.
Participating sites include both the primary training site and other training sites.
The primary training site is defined as the health-care facility that provides the
required training resources, should be the location of the program director's
major activity, the location where the fellow spends the majority of their clinical
training time, and the primary location of the core program in internal medicine.
I.B.1.a) identity the faculty who will assume both educational and
supervisory responsibilities for fellows;
I.B.1.d) state the policies and procedures that will govern fellow
education during the assignment.
I.B.3. The Review Committee must give prior approval for participation by any
site providing three months or more of training in a 12 or 24 month
program, or six months or more of training in a 36 month program.
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II.A. Program Director
II.A.2. The program director should continue in his or her position for a
length of time adequate to maintain continuity of leadership and
program stability.
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II.A.4.g) provide each fellow with documented semiannual evaluation
of performance with feedback;
II.A.4.k) monitor the need for and ensure the provision of back up
support systems when patient care responsibilities are
unusually difficult or prolonged;
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II.A.4.n).(2) changes in fellow complement;
II.A.4.p) seek the prior approval of the Review Committee for any changes
in the program that may significantly alter the educational
experience of the fellows.
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II.A.4.s) participate in academic societies and in educational programs
designed to enhance his or her educational and administrative
skills.
II.B. Faculty
II.B.3. The physician faculty must possess current medical licensure and
appropriate medical staff appointment.
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II.B.5.b).(1) peer-reviewed funding;
The institution and the program must jointly ensure the availability of all
necessary professional, technical, and clerical personnel for the effective
administration the program.
In addition to the program director, each program must have two key
clinical faculty. Key clinical faculty are attending physicians who dedicate,
on average, 10 hours per week throughout the year to the training
program. For programs with more than five fellows enrolled during the
accredited portion of the training program, a ratio of key clinical faculty to
fellows of at least 1:1.5 must be maintained. (N.B.: The required number
of key clinical faculty may vary by subspecialty.)
II.C.1.a) Qualifications:
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qualifications judged by the Review Committee to be
acceptable.
II.D. Resources
The institution and the program must jointly ensure the availability of
adequate resources for fellow education, as defined in the specialty
program requirements.
II.D.1.b) Facilities
Clinical records that document both inpatient and ambulatory care must
be readily available at all times. (See Institutional Requirements, Section
II.D.3.d))
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and help to define, the subspecialty.
II.D.3.b) There must be patients of both sexes, with a broad age range,
including geriatric patients.
The program director must comply with the criteria for fellow eligibility as
specified in the Institutional Requirements.
The program director may not appoint more fellows than approved by the
Review Committee, unless otherwise stated in the specialty-specific
requirements. The program’s educational resources must be adequate to
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support the number of fellows appointed to the program.
The presence of other learners (including, but not limited to, residents from
other specialties, subspecialty fellows, PhD students, and nurse
practitioners) in the program must not interfere with the appointed fellows'
education. The program director must report the presence of other learners
to the DIO and GMEC in accordance with sponsoring institution guidelines.
Fellows must have clearly defined written lines of responsibility for all clinical
experiences.
III.F. When averaged over any five-year period, a minimum of 75% of fellows in each
subspecialty training program must be graduates of an ACGME accredited
internal medicine training program. Non-ACGME internal medicine trained
fellows must have at least three years of internal medicine training prior to
starting fellowship. Prior to appointment, the program director must inform non-
ACGME trained applicants in writing of the ABIM policies and procedures that
may affect the fellow=s eligibility for ABIM certification. (N.B.: Fellows in the
subspecialty of geriatric medicine may be graduates of an ACGME-accredited
family medicine training program.)
IV.A.1. Overall educational goals for the program, which the program must
distribute to fellows and faculty annually;
IV.A.2.a) for each rotation or major learning experience, the written goals
and objectives:
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IV.A.2.a).(1) should include the educational purpose; teaching methods;
the mix of diseases, patient characteristics, and types of
clinical encounters, procedures, and services; reading lists,
pathological material, and other educational resources to
be used; and the method for evaluation of fellows’
competence;
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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.
Fellows are expected to develop skills and habits to be able
to meet the following goals:
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IV.A.5.e) Professionalism
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IV.B. Fellows’ Scholarly Activities
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IV.C.2. To be eligible for accreditation, a subspecialty program must function as
an integral part of an accredited residency program in internal medicine.
IV.C.4. The discipline must be one for which a certificate or a certificate of added
qualifications is offered by the American Board of Internal Medicine. (For
editorial purposes, the term subspecialty is used throughout the
document for both types of training programs.)
IV.C.5. Subspecialty programs must provide advanced training to allow the fellow
to acquire competency in the subspecialty with sufficient expertise to act
as a consultant.
IV.D. Didactics
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IV.D.2.a).(4).(b) The core curriculum conference series must cover
the major clinical topics in the subspecialty; and,
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IV.E.2.a).(1) A single continuity clinic for the length of the accredited
fellowship, or
IV.E.2.a).(2) Blocks of at least six months duration for the length of the
accredited fellowship.
IV.E.3. Procedures
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V. Evaluation
V.A. Fellow
V.A.1.a).(1) The faculty must discuss this evaluation with the fellow at
the completion of the assignment.
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procedures. These records must state the indications and
complications, and include the names of the supervising
physicians. Such records must be of sufficient detail to
permit use in future credentialing.
V.B. Faculty
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V.B.4. Provision must be made for fellows to confidentially provide written
evaluations of each teaching attending at the end of a rotation, and for the
evaluations to be reviewed annually with faculty.
V.B.6. The fellows must have the opportunity to assess formally the
effectiveness of ambulatory teaching on an ongoing basis.
V.C.2. If deficiencies are found, the program should prepare a written plan
of action to document initiatives to improve performance in the
areas listed in section V.C.1. The action plan should be reviewed
and approved by the teaching faculty and documented in meeting
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minutes.
VI.A. Principles
VI.A.3. Didactic and clinical education must have priority in the allotment of
fellows' time and energy.
VI.A.4. Duty hour assignments must recognize that faculty and fellows
collectively have responsibility for the safety and welfare of patients.
VI.C. Fatigue
Faculty and fellows must be educated to recognize the signs of fatigue and
sleep deprivation and must adopt and apply policies to prevent and
counteract its potential negative effects on patient care and learning.
VI.D. Duty Hours (the terms in this section are defined in the ACGME Glossary
and apply to all programs)
Duty hours are defined as all clinical and academic activities related to the
program; i.e., patient care (both inpatient and outpatient), administrative
duties relative to patient care, the provision for transfer of patient care,
time spent in-house during call activities, and scheduled activities, such as
conferences. Duty hours do not include reading and preparation time spent
away from the duty site.
VI.D.1. Duty hours must be limited to 80 hours per week, averaged over a
four-week period, inclusive of all in-house call activities.
VI.D.2. Fellows must be provided with one day in seven free from all
educational and clinical responsibilities, averaged over a four-week
period, inclusive of call.
VI.D.3. Adequate time for rest and personal activities must be provided.
This should consist of a 10-hour time period provided between all
daily duty periods and after in-house call.
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VI.E. On-Call Activities
VI.E.1. In-house call must occur no more frequently than every third night,
averaged over a four-week period.
VI.E.2. Continuous on-site duty, including in-house call, must 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.
VI.E.3.a) A new patient is defined as any patient to whom the fellow has not
previously provided care.
VI.E.4.b) Fellows taking at-home call must be provided with one day in
day completely free from all educational and clinical
responsibilities, averaged over a four-week period.
VI.E.4.c) When fellows are called into the hospital from home, the
hours fellows spend in-house are counted toward the 80-hour
limit.
VI.F. Moonlighting
VI.F.1. Moonlighting must not interfere with the ability of the fellow to
achieve the goals and objectives of the educational program.
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VI.G.2. Prior to submitting the request to the Review Committee, the
program director must obtain approval of the institution’s GMEC and
DIO.
VI.G.2.a) The Review Committee for Internal Medicine will not consider
requests for exceptions to the limit to 80 hours per week,
averaged over a four-week period.
VI.H.2. Fellows' service responsibilities must be limited to patients for whom the
teaching service has diagnostic and therapeutic responsibility
VI.H.3. The admission and continuing care of patients by fellows must be limited
to those patients on the teaching service.
VI.I.2. There must be a written policy that ensures that academic due process is
provided.
Requests for experimentation or innovative projects that may deviate from the
institutional, common and specialty specific program requirements must be
approved in advance by the Review Committee. In preparing requests, the
program director must follow Procedures for Approving Proposals for
Experimentation or Innovative Projects located in the ACGME Manual on Policies
and Procedures. Once a Review Committee approves a project, the sponsoring
institution and program are jointly responsible for the quality of education offered
to fellows for the duration of such a project.
VII.A.1. The program should identify and participate in at least one ongoing
performance improvement activity which relates to the competencies.
VII.A.2. The performance improvement activities must involve both fellows and
faculty in planning and implementing.
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VII.A.3. The performance improvement activities should result in measurable
improvements in patient care or residency education.
IX. Faculty
In addition to the facilities and resources outlined in the Program Requirements for
Fellowship Education in the Subspecialties of Internal Medicine, each of the following
must be present at the primary training site:
X.B. Imaging
X.D.1. Facilities for the isolation of patients with infectious diseases must be
available.
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X.D.2. It is suggested that the training program be conducted in a setting in
which training programs in surgery, obstetrics, gynecology, pediatrics,
and other medical and surgical specialties and subspecialties are
available.
XI.B.1. Fellows must receive formal instruction and gain practical experience in
hospital epidemiology and infection control. This can be accomplished by
didactic or practical experience, as offered through organized
coursework, service on an infection control committee, or by an assigned
rotation on a hospital epidemiology service.
XI.B.2. Fellows must receive formal instruction and gain practical experience in
clinical microbiology.
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XI.B.3.b).(3) patients following solid organ or bone marrow
transplantation; and
XI.B.4. Fellows must have formal instruction or clinical experience and must
demonstrate competence in the evaluation and management of the
following disorders:
XI.B.5.a) Inpatient General Medical and Surgical Wards, and Intensive Care
Units
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XI.B.5.a).(5) gastrointestinal and intra-abdominal infections;
XI.C.1. The training program must provide formal instruction for the fellows in the
cognitive aspects of the following:
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abscess cavities;
***
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ABIM REQUIREMENTS:
103
104
105
106
CERTIFICATION
JULY 2008
1
TABLE OF CONTENTS
Requirements for Certification in Internal Medicine
Requirements for Certification in Subspecialties
Certification Using the Research Pathway
Special Training Policies
Other Policies
INTRODUCTION
The American Board of Internal Medicine (referred to throughout this document as “ABIM”)
was established in 1936 and is a private, not-for-profit corporation. Board members are elected
by the Board of Directors and serve two-year terms.
ABIM receives no public funds and has no licensing authority or function. ABIM’s mission is to
enhance the quality of health care by certifying internists and subspecialists who demonstrate the
knowledge, skills, and attitudes essential for excellent patient care.
Certification by ABIM recognizes excellence in the discipline of internal medicine and its
subspecialties.
Certification is not a requirement to practice internal medicine, and ABIM does not confer
privileges to practice. ABIM does not intend either to interfere with or to restrict the professional
activities of a licensed physician based on certification status.
ABIM administers the certification process by: (1) establishing requirements for training and
self-evaluation; (2) assessing the professional credentials of candidates; (3) obtaining
substantiation by appropriate authorities of the clinical competence and professional standing of
candidates; and (4) developing and conducting examinations and other assessments.
All ABIM certificates issued in 1990 (1987 for critical care medicine and 1988 for geriatric
medicine) and thereafter are valid for 10 years. Dates of validity are noted on the certificates.
To remain valid, these certificates must be renewed through
ABIM’s Maintenance of Certification program. Certificates issued before these dates are valid
indefinitely, although ABIM strongly recommends such certificate holders recertify as well.
For information about the Maintenance of Certification program, visit ABIM’s website,
www.abim.org, or contact ABIM, 1-800-441-2246.
A candidate's eligibility for certification is determined by the policies and procedures described
in this document and on ABIM’s website, www.abim.org. This edition of Policies and Procedures supersedes
all previous publications. ABIM reserves the right to make changes in its fees, examinations, policies, and
procedures at any time without advance notice. Admission to ABIM’s examinations will be
determined under the policies in force at the time of application.
July 2008
107
REQUIRMENTS FOR CERTIFICATION IN INTERNAL MEDICINE
Candidates who graduated from medical schools in the United States or Canada must have
attended a school that was accredited at the date of graduation by the Liaison Committee on
Medical Education (LCME), the Committee for Accreditation of Canadian Medical Schools, or
the American Osteopathic Association.
Graduates of international medical schools must have one of the following: (1) a standard
certificate from the Educational Commission for Foreign Medical Graduates without expired
examination dates; (2) comparable credentials from the Medical Council of Canada; or (3)
documentation of training for those candidates who entered graduate medical education training
in the United
States via the Fifth Pathway, as proposed by the American Medical Association.
The 36 months of residency training must include 12 months of accredited internal medicine
training at each of three levels: R-1, R-2, and R-3. No credit is granted for training repeated at
the same level or for administrative work as a chief medical resident.
Content of Training
The 36 calendar months of full-time medical residency education:
(1) Must include at least 30 months of training in general internal medicine, subspecialty
internal medicine and emergency medicine. Up to four months of the 30 months may include
training in areas related to primary care, such as neurology, dermatology, office gynecology, or
office orthopedics.
(2) May include up to three months of other electives approved by the internal medicine program
director.
108
(3) Must include three months of leave for vacation time (or for parental or family leave or
illness, including pregnancy-related disabilities). Vacation or other leave cannot be forfeited to
reduce training time.
In addition, the following requirements for direct patient responsibility must be met:
(1) At least 24 months of the 36 months of residency education must occur in settings where the
resident personally provides, or supervises less experienced residents who provide, direct
care to patients in inpatient or ambulatory settings.
(2) At least six months of the direct patient responsibility on internal medicine rotations must occur
during the R-1 year.
As outlined in the table above, all residents must receive satisfactory ratings in overall clinical
competence and moral and ethical behavior in each year of training. In addition, residents must
receive satisfactory ratings in each of the components of clinical competence during the final
year of required training. It is the resident's responsibility to arrange for any additional training
needed to achieve a satisfactory rating in each component of clinical competence.
109
Procedures Required for Internal Medicine
Safety is the highest priority when performing any procedure on a patient. ABIM recognizes that
there is variability in the types and numbers of procedures performed by internists in practice.
Internists who perform any procedure must obtain the appropriate training to safely and
competently perform that procedure. It is also expected that the internist be thoroughly evaluated
and credentialed as competent in performing a procedure before he or she can perform it
unsupervised. For certification in internal medicine,
ABIM has identified a limited set of procedures in which it expects all candidates to be
competent with regard to their knowledge and understanding. This includes:
(1) demonstration of competence in medical knowledge relevant to procedures through their
ability to explain indications, contraindications, patient preparation methods sterile techniques,
pain management, proper techniques for handling specimens and fluids obtained, and test results;
(2) ability to recognize and manage complications
(3) ability to clearly all facets of the procedure necessary to obtain informed consent. For a subset of
procedures, ABIM requires all candidates to demonstrate competence and safe performance by
means of evaluations performed during residency training. The set of procedures and associated
competencies required for each are presented in the table on page 4.
COMPETENCY
KNOW UNDERSTAND EXPLAIN
Indications; Contraindications; Specimen Handling Interpretation of Requirements and Perform Safely
Recognition and Management Results Knowledge to Obtain
of Complications; Pain and Competently
Informed Consent
Management; Sterile Techniques
Abdominal paracentesis X X X X
Advanced cardiac life X N/A N/A N/A X
support
Arterial line placement X N/A X X
Arthrocentesis X X X X
Central venous line X X N/A X
placement
Drawing venous blood X X X N/A X
Drawing arterial blood X X X X X
Incision and drainage of X X X X
an abscess X X X X
Lumbar puncture X X X X
Pap smear and X X X X
endocervical culture X X X X X
Placing a peripheral X N/A N/A N/A X
venous line
Pulmonary artery catheter N/A X X
placement
Thoracentesis X X X X
To help acquire both knowledge and performance competence, ABIM believes that residents
should be active participants in performing procedures. Active participation is defined as serving
as the primary operator or assisting another primary operator. ABIM encourages program
directors to provide each resident with sufficient opportunity to be observed as an active
participant in the performance of required procedures. In addition, ABIM strongly recommends
that procedural training be conducted initially through simulations. At the end of training, as part
of the
evaluation required for admission to the Certification Examination in Internal Medicine, program
directors must attest to each resident’s knowledge and competency to perform the procedures in
the table above. ABIM does not specify a minimum number of procedures to demonstrate
110
competency; however, to assure adequate knowledge and understanding of the common
procedures in internal medicine, each resident should be an active participant for
each procedure five or more times.
(1) Month-for-month credit may be granted for satisfactory completion of internal medicine
rotations taken during a U.S. or Canadian accredited non-internal medicine residency program if
all of the following criteria are met:
(a) the internal medicine training occurred under the direction of a program director of an
accredited internal medicine program;
(b) the training occurred in an institution accredited for training internal medicine residents; and
(c) the rotations were identical to the rotations of the residents enrolled in the accredited internal
medicine residency program.
(2) For trainees who have satisfactorily completed some U.S. o Canadian accredited training in
another specialty, ABIM may grant
(a) month-for-month credit for the internal medicine rotations that meet the criteria listed
under (1) above;
plus,
(b) a maximum of six months of credit for the training in family medicine or a pediatrics
program; or,
(c) a maximum of three months of credit for training in a non-internal medicine specialty
program.
(3) Up to 12 months of credit may be granted for at least three years of U.S. or Canadian
accredited training in another clinical specialty and certification by an ABMS member Board in
that specialty.*
(4) Up to 12 months of credit may be granted for at least three years of verified internal medicine
training abroad.*
* Requires a fee of $300. Guidelines for proposals are available at
www.abim.org/certification/policies/special.aspx.
To become certified in a subspecialty, physicians must have been reviously certified in internal
medicine by ABIM and must satisfactorily complete the requisite graduate medical education
fellowship training, demonstrate clinical competence in the care of patients, meet the licensure
and procedural requirements, and pass the secure examination for that discipline.
112
In order to be eligible for certification and renewal of a certificate in adolescent medicine,
hospice and palliative medicine, sleep medicine, and sports medicine, diplomates must maintain
a valid underlying certificate in either internal medicine or a subspecialty. Diplomates must
maintain a valid underlying certificate in cardiovascular disease to obtain certification and be
eligible for renewal of a certificate in clinical cardiac electrophysiology or interventional
cardiology. Diplomates must maintain a valid underlying certificate in gastroenterology to obtain
certification and be eligible for renewal of a certificate in transplant hepatology.
Fellowship training must be accredited by the Accreditation Council for Graduate Medical
Education (ACGME), the Royal College of Physicians and Surgeons of Canada, or the
Professional Corporation of Physicians of Quebec. No credit will be granted toward certification
in a subspecialty for training completed outside of an accredited U.S. or Canadian program.
Fellowship training taken before completing the requirements for the MD or DO degree, training
as a chief medical resident, practice experience, and attendance at postgraduate courses may
not be credited toward the training requirements for subspecialty certification.
To be admitted to an examination, candidates must have completed the required training in the
subspecialty, including vacation time, by October 31 of the year of examination. Candidates for
certification in the subspecialties must meet ABIM’s requirements for duration of training as
well as minimum duration of full-time clinical training. Clinical training requirements may
be met by aggregating full-time clinical training that occurs throughout the entire fellowship
training period; clinical training need not be completed in successive months. Time spent in
continuity outpatient clinic, during non-clinical training, is in addition to the requirement for full-
time clinical training. Educational rotations completed during training may not be
double-counted to satisfy both internal medicine and subspecialty training requirements.
Likewise, training which qualifies a diplomate for admission to one subspecialty examination
cannot be double-counted toward certification in another subspecialty, with the exception of the
formally approved pathways for dual certification.
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Microscopic evaluation of diagnostic specimens including preparation,staining, and
interpretation; management, maintenance, and removal of indwelling venous access catheters;
and administration of antimicrobial and biological products via all routes.
recommended.
113
(1) have completed the full training required by ABIM in the subspecialty in another country and
have met all current applicable ABIM procedural requirements;
(2) are a full-time Associate Professor or higher in the specifies subspecialty division of the
Department of Medicine in an LCME-accredited medical school or an accredited Canadian
medical school;
(3) have served eight years, after formal training, as a clinician educator or clinical investigator
with a full-time appointment on a medical school faculty.
* Proposals require a fee of $300. Guidelines for proposals are
The Research Pathway for certification in internal medicine and a subspecialty that requires 12
months of clinical training is a six-year program. For subspecialties such as cardiovascular
disease and gastroenterology, which require more than 12 months of clinical training, and for
dual certification in hematology/oncology, pulmonary disease/critical care medicine, and
rheumatology/allergy and immunology, the Research Pathway is a full seven-year program,
including 36 to 42 months of research, depending on the number of months of clinical training
completed
During the research period, 80 percent of time is devoted to research and 10 to 20 percent of time
to clinical work. The trainee must attend a minimum of one half-day per week in continuity
outpatient clinic. Time spent in continuity outpatient clinic during non-clinical training is in
addition to the requirement for full-time clinical training. ABIM defines research as scholarly
activities intended to develop new scientific knowledge. The research experience of trainees
should be mentored and reviewed. Unless the trainee has already achieved an advanced graduate
degree, training should include completion of work leading to one or its equivalent. The last year
of the Research Pathway may be taken in a full-time faculty position if the level of commitment to
mentored research is maintained at 80 percent.
During internal medicine research training, 20 percent of each year must be spent in clinical
experiences including a half-day per week in a continuity clinic. During subspecialty research
training, at least one half-day per week must be spent in an ambulatory clinic.
Ratings of satisfactory clinical performance must be maintained annually for each trainee in the
ABIM Research Pathway. For additional information, see
www.abim.org/certification/policies/research/requirements.aspx.
SPECIAL TRAINING POLICIES
Disclosure of Performance Information
Trainees planning to change programs must make requests to their current program and to ABIM
to send written evaluations of past performance to the new program. These requests must be
made in a timely manner to ensure that the new program director has the performance
evaluations for review before offering a position. A new program director may also request
performance evaluations from previous programs and from ABIM concerning trainees who
114
apply for a new position. ABIM will respond to requests from trainees and program directors by
providing any performance evaluations it has in its possession and the total credits accumulated
toward ABIM’s training requirements for certification. This information will include the
comments provided with the evaluation.
Reduced-Schedule Training
Interrupted full-time training is acceptable, provided that no period of full-time training is shorter
than four weeks. In any 12-month period, at least six months should be spent in training. Patient
care responsibilities should be maintained in a continuity clinic during the non-training
component of the year at a minimum of one-half day per week. ABIM approval must be obtained
before initiating an interrupted training plan. Part-time training, whether or not continuous, is not
acceptable.
OTHER POLICIES
ABIM may make inquiry of persons named in candidates' applications and of other persons, such
as authorities of licensing bodies, hospitals, or other institutions as the ABIM may deem
appropriate with respect to such matters. Candidates agree that the ABIM may provide
information it has concerning them to others whom ABIM judges to have a legitimate need for it.
ABIM makes academic and scientific judgments in its evaluations of the results of its
examinations. Situations may occur, even through no fault of the candidates, that render
examination results unreliable in the judgment of ABIM. Candidates agree that if ABIM
determines that, in its judgment, the results of their examination are unreliable, ABIM may
require the candidates to retake an examination at its next administration or other time designated
by ABIM.
115
Board Eligibility
ABIM does not use, define, or recognize the term "Board Eligible."
On a candidate's written request to ABIM, the following information will also be provided in
writing: (1) that an application is currently in process; and/or (2) the year the candidate was last
admitted to examination.
Re-examination shall be the candidate's sole remedy. ABIM shall not be liable for
inconvenience, expense, or other damage caused by any problems in the creation, administration,
or scoring of an examination, including the need for retesting or delays in score reporting. In no
circumstance will ABIM reduce its standards as a means of correcting a problem in examination
administration.
Confidentiality Policy
ABIM considers the certification or recertification status of its candidates and diplomates to be
public information.
ABIM provides a diplomate's certification status and personal identifying information, including
mailing address, e-mail address and social security number, to the Federation of State Medical
Boards (FSMB) and the American Board of Medical Specialties (ABMS) which publishes The
Official ABMS Directory of Board
Certified Medical Specialists. The FSMB and ABMS use personal identifying information,
including social security numbers, as a unique internal identifier and maintain the confidentiality
of this information. On request, ABIM provides a diplomate’s certification status and address to
the professional medical societies that provide educational resources relevant to the Maintenance
of Certification program.
116
ABIM provides residency and fellowship training directors with information about a trainee's
prior training and pass/fail status on certifying examinations. If a trainee has given permission,
ABIM will provide the program director with the trainee's score on his/her first attempt at the
certification examination for that area of training. ABIM uses examination performance, training
program evaluations, self-evaluations of knowledge and practice performance, and other
information for research purposes, including collaboration with other research investigators and
scientific publications. In such research, ABIM will not identify specific individuals, hospitals,
or practice associations. All practice performance data is HIPAA compliant.
ABIM reserves the right to disclose information it possesses about any individual whom it
judges has violated ABIM rules, engaged in misrepresentation or unprofessional behavior, or
shows signs of impairment.
Licensure
Candidates for certification and Maintenance of Certification must possess a valid, unrestricted,
and unchallenged medical license in the United States, its territories, or Canada. Candidates
practicing exclusively abroad and who do not hold a US or Canadian license, must hold a license
where they practice and provide documentation from the relevant licensing authority that their
license is in good standing and without conditions or restrictions. A candidate whose license has
been restricted, suspended, revoked, or surrendered in lieu of disciplinary action, in any
jurisdiction, cannot be certified recertified, or admitted to a certification examination.
Restrictions include but are not limited to conditions, contingencies, probation, and stipulated
agreements.
Disabled Candidates
ABIM recognizes that some candidates have physical limitations that make it impossible for
them to fulfill the requirement for proficiency in performing procedures. For such individuals,
the procedural skills requirement may be waived. Program directors should write to ABIM for an
exception before the individual enters training or when the disability becomes established.
Substance Abuse
If a candidate or a diplomate has a history of substance abuse, documentation of at least one year
of continuous sobriety from a reliable monitoring source must be submitted to ABIM for
admission to an examination or to receive a certificate. ABIM treats such information as
confidential.
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