SPECIFIC PROGRAM CONTENT

A. Patient Care Experience

Infectious Diseases fellows will be required to complete at least 12 months of clinical training in consultative and continuing patient care and are required to maintain a patient care experience in the ambulatory setting for at least one half-day each week throughout at least 18 months of a 24-month training program. The following provides a description of the clinical activities, duties and responsibilities of Infectious Disease fellows.

1. Inpatient Clinical Experience

1. First and second year ID fellows will receive clinical inpatient subspecialty consultative and continuing care experience through rotation on the Infectious Diseases Primary Service at Rush, the Infectious Diseases Consultation Service at Rush, and the Infectious Diseases Consultation Services at SHCC. There is no inhouse overnight call for Infectious Disease fellows. The scheduling of inpatient rotations will be left to the discretion of the fellows, will be completed at the beginning of each academic year, and will assure that each fellow receives at least 12 months of clinical experience during the first 24 months of the fellowship. For the most part, clinical consultative and inpatient rotations will be equally divided between Rush and SHCC. A primary and back-up fellow should be scheduled for each rotation. Back-up fellows will be utilized only in the event of serious illness or prolonged absence (4 or more working days) of the assigned primary fellow.

   For each clinical experience outlined below, the ID attending physician on service with the fellow will be responsible for didactic teaching related to the cases and situations which arise during the clinical rotation. Teaching will be accomplished through fellow performance of the duties and responsibilities detailed below, through individual discussion and instruction by the ID attending physician, and through fellow observation of procedures and interactions. With attending supervision, fellows will be responsible for searching for, reading, and often presenting published literature related to the patients and diseases encountered during each rotation.
   
   

2. Rush Infectious Diseases Primary Service: This service consists, on average, of a daily census of 8-15 inpatients hospitalized at Rush under the primary and tertiary care of Rush ID attending physicians. Patients followed by this service include inpatients admitted to ID attendings, patients admitted to other services who are followed as outpatients by Infectious Disease attendings, orthopedic consults, neurosurgical consults, and heart transplant consults. These patients represent a diverse group with a variety of infectious disease-related conditions including complicated cases of endocarditis, FUO, osteomyelitis, septic arthritis, meningitis, encephalitis, pulmonary infections, intra-abdominal abscesses, infections with unusual organisms, infections in immunocompromised hosts, tropical diseases, and HIV/AIDS and its complications.

   Rounding responsibilities will include the daily evaluation of all patients with regard to history and physical assessment, review of diagnostic tests, management of medical therapy (including antimicrobial therapy and short- and long-term indwelling catheter care), consultation with other specialty services, and interactions with family members. The fellow will interact closely with the housestaff caring for the patient. Each of these activities will be performed in conjunction with and under the supervision of an ID attending physician on service who will evaluate the fellow in the manner described in Section VII.A.1-2. below. The fellow will be responsible for writing an admission history, physical examination, assessment and plan, daily progress notes, and discharge notes, unless otherwise directed by the ID attending physician on service. The supervising ID attending will be responsible for reviewing the written record and counter-signing notes where appropriate. The fellow will round with the ID attending physician each weekday. The schedule for daily rounds will be at the discretion of the ID attending physician. ID fellows rotating on the Rush ID Primary Inpatient Service are required to round on weekends, on an every other weekend schedule, alternating with the ID fellow assigned to the Rush ID Consultation Service. The weekend rounding schedule will be formulated in conjunction with the ID attending physicians rotating on the Primary and Consultation Services.
   
   

3. Rush Infectious Diseases Consultation Service: This service consists, on average, of a daily census of 30-60 inpatients hospitalized at Rush under the primary care of attending physicians from non-ID disciplines, consisting of inpatients admitted to ICU and non-ICU services throughout the medical center, including psychiatry and the Johnston R. Bowman geriatrics center. Inpatients followed by the Rush ID Primary Inpatient Service – inpatients admitted to Rush ID attending physicians, orthopedic consults, neurosurgical consults and heart transplant consults – will be seen by the consult service fellow only when covering on weekends (see below). This service is staffed by one ID attending physician, one fellow, 3-4 second or third year internal medicine residents, and 3-4 third or fourth year medical students. Periodically, other personnel may be added in limited number and may include a pharmacist/pharmacy intern, residents from other specialties (surgery, OB-GYN, ophthalmology, family practice), and nurse clinicians/clinical specialists. An average of 3-6 new consults are seen daily. The consultation patients represent a diverse population of adult medical, surgical, geriatric, obstetric/gynecologic, and intensive care patients with a wide variety of infectious disease-related conditions including FUO, sepsis with multiorgan dysfunction syndromes, bacteremia/fungemia, upper and lower respiratory tract infections, oral and periodontal infections, cardiovascular/endovascular infections (including endocarditis, pericarditis, infections of indwelling venous and arterial catheters and prosthetic devices/material), central nervous system infections, skin, soft tissue, bone and joint infections, intra-abdominal infections, gastrointestinal infections, hepatitis, foodborne and waterborne infections, infections of the reproductive organs, sexually transmitted diseases, urinary tract infections, eye infections, nosocomial infections, postoperative infections, AIDS and its associated opportunistic complications, infections in bone marrow and solid organ transplant recipients, infections in other immunocompromised hosts, and tropical diseases. Requests are also received for consultative advice regarding immunization, antimicrobial prophylaxis, antimicrobial therapy for specific infectious processes already identified, management of complications of antimicrobial therapy, and management of long-term outpatient antimicrobial therapy. Infectious processes identified from among this patient population include those due to viruses, chlamydiae, mycoplasmas, rickettsiae, gram-positive, gram-negative, intracellular, and unusual bacteria, spirochetes, mycobacteria, fungi, protozoa, helminths, and ectoparasites.

   Rounding responsibilities include daily evaluation of all patients, either at the bedside or based on the reports of residents and medical students rotating on the service, including review of test results, management of medical therapy (including antimicrobial therapy and short- and long-term indwelling catheter care), consultation with primary services and other specialty services, and interactions with patients and family members. In addition, the fellow provides direction, instruction and supervision of the activities of the students and residents rotating on the service, and assists in the preparation of clinical cases for presentation in the weekly ID conference. Finally, the fellow will respond to requests for approval for the use of a limited number of restricted antimicrobial drugs while on duty during evenings and weekends. Each of these activities will be performed in conjunction with and under the supervision of an ID attending physician on service who will evaluate the fellow in the manner described in Section VII.A.1-2. below. The fellow will participate in clinical microbiology rounds while on the service. The schedule for daily rounds will be at the discretion of the ID attending physician. ID fellows rotating on the Rush ID Consultation Service are required to round on weekends, on an every other weekend schedule, alternating with the ID fellow assigned to the Rush ID Primary Inpatient Service. The weekend rounding schedule will be formulated in conjunction with the ID attending physicians rotating on the Primary and Consultation Services.
   
   

4. Stroger Infectious Diseases Inpatient Consultation Services: This consists of two separate services, each with an average daily census of 15-20 inpatients hospitalized at Stroger under the primary care of attending physicians from non-ID disciplines for whom consultative assistance has been requested. Patients followed by these services include inpatients admitted to ICU and non-ICU services throughout the hospital. However, inpatients with known HIV infection who do not require intensive, surgical or obstetric care are hospitalized under the primary care of HIV ward services supervised separately by other ID attending physicians.

   Rounding responsibilities include daily evaluation of all patients, either at the bedside or based on the reports of residents and medical students rotating on the service, including review of test results, management of medical therapy (including antimicrobial therapy and short- and long-term indwelling catheter care), consultation with primary services and other specialty services, and interactions with patients and family members. In addition, the fellow provides direction, instruction and supervision of the activities of the students and residents rotating on the service, and assists in the preparation of clinical cases for presentation in the weekly ID conference. Finally, the fellow will respond to requests for approval for the use of a limited number of restricted antimicrobial drugs while on duty during evenings and weekends. Each of these activities will be performed in conjunction with and under the supervision of an ID attending physician on service who will evaluate the fellow in the manner described in Section VII.A.1-2. below. The fellow will round with the ID attending physician and students and residents on the service each weekday; the service also rounds in the microbiology laboratory with the Director of Microbiology every Monday and Wednesday. The schedule for daily rounds will be at the discretion of the ID attending physician. Fellows rotating on the Stroger ID Consultation Service are required to round on weekends, on an every other weekend schedule, alternating with the ID fellow assigned to the alternate Stroger ID Consultation Inpatient Service. The weekend rounding schedule will be formulated in conjunction with the ID attending physicians rotating on the two Stroger ID Consultation Services.
   
   

5. Pediatric Infectious Diseases Clinical Activities: Optional pediatric infectious diseases clinical activities will be arranged individually by the fellow in conjunction with the Pediatric Infectious Diseases Service. Pediatric Infectious Diseases Attending Faculty and services are available at both Rush and at SHCC. Pediatric Infectious Diseases Faculty also participate in and present cases during the weekly Infectious Diseases Clinical Conferences at Rush and at SHCC.

2. Outpatient Clinical Experience

1. ID fellows will have experience in the outpatient ambulatory setting that will consist of consultative and continuing care at least one-half day each week throughout at least 18 months of their first 24 months of training. Each fellow will be responsible for 1-3 new patients and 3-6 return patients during each half-day session. Each fellow will be assigned to attend outpatient clinic at The Mark Weiss Memorial Clinic for Infectious Diseases and the CORE Center to provide a broad exposure to a variety of outpatient experiences. Fellows will practice in pairs and will share a clinic at each site.
   
   
2. The Mark Weiss Memorial Clinic for Infectious Diseases maintains hours on weekdays and is staffed by ID attending physicians and fellows, a receptionist, a phlebotomist, a pharmacy technician, and 3-4 research nurses. Access to laboratory diagnostic and radiographic services, other medical or surgical specialty services, social services, mental health counseling, dietary counseling, and other support services are available to outpatients through appropriate referral within RUSH. Ambulatory patients are seen in The Mark Weiss Memorial Clinic for Infectious Diseases by referral and appointment. Among the ambulatory patients seen in the Center, 80-85% are HIV-infected and 15-20% span the spectrum of other infectious diseases generally referred for ambulatory care or consultation, including patients discharged from inpatient settings and managed with long-term oral or home IV antimicrobial therapy (such as osteomyelitis, endocarditis, endovascular infections, infections of prosthetic devices, complicated respiratory tract infections, deep-seated fungal infections, tuberculosis) and ambulatory patients referred for evaluation of FUO, exanthems, diarrheal illnesses, bone and joint infections, sexually transmitted diseases, urinary tract or reproductive tract infections, tropical diseases, post-exposure prophylaxis induction following occupational exposure to HIV or hepatitis, or other non-urgent acute or chronic infectious diseases. The HIV-infected population followed in the Mark Weiss Memorial Clinic for Infectious Diseases spans the full spectrum of HIV-associated complications and range of immunosuppression from asymptomatic HIV-seropositive individuals to those with very advanced disease. Approximately 60% of the HIV-infected patients are enrolled in a variety of clinical research trials; the remaining 40% receive primary and tertiary HIV care by ID attending physicians in the Rush Section of Infectious Diseases. Clinical research protocols and research support personnel are funded by and conducted under the auspices of the National Institutes of Health (NIH), Division of AIDS (DAIDS), AIDS Clinical Trials Group ACTG), the NIH/DAIDS Epidemiology Branch (Women's Interagency HIV Study), the NIH/DAIDS Treatment Research Initiative (DATRI), and contracts with pharmaceutical sponsors.

   Fellows assigned to The Mark Weiss Memorial Clinic for Infectious Diseases will be responsible for assisting research nurses in the evaluation and management of HIV-infected patients enrolled in outpatient clinical trials, providing consultation, evaluation and management for outpatients referred for infectious disease conditions and assigned to the fellow(s) for initial and continuing care, and evaluating outpatients urgently referred to The Mark Weiss Memorial Clinic for Infectious Diseases for same day consultation. The ID faculty attending physician(s) assigned to The Mark Weiss Memorial Clinic for Infectious Diseases for the day will be responsible for reviewing and supervising the clinical activities of the fellow(s) for that day. In addition, the ID faculty will provide the opportunity for fellows to observe and discuss unusual, difficult or complicated outpatient cases referred to the attending physician(s) in The Mark Weiss Memorial Clinic for Infectious Diseases.
   
   

3. The CORE Center for the diagnosis, treatment, and prevention of infectious diseases is a 60,000 square foot facility developed jointly by Rush and Cook County for the ambulatory care of patients with infectious diseases, primarily HIV/AIDS. In addition to ID attending physicians, the Center is staffed by pediatricians, gynecologists, a psychiatrist, nurse clinicians, physician assistants, and a variety of support personnel, including social workers, case managers, nursing, dietary, chemical dependency, and mental health counselors . Diagnostic laboratory and radiographic services and other medical and surgical specialty services are available on site. Fellows participate in two separate clinics at the CORE Center:
   
   
   1. Each first-year ID fellow, together with a second-year fellow with whom he or she is paired, will help to staff a weekly half-day longitudinal clinic for the management of patients with HIV/AIDS. Thus, on average, each fellow will attend the clinic one half-day every other week, thereby maintaining continuity of care while providing flexibility for the coverage of inpatient service or vacation. On average, the fellow should see 1-2 new and up to six follow-up patients per clinic session. The schedule for clinic coverage will be at the discretion of each first- and second-year ID fellow pair who must notify the resource attending (see below) for any absence due to illness and from whom approval must be obtained for any planned, non-emergent absences.

      Clinic responsibilities include the initial evaluation and long-term management of a wide variety of adult patients encompassing nearly all risks for and stages of HIV infection. Management of patients seen in clinic includes the initial assessment and management of acute and subacute medical illness; gender- and age-appropriate screening for risks for and the presence of HIV- and non-HIV-associated diseases; adherence with, complications of and response to antiretroviral and other therapies, including the monitoring of clinical, immunologic and virologic parameters; assessment of antiretroviral therapy failure, including evaluation of both antiviral resistance and the adequacy of and barriers to adherence; and the assessment and management, often including in-house referral, of chronic, subacute and acute problems relating to nutrition, mental illness, chemical dependency, and access to medical and financial benefits. Patient care must be coordinated with medical and non-medical providers both within and outside the CORE Center, and specialized laboratory and radiographic tests obtained and interpreted as appropriate. Each of these activities will be performed under the supervision of an attending ID physician (known as the resource attending) assigned exclusively to provide teaching and guidance to the fellows, mid-level practitioners and non-ID physicians staffing that clinic session. The resource attending will evaluate the fellow in the manner described in Section VII.A.1-2. below. The resource attending will also be responsible for reviewing the written record and counter-signing notes where appropriate.
      
      

   2. The Screening Clinic: This is a walk-in clinic geared primarily for patients with sexually transmitted diseases and/or persons desiring confidential HIV testing. As such, it offers firsthand experience in the diagnosis and treatment of STDs. Fellows spend a half-day every other month in the Screening Clinic under the supervision of an Infectious Disease attending.
      
      
   3. The Hepatitis Clinic: The purpose of the Hepatitis Clinic is to provide in-depth experience and familiarity with the clinical management of chronic viral hepatitis. Second year fellows will be allowed to perform an elective rotation in the Hepatitis Clinic that will consist of at least 4 consecutive Thursday morning clinic sessions in a block (every other week), paired with Toyin Adeyemi, MD. Participating fellows will miss the Rush ID conference on those clinic days. Along with Dr. Adeyemi, the Hepatitis Clinic will be staffed with 2 hepatologists (Rush and Stroger), 2-3 GI fellows (Rush and Stroger), 1 Research nurse (Rush), 2 nurse practitioners (CORE), 1 physician’s assistant (CORE). The patient population consists of new patients being evaluated for hepatitis C or B treatment, patients status post liver biopsy and being evaluated for eligibility for and timing of antiviral therapy, patients on therapy for scheduled follow up (usually every 2 –4 weeks), patients requiring management of decompensated liver disease (Hep C, B, alcohol, other), and patients who are prior interferon non-responders. Clinic patient demographics include 90% Hepatitis C (65-70% co-infected), 10% Hepatitis B (70-80% mono-infected). A typical clinic day would normally consist of 4-8 new consults (average seen 5), 30-35 scheduled follow-ups, 3 liver biopsies/week (average 2), and 5-8 study patients on Rx.

   The fellows’ role in the Hepatitis Clinic includes shadowing the attendings (ID and hepatology), listening to presentations from hepatology fellows, and asking questions. This format facilitates exposure to new patients, follow- up visits and patients on antiviral therapy. In addition, the fellows will observe liver biopsies (also a good time for teaching). [9-9.30am on clinic days], participate in treatment initiation counseling, follow up on treatment, mental health evaluations (performed at every visit), monitor labs, etc., and participate in new or ongoing research projects (optional).

   Assigned readings: 10-12 important articles (reviews, clinic trials, basic science) on the diagnosis, management and treatment of hepatitis C and B (especially in co-infected patients). These should be reviewed before the rotation to enhance the educational experience in the clinic.

   Upon completion of rotation in the Hepatitis Clinic, the fellow should be able to:

   
   
   1. Diagnose chronic HCV infection; understand types of tests (quantitative, qualitative, sensitivity/specificity of these tests).
      
      
   2. Evaluate patients presenting for treatment of chronic hepatitis C (diagnostic tests needed, exclusion of other causes of chronic liver disease, pretreatment evaluation including medical history, psychiatric evaluation, need for cardiac w/u, etc.). Assess treatment candidacy of referred patients.
      
      
   3. Understand the indications for and risks of liver biopsy in the management of chronic hepatitis C.
      
      
   4. Understand the data on Interferon, Pegylated IFN plus ribavirin, differences and similarities between Peg 2a and Peg2b, etc, response rates. Understand terms used in reporting results of these studies, e.g., EVR, ETR, SVR, etc.
      
      
   5. Understand the role of hematologic growth factors (EPO, G-CSF) and anti-depressants in HCV treatment
      
      
   6. List the toxicities/side effects and know the major drug-drug interactions between these and antiretroviral medications.
      
      
   7. Understand critical decision-making points in the initiation, and discontinuation of treatment for hepatitis C and timing of clinical follow-up and lab monitoring.
      
      
   8. Management of the patient with cirrhosis and/or with decompensated liver disease.
      
      
   9. Understand the treatment indications and options for chronic hepatitis B.