Curriculum

Major Resident Assignments

I. Inpatient Clinical Consultations
II. Outpatient Clinical Care
III. Clinical Laboratory
IV. Research

GOALS

1. To become knowledgeable in the methods of classification, isolation and identification of microorganisms which are pathogenic for humans.
2. To understand the pathogenic mechanisms of human disease caused by bacteria, viruses, fungi and parasites.
3. To understand the pathophysiology of human disease caused by bacteria, viruses, fungi and parasites.
4. To understand immunologic mechanisms of host-microbe interaction, including human defense mechanisms.
5. To become knowledgeable in the means by which infectious diseases are diagnosed, including microbial isolation, antibody and antigen assay, nucleic acid identification.
6. To utilize the above information in the prevention, diagnosis, and therapy of human infection.
7. To understand the mechanisms of action and pharmacology of antimicrobial agents, and the mechanisms by which microorganisms resist the action of these agents.
8. To understand principles of clinical epidemiology and infection control in order to minimize transmission of hospital and community acquired infection.
9. To understand principles of clinical investigation in order to construct research protocols which define reasonable goals, utilize appropriate methods, collect sufficient data, and utilize accepted methods of statistical analysis.
10. To understand the role of an infectious disease specialist as an effective clinical consultant, epidemiologist, and clinical investigator.

Clinical Consultations - 15 months

The Infectious Disease consultation team consists of two Infectious Disease residents and one or two Internal Medicine residents or medical students. Initial consultations are assigned by the second year Infectious Disease resident who is the team leader. Consultations include chart review, history, physical examination, radiology and laboratory review, necessary microscopic examination, written report, and pertinent literature review prior to presentation of findings and formulation to the attending Infectious Disease physician during daily teaching rounds. The presentation is concise, and is followed by a discussion of basic science, clinical, and laboratory issues. Radiologic results are reviewed and discussed in the Department of Radiology daily with an attending radiologist.

Microscopic findings are confirmed and discussed by the Infectious Disease attending physician, including review of all pathology slides with an attending pathologist in the Department of Pathology. All new consultations are seen on the same day by the resident and Infectious Disease attending physician who adds a brief summary paragraph to the consultation report, and provides a brief statement supplementing each follow up note written by the resident. After presentation, discussion and examination of new consultations, pertinent follow up visits are conducted by the attending physician and consultation team. Supervised clinical consultations and follow up visits are held for 4-5 hours daily for 6 days per week. Two residents share this rotation and divide night and weekend call. They also divide calls from the Pharmacy Department for approval of restricted antibiotics, and Emergency Department calls regarding accidental needlestick exposure of health care workers. Management of the latter is always discussed with the attending physician. Infectious Disease teaching and clinical rounds are held once per weekend for new consultations and follow up visits, as necessary. An introductory course in basic principles of Infectious Diseases is conducted yearly from July through September with weekly didactic lectures by Infectious Disease, Microbiology, Immunology, Pharmacology, and Infection Control staff members. During the remainder of the year, weekly conferences are conducted by the infectious Disease Section for 1 hour and are attended by all members of the section as well as representatives from Infection Control, Pharmacy and Microbiology. The following topics and presentations occur on a rotating schedule: Pharmacy and Therapeutics, Infection Control, Research, HIV Infection, Journal Club (presented by resident only), and clinical cases (presented by residents only, with literature review). Residents attend all monthly Infection Control Committee meetings, chaired by the Program Director, and participate in the discussion and investigation of infection control issues. These include the maintenance of standard precautions and prevention of infection among health care workers.

The Infectious Disease attending staff presents ten basic lectures per year to the medical house staff, with infectious disease residents in attendance. The Infectious Disease Training Program Director supervises the house staff Journal Club which meets biweekly. Attendance by infectious disease residents is mandatory for all infectious disease articles discussed. Infectious disease topics are discussed at Medical Grand Rounds by visiting speakers on 8-10 occasions per year, and attendance by infectious disease residents is mandatory. Clinical experience in the care of transplant associated infections and sexually transmitted diseases is obtained during rotation periods at Columbia University and Albert Einstein Medical Centers.

Clinical entities encountered during the Infectious Disease clinical consultation rotation include upper and lower respiratory, peritoneal, gastrointestinal, urinary, cardiovascular, central nervous system, skin and soft tissue, bone and joint, gynecologic, urologic, ocular, and nosocomial infections. Fever of unknown origin is a frequent clinical presentation. Management of occupational exposure to blood-borne pathogens is emphasized, and residents are involved extensively with Infectious Disease attendings in decisions regarding post-exposure prophylaxes and follow up care. Hepatic, traumatic, animal-associated, vector-borne and sexually transmitted infections are encountered among immunocompetent, immunocompromised, oncologic, geriatric, and pediatric patients. Infections associated with world-wide travel are seen frequently, as well as those associated with drug abuse and HIV infection. Infections associated with burns are encountered in the acute stage, or when they are mild to moderate in degree. Patients with more serious burns are transferred to established burn units.

Available diagnostic procedures include gastrointestinal and pulmonary endoscopy with biopsy, transesophageal and transthoracic echocardiography, a wide variety of CT guided needle aspirations, transjugular as well as laparoscopic or percutaneous hepatic biopsy, and bone marrow biopsy.

Outpatient Clinical Care - 24 months (concurrent with clinical and research rotations).

Residents are assigned to the continued care of specific patients in the infectious disease clinic throughout the two year training period. They perform a history, physical examination and laboratory/radiology review of each patient seen, write a summary of findings, formulation and plan, followed by discussion with the attending physician. Weekly case management conferences are held in which medical, social, personal and financial issues involving each patient are discussed by residents, attending physicians, social workers and case managers. A yearly symposium on management of HIV infection is sponsored by the AIDS Designated Center. Speakers of national prominence are invited to address all health care workers involved in the care of HIV-infected persons. Curricular goals are accomplished as follows:

1. The resident has the opportunity to evaluate at least one-two new patients and three follow-up patients per session.
2. The resident is assigned patients of varying age and sex to evaluate a broad spectrum of illnesses.
3. Sixty minutes are allotted for the evaluation of new patients and 20-30 minutes for the evaluation of follow-up visits (these times include discussion with the preceptor). The preceptor may modify these times after determining the competency and skills of the assigned resident.
4. The office preceptor ensures resident competency in patient interviewing, physical examination skills, medical decision making, delivery of comprehensive health care, psychosocial skills, patient-doctor communication and patient education.
5. The preceptor reviews all aspects of the resident’s evaluation and management of each patient and reviews chart documentation for accuracy and completeness.
6. The resident has the opportunity to learn and implement preventative health measures, e.g., administration of vaccines, advice regarding prevention of sexually transmitted diseases and tuberculosis, prevention of travel-related illness, and use of prophylactic antibiotics when indicated.
7. The resident is involved in the coordination of consultations and all management decisions which result from consultation.
8. A written evaluation of the experience by the resident is submitted directly to the Training Program Director after each rotation.
9. A written evaluation of the resident is prepared by the preceptor, discussed with the resident, and submitted to the Training Program Director after each rotation.

Clinical Laboratory - 24 months (concurrent with clinical and research rotations).

Residents are instructed in the techniques and basic science of clinical microbiology and immunology during a weekly ninety-minute morning session throughout the year, from September through June. Study of bacteria, mycobacteria, fungi, rikettsiae and chlamydiae are included. These sessions are conducted in the Infectious Disease Research Laboratory by the Research Director, a Ph.D. microbiologist. This laboratory and its director, a full time training program faculty member, functions separately from the hospital clinical microbiology laboratory. The Research Director is certified in clinical microbiology and supervises two research technicians who instruct residents in the techniques of measuring batteries and bactericidal activity of antibiotics, as well as that of serum and other body fluids from treated patients. Techniques for measuring antibiotic concentrations in such fluids are included.

Residents are also instructed in the principles and practices of infectious disease during a weekly ninety-minute morning session throughout the year from September through June. These sessions discuss infectious disease topics and cases not usually encountered in daily clinical practice, such as prions, infections transmitted to the fetus in utero, bioterrorism, zooneses, host defenses and travel medicine. These sessions cover the epidemiology, pathophysiology, clinical presentation, diagnosis and management of these diseases and are conducted by one of the infectious disease attendings.

Residents also make daily visits to the clinical microbiology laboratory where they observe the processing of clinical specimens, obtain interim data on clinically important specimens, and examine selected stained smears with laboratory technicians and/or Infectious Disease attending physicians.

A two week training period in clinical virology and parasitology is conducted at the Clinical Microbiology Laboratory, Columbia Presbyterian Hospital. Residents are assigned to this laboratory on a full time daily basis where they receive personal instruction from the Director and technical staff.

Research - 6 months

Principal Teaching Method

The research rotation is supervised by the Research Director, a Ph.D. microbiologist and full time Training Program faculty member. Projects are selected with the advice of all faculty members. Supervision of clinical aspects of the project is conducted by one or more faculty clinicians .Written protocols describing clinical studies are submitted to the Institutional Review Board. Collaboration with outside facilities or investigators, as necessary, is arranged by a faculty member. The resident is responsible for the recording and analysis of data, with assistance as required, and for production of a first draft manuscript. The resident is acknowledged as first author of such a manuscript which is then completed in collaboration with a faculty member.

Educational Content

The Infectious Disease Research Laboratory is fully equipped and staffed by the Research Director and two technicians. Current research involves the analysis of mechanisms of antibiotic resistance among gram-negative nosocomial pathogens. Facilities are available for tube dilution and E test quantification of resistance, identification of enzymatic and non-enzymatic mechanisms, and for DNA restriction fragment analysis to identify clonal resistance patterns. Several publications by residents have identified novel resistant clones, mechanisms of resistance, and therapies.