Community Regional Medical Center (CMRC)
CRMC is an academic center which has over 700 beds, with approximately 80 beds dedicated for the ICU. It houses Central California's only Burn and Level 1 Trauma Center, and is the core training site for the UCSF Fresno Medical Education Program (residencies in Internal medicine, Family Practice, Surgery, Pediatrics, Oral-Maxillofacial Surgery, OBGYN, and Psychiatry and Fellowships in Cardiology, Pulmonary/Critical Care, Sleep Medicine, and Gastroenterology). Surgical specialty programs such as general, orthopedic, gynecological, urological, vascular, neurological, trauma, burn and ENT are also onsite. New innovations in cardiac, vascular and neurological surgery are offered, including left ventricular assist device (LVAD) surgery, TVAR, a hyperbaric chamber, robotic surgery such as CyberKnife, the da Vinci Surgical System, laser trans-myocardial revascularization, aortic and peripheral vascular stent placement, interventional neurology, and prostate brachytherapy.
The infectious diseases consult team includes the ID attending physician, the ID fellow(s), 1 to 3 residents and medical students, an ID pharmacist and pharmacy resident, as well as medical 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. Approximately 60% of all consults are men and 40% are women. Our fellows see an consultations 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 ranging from general medical problems to the severely immunocompromised and intensive care patients . Common presentations include: coccidioidomycosis, tuberculosis, febrile neutropenia, AIDS/opportunistic infections, fever of unknown origin, bacteremia, infectious endocarditis, pneumonia, empyema, meningitis, brain abscess, osteomyelitis, and urinary tract infections, and more. 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 an antimicrobial management program to ensure the appropriate utilization of antibiotic therapy. It will allow the fellows to acquire expertise and knowledge in the appropriate utilization and management of antimicrobial agents in order to optimize patient care, minimize toxicities, minimize the development of resistant nosocomial pathogens and practice cost effective medicine. Fellows receive calls for all restricted antimicrobials, though many antimicrobials allow for a “first dose” administration by the treating clinician. This “antibiotic pager” is required to be on and available 24/7, staffed by the Infectious Diseases fellows on clinical rotations at CRMC. It is expected that calls are returned as soon as possible where practical. The pager will be supervised by the attending on the consult service. There is no in-house call.
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 dedicated weeks at the beginning of their fellowship in the clinical microbiology laboratory. Subsequently through the rest of the year, all fellows on clinical rotations have frequent clinical microbiology rounds 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.
General Fellow responsibilities:
1. The fellows or program will develop the on-call schedule for him/herself and for the rotating residents
2. The fellow will take first call regarding antimicrobial approvals.
3. The fellow will be responsible for management of the patients
a. Assigning new consultations to students and residents rotating on the consultation service.
b. Determining the appropriate strategy for diagnosis and treatment of the patient.
c. Providing a link between the inpatient consultation service and the outpatient clinic in order to maintain continuity and prevent medical errors.
d. Suggest appropriate times to sign off of patients
4. The fellow will supervise all the residents and medical students on the service:
a. Confirm the history and physical examination
b. Help the student develop a plan for the management of the patient.
c. Provide education and references to the students and residents
d. Allow residents to go to clinic and conferences in a timely manner
e. Provide constructive feedback to the students and residents.
5.The fellow will present cases to the faculty physician.
6. The fellow will confer with the attending physician if difficulties are encountered in running the service.
7. The fellow will be responsible for organizing and presenting cases at the weekly case conferences.
8. The fellow will be responsible for interaction with the requesting services.
9. 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.
10. The fellow on service should be available 24 hours per day by telephone except during the weekend off or when being covered by a colleague.
Fresno VA Hospital
The fellowship rotation at the Veterans Affairs Central California Health Care System (VACCHCS) facility will include both inpatient and outpatient experiences. The fellows will learn to work in the unique system of health care that has been developed for veterans and participate in health care using a mature integrated electronic records system that has been a model for other health care systems.
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 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, MRSA and C. difficile infections. 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 and HIV clinic 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 conditions.
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.
Special Services Clinic (HIV)
The Special Care Clinic (HIV) at CRMC provides care to over 1000 active patients who span the spectrum of disease from acute to far advanced infection. In addition, 25-30 pediatric patients are cared for by the HIV clinic. The clinic also provides primary care for 15-20 HIV-infected pregnant women every year.
Fellows are assigned one half-day clinic per week for the 24 months of the fellowship program in order to provide continuity of care. Each fellow will be assigned a panel of 50 patients for their longitudinal continuity care clinic. With dieticians, pharmacists, social workers and nurses all working in the clinics, fellows are exposed to an inter-disciplinary approach to patient care. In addition, the inpatient consult service provides at least 3 HIV consults/week which allows the fellow to focus on the inpatient HIV-related complications and to gain in depth knowledge of the acute care aspect of these immunosuppressed patients.
General Fellow Responsibilities:
University of California, San Francisco: Moffitt Hospital
The goal of this mandatory rotation is to provide the fellow with the skills necessary to understand the unique infectious complications in transplant patients and to learn the appropriate evaluations required for diagnosis and treatment of these infections. The fellows will join the ID consultative service at UCSF-Moffett Hospital in San Francisco and participate by both seeing the transplant patients as primary consultative contact and by supervising residents making primary contact. They will be supervised by the Infectious Disease Specialist attending on the ID transplant service and will be monitored by the site director. During the rotation they will not only learn the diagnostic and treatment skills required for transplant patients, but also gain knowledge on the indications and approach to infection prophylaxis. They will also learn how to assess the literature relative to infections in the transplant patients and be prepared to discuss key articles.