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Infectious Diseases Fellowship Curriculum |
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University of Virginia Health System GENERAL FEATURES OF THE PROGRAM: The Infectious Disease Fellowship at the University of Virginia is a three year program aimed at training future faculty in academic infectious diseases. It provides rigorous training and supervised experience with a faculty of broad clinical expertise at a sufficient level for the resident to acquire outstanding skills as a specialist in infectious diseases. Fellows have access to a laboratory for clinical microbiology, including diagnostic bacteriology, immunology, mycology, parasitology, and virology. Facilities for the isolation of patients with infectious diseases are available. The University of Virginia has training programs in surgery, obstetrics, gynecology, pediatrics, and other medical and surgical specialties and subspecialties. Clinical experience includes opportunities to observe and manage adult patients with a wide variety of infectious diseases on both an inpatient (Inpatient Consultation Service) and an ambulatory basis (Infectious Disease Clinics, Sexually Transmitted Disease Clinic, Travelers' Clinic). Such opportunities encompass longitudinal experiences in a continuum of care to observe the course of illness and the effects of therapy. Patients seen on the Inpatient Consultation Service are followed during the acute and recovery phases of their illnesses. When necessary, outpatient followup is provided in Infectious Disease Clinic-2. Each fellow on a rotating basis carries the outpatient beeper and serves as the initial consultant for calls from outside physicians; these call involve management of both outpatients and inpatients. In Infectious Disease Clinic-1, each fellow has primary, appropriately supervised responsibility for following a panel of HIV-infected patients and managing antiretrovirals and prevention and treatment of opportunistic infections over two years. The fellow also provides consultative services to outpatient clinics in other specialties and subspecialties (e.g. Orthopedics, Gynecology) Fellows' experience thus includes management of antibiotic administration in such settings as the hospital, the office, or in conjunction with home-care services. Experience with pediatric infectious diseases is provided primarily through the presentation of instructive cases in the weekly Infectious Disease Case Conference. Each fellow will develop a research program in connection with one or more faculty members from the Infectious Disease Group (Infectious Disease, Geographic Medicine, Epidemiology and Virology) or from another department (e.g. Microbiology, Cellular Biology, etc.). The fellow will participate in all aspects of research, including project definition, experimental design, interpretation of data, and obtaining of funding. By employing cross coverage, fellows have at least one day in seven free of patient care duties averaged over four weeks. Fellows do not work more than 80 hours/week, averaged over a four week period. All clinical responsibilities are adequately supervised by board certified faculty, and faculty backup is present for periods of clinical overload. Residents completing the fellowship are qualified to sit for Infectious Disease Boards.
This year is entirely devoted to research, as well as parts of the 2nd and 3rd years. The research may be based in the clinic or the laboratory. During this year, fellows have no primary clinical responsibility. All fellows attend lectures and seminars, including Research Conference, Journal Club, Microbial Pathogenesis Club, Didactic Conference, and Infectious Disease Case Conference. Fellows present annually at Research Conference. Occasionally, fellows conduct the research year after the clinical years. Research Training Plan. The fellowship is designed to recruit outstanding physicians who are motivated to pursue an academic career, with the aim of preparing them to be independent investigators on the faculty of medical schools. The need for such training has most recently been articulated by Thomas Cech et al. ("The Biomedical Research Bottleneck", Science 2001; 293:573) who cite the 40% decline in physician-investigators in the last 15 years despite the tremendous promise of translational research in the 21st century. Near the end of training as fellows prepare to leave to establish careers as independent investigators, fellows will be expected to write grant applications such as the Mentored Clinical Scientist Development Awards. Formal course work for fellows. Our philosophy is that training of all postdoctoral fellows should favor research over formal didactic course work, and that the emphasis need always be placed on research productivity and attainment of independent investigator status. However, without an adequate academic background a trainee is hindered from having meaningful intellectual input, perspective, and independent thought in research. It is expected that all trainees will take (audit or for credit, based on the recommendations of the Trainee Advisory Committee) at a minimum one graduate level course in the first year. Fellows following the more traditional path of basic science and translational "bench" research have several options to correct deficits in their backgrounds of modern cellular and molecular biology, infectious diseases, and immunology. The decision on what course work will be required is necessarily individualized, with the Trainee Advisory Committee having the deciding power. Course work that could be included in an individual fellow's training plan includes Microbial Pathogenesis (MICR 810), Biochemistry (BIOC 503), Cell Structure and Function (MICR 812), Fundamental Immunology (MICR 803), and Gene Structure, Expression, and Regulation (MICR 811). All of these courses are taught each year; it is anticipated that fellows would take a total of no more than two graduate level courses. Additionally, since 1996 the Program faculty has organized and taught an extremely well attended (30-40 trainees from the medical school) summertime "how to" course in molecular biology which all Program trainees are encouraged to attend. The Research Ethics Course (GSAS 710) is taken by all trainees. Faculty Research Interests. The Research Program of the Faculty as a whole is not narrowly focused in one area of Infectious Diseases, but spans many of the modern issues of basic, translational and clinical research. The major strength of the Program is the uniquely interdisciplinary training environment provided by the close interactions, collaborations and cooperation of the Faculty. Faculty Research interests can be sub-categorized into 5 themes: Pathogenesis of Bacterial and Fungal Infections, Immune Response to Infections, Parasitology and International Medicine, Virology, and Epidemiology of Infectious Diseases. The division of the research interests into themes is of course to some extent artificial, and faculty interactions and collaborations are not restricted to other investigators within that theme. This is perhaps best appreciated by the fact that 11/26 faculty have research interests encompassing 2 or more themes. Research within the "Pathogenesis of Bacterial and Fungal Infections" has an emphasis on toxins of respiratory and enteropathogens (Casanova, Guerrant, Hewlett, Obrig, and Smith), and microbial pathogen cell surface and transport (Casanova, Goldberg, Guerrant, Hazen, and Pearson). "Immune Response to Infections" includes emphasis on mucosal immunology (Petri, Braciale, Engelhard, Fu, Obrig, Smith), immunopathogenesis of infections (Petri, Braciale, Hahn, Hammarskjold, Obrig, Ravichandran, Roberts and Smith), and T cell activation (Braciale, Engelhard, Fu, Hahn, Ravichandran and Roberts). "Parasitology and International Medicine" is more narrowly focused on enteropathogens of importance in the developing world, an interest shared by all 4 investigators (Petri, Farr, Guerrant, Mann). "Epidemiology of Infectious Diseases" encompasses a highly interactive group of faculty with interests in infections in the hospital (Connors, Farr, Guerrant, Knaus) and the developing world (Petri, Farr, Guerrant). Finally the "Pathogenesis and Therapy of Viral Infections" includes emphasis on respiratory viral infections (Braciale, Hayden and White), HIV (Hammarskjold, Ravichandran and Rekosh), and viral modulation of the immune system (Braciale, Hahn, Hammarskjold, Kedes and Ravichandran).
The Beirne Carter Center for Immunology Research and the NIH-funded Immunology Training Program play an integral role in the Infectious Diseases Training Program. The PI of the Infectious Diseases Program, Dr. Petri, is a member of the steering committee of the Immunology Training Program and is a member of the Center. The Immunology Center Director and PI of the Immunology Training Grant, Dr. Braciale, is a mentor on the Infectious Diseases Training Grant. The close interaction of the Center with our Program highlights the importance that we place on the interface of Immunology with Infectious Diseases. The Beirne Carter Center is located in 8,000 square feet of modern space in Medical Research Building 4 (MR4), in close proximity to Infectious Diseases Program faculty labs in MR4 and Jordan Hall. The Center is occupied by nine investigators with a primary interest in immunology, four of which are preceptors in this application (T.J. Braciale, V. Engelhard, K. Ravichandran, and Y. Hahn). Expansion of the Center into the MR6 Research Building is planned in 2003 and is supported by an additional gift from the Beirne Carter Foundation of $5 million. Programs of the Beirne Carter Center that directly involve the participation of Infectious Diseases Program trainees and faculty include: The Myles Thaler Center for AIDS and Retrovirus Research was endowed and Center Director David Rekosh, Ph.D. recruited after a nationwide search in 1992. Dr. Rekosh has a central role in the Infectious Diseases Program as a member of the Steering Committee. The Center consists of five faculty members, all of whom are preceptors for this training grant (D. Rekosh, L. Hammarskjold, D. Camerini, D. Kedes , and M. Roberts). The research interests of the Center investigators include the molecular biology of HIV RNA transport, interaction of HIV gene products with the immune system, virulence of HIV isolates in a human - SCID mouse model, and molecular mechanisms of latency of Kaposi Sarcoma associated herpes virus. The Center is located in 6,000 square feet of laboratory space in Jordan Hall (again in close proximity to other Infectious Diseases Program faculty laboratories in Jordan Hall and MR4). Programs sponsored by the Thaler Center of special interest to trainees in the Infectious Diseases Program include the weekly Research in Progress series, and Thaler Center Seminars which are incorporated into the Department of Microbiology seminar series. The Department of Microbiology this year ranks #2 of all Microbiology Departments in the nation for NIH funding. It is a central component of the Infectious Diseases Program, with eight of the mentors (V. Engelhard, J. Goldberg, M. Hammarskjold, R. Kadner, K. Ravichandran, D. Rekosh and M. Roberts) having primary, and 11 mentors (T. Braciale, S. Fu, Y. Hahn, K. Hazen, D. Kedes, B. Mann, T. Obrig, W. Petri, K. Ravichandran, M. Smith and J. White) with joint appointments in the Department. A major programmatic contribution of the Microbiology Department to the training environment is the graduate student course on microbial pathogenesis (MICR 810 - Microbial Pathogenesis), which is a required course for Infectious Diseases predoctoral trainees and is organized and taught by the faculty of the Infectious Diseases Training Program. Thomas Parsons, Ph.D., Chair of the Department of Microbiology, has made it a priority to hire new faculty in the area of microbial pathogenesis, with a new search underway for a tenure track faculty member in the area of microbial pathogensis. The Center for International Health was established in 1978 by Richard Guerrant M.D as one of the four original Rockefeller Foundation supported programs. The Center is an integral part of the Infectious Diseases Program, with a focus on emerging enteric and protozoan infections, with both laboratory and field components of the research. Dr. Guerrant is the Principal Investigator for two major program projects in the Center: the NIH International Collaborations for Infectious Diseases Research (ICIDR) program project grant "Recognition and Expression of Tropical Infectious Diseases" and the NIH Tropical Medicine Research Centers (TMRC) "Pathogenesis and Therapy of Tropical Diseases". The faculty of the Center (including preceptors R. Guerrant, B. Mann and W. Petri) also teach trainees in a growing Travelers' Clinic, conduct international electives for students, and have developed major international collaborations with the sister institutions the Federal University of Ceara in the northeast of Brazil and the University of Ghana Medical School, Accra, Ghana. The Center is the home for the "International Training in Emerbing Infectious Diseases" NIH Training Grant which is exclusively for the training of foreign nationals. Certification in Tropical Medicine and Travelers Health is available for M.D. trainees in the Program (one of only a handful of infectious diseases programs nationwide to offer this certification training). Certification is administered by the American Society of Tropical Medicine and Hygiene, and provides added emphasis on tropical medicine. The Certification course is directed by Infectious Diseases Program mentor B. Mann, and includes seminars, conferences, laboratory training, and outpatient experience. The Department of Health Sciences Evaluation and its Chair William Knaus, M.D. add expertise in the design and interpretation of clinical infectious diseases research. The Master's Degree in Health Evaluation Sciences is required for all Infectious Diseases M.D. postdoctoral trainees specializing in clinical research. Tuition for the Master's Degree is provided by the training grant, and to date all 9 M.D. postdoctoral trainees specializing in clinical research and supported over the last 10 years by this grant have completed, or are currently enrolled, in the program. The typical coursework for the program is: The General Clinical Research Center is a fully NIH-funded ten-bed clinical unit with its own nursing staff. The center is located on the eighth floor of University Hospital in 8,000 square feet of space. The inpatient beds are equipped with extensive monitoring facilities including two channel blood pressure, ECG monitoring, pulse oximetry, temperature and non-invasive blood pressure determinations. In addition to the inpatient space the center has an off-unit outpatient space, as well as a state of the art fully staffed exercise physiology laboratory, sleep laboratory, metabolic kitchen and RIA core laboratory. The scope of NIH funding for this center allows investigators to carry out research in both healthy and ill human volunteers. Investigators have access to extensive computer facilities on the center staffed by a trained systems manager. An example of the use of this center by the Infectious Diseases Program is the study of diarrhea in HIV-infected patients by trainee Nathan Thielman, M.D. with preceptor Dr. R. Guerrant. Dr. Thielman's work was supported by a Clinical Associate Physician award through the Clinical Research Center. The Respiratory Disease Study Unit is part of the University's Center for Prevention of Disease and Injury. It coordinates and supports the investigative activities of faculty and fellows interested in a broad range of questions related to respiratory viral disease, specifically clinical trials involving ambulatory adults. Fred Hayden, M.D. is the Infectious Disease Program preceptor that works in the Unit with trainee Michael Ison. The Unit is physically located within the Elson Student Health Center and encompasses 300 square feet of laboratory space for virus isolation and identification, serologic testing, and nucleic acid amplification; two nursing offices; and a 500 square foot clinical work area. The current support staff consists of three research nurses and two and one-half full time technicians. The Infectious Diseases Clinic cares for 350-400 HIV-infected patients in the Primary Care Center, which is a five minute walk from the Infectious Diseases Program labs in MR4 and Jordan Hll. It also provides support to satellite clinics that care for an additional 150 patients. Directors of the Clinic are Program graduates Brian Wispelway, M.D. and Greg Townsend, M.D. Clinical research conducted at the Clinic includes participation in antiretroviral protocols, protocols of the NIH Mycoses Study Group, and evaluation of therapies for opportunistic infections. More basic retroviral research, utilizing HIV isolates from patients, is conducted by the Thaler Center (above). The Clinic encompasses the AIDS Resource and Consultation Center, which serves half of the Commonwealth of Virginia by providing workshops, lectures, HIV testing and counseling courses, and a preceptor program. Trainees of the Infectious Disease Program receive instruction and participate in the care of HIV infected individuals through the clinic. The Clinical Microbiology Laboratory provides comprehensive microbiological diagnostic services for the inpatient and outpatient activities of the University of Virginia Health Sciences Center. The staff includes approximately 20 full time technical staff and four faculty members with specific expertise (including mentor K. Hazen). Each of the laboratory components (Virology, Molecular Diagnostics, Mycology, Mycobacteriology, Bacteriology) provide research and educational opportunities for trainees. The laboratory is a ready source of clinical specimens for assessing rapid diagnostic techniques and also has support laboratories to allow fellows to engage in the development of new techniques. Shared Medical Center Research Facilities are a major part of the research and training environment at the School of Medicine. These service centers complement the expertise of the laboratories of the Infectious Diseases Program mentors, and are supported by income from a $50 million endowment from the Pratt Foundation as well as user fees. They provide extensive teaching and consultation through their faculty directors, and include: Center for Comparative Medicine in Jordan Hall and MR4 that is overseen by 3 full time veterinarians and is AAALAC accredited and also houses the Transgenic Animal Facility and the Embryonic Stem Cell Facility. Institutional support for the Infectious Diseases Training Program includes supplementation by the School of Medicine of predoctoral and by the Department of Medicine of M.D. postdoctoral stipends (M.D. supplements were $19,611.20 for 2001), tuition support, support of the Director's 10% effort, and the provision of one full institutionally-funded graduate student position per year.
Second Year back to top Second year fellows participate in the Infectious Disease Consultation Service for two rotations of four weeks each. During this time, the fellow runs the service, supervising up to three internal medicine residents and up to six fourth year medical students. The fellow initially sees all inpatient consultations, and these are then presented to the attending physician. The fellow makes rounds with the attending physician 7 days per week. These inpatient attending rounds last on average 2 hours/day and include direct interaction of the fellow and attending with the patient, as well as demonstration and evaluation of the fellow's interview, physical exam, assessment and plan as well as ethical and professional behavior. Bedside teaching by the attending is included in these rounds daily. The fellow is expected to collect clinical information carefully and completely and present in a logical manner. The fellow with be conversant with the recent relevant literature. A very wide variety of cases is encountered in this tertiary care center. Consultations are obtained from all adult medical and surgical services including the Emergency Department. The outpatient fellow covers the inpatient service every other weekend, giving the inpatient fellow the weekend off. Second year fellows also participate in the outpatient infectious diseases service. These fellows serve as the primary contact for outside physicians requesting consultation advice. These consultations may be presented to the attending physician at the discretion of the fellow. Second year fellows rotate for a total of 8 weeks (two block of four weeks each). The outpatient fellow also covers the inpatient service every other weekend, giving the inpatient fellow the weekend off. Second year fellows spend 13 half days in the Sexually Transmitted Disease Clinic at the Thomas Jefferson District Health Department. Here they are directly involved with all aspects of the management of STD, including differential diagnosis, antimicrobial therapy and public health issues. The fellows spend one half day per week in Infectious Disease Clinic I. Most of the activity in this clinic centers around the long-term management of patients with HIV/AIDS. Under the direction of several faculty, each fellow assumes primary responsibility for a panel of such patients and deals with issues of antiretroviral therapy, prophylaxis and management of opportunistic infections, and the social and financial aspects of case management. The fellows provide continuity of care over a 2 year period for their patients in Infectious Diseases Clinic I. Infectious Disease Clinic II takes place on Friday mornings. The outpatient fellow sees nonHIV illness, primarily among patients referred from the inpatient consultation service. Traveler's Clinic is attended by the fellow on the outpatient consultation service. This clinic meets once per week and focuses on the needs of international travelers. Travelers returning with illnesses may also be initially evaluated in this clinic. The fellows here deal with many issues related to tropical medicine. A new initiative is the Transplant Infectious Disease Service. The inpatient fellow will have initial responsibility for consultation on inpatients with bone marrow or solid organ transplants. A specific cadre of attending physicians will supervisor this service. On the Antibiotic Surveillance Team, attending physicians review antibiotic use on inpatient service throughout the hospital. The fellows are invited to join these rounds at their discretion.
The third year rotations mirror those in the second year. Third year fellows attend 18 weeks on the inpatient and 18 weeks on the outpatient services. Clinic responsibilities remain the same. Third year fellows have additional administrative responsibilities including planning the Didactic Lecture Series and scheduling the fellowship rotations. PROFESSIONAL ETHICAL BEHAVIOR The training program mentors strive to maintain and role-model a culture that values professionalism and ethical behavior. The faculty serve to emphasize the importance of such qualities in the fellows. This includes but is not limited to values such as that the needs of the patient are paramount, commitment to scholarship, excellence in clinical care, teaching and research, humanistic qualities including respect, compassion towards patients and a professional and collegial attitude towards colleagues. Fellows are instructed to recognize and intervene if colleagues suffer physical or psychologic impairment, including substance abuse. High standards of moral and ethical behavior are fostered for fellow interactions with pharmaceutical and funding organizations. Opportunity is taken in conferences, bedside rounds and in one-on-one evaluation sessions with the program director and faculty to discuss and educate the fellows on biomedical ethics and to allow the fellows to participate in ethical decisions arising from the management of their patients. In addition all fellows take the graduate level course in research ethics. SPECIAL EDUCATIONAL REQUIREMENTS The training program provides specific education tailored to infectious diseases in ethics of medical care and biomedical research, social and economic impact of medical decisions on patients and society, the need for physicians to be advocates for their patients, quality assessment and improvement, risk management, preventive medicine, occupational and environmental health, medical informatics and computer skills, critical assessment of the medical literature, law and public policy, pain management, end of life care, principles of managed carre, violence (domestic, sexual), and substance use disorders. Much of this training occurs at the bedside and in conferences, lectures and seminars and some in the research part of the fellowship. CONFERENCES, LECTURES, AND SEMINARS: Infectious Disease Case Conference takes place for 90 minutes every Monday afternoon. Fellows who are not currently on the inpatient consultation service present selected cases. These cases are usually presented in segments, with faculty being asked to develop an approach to the case and discuss interpretation of clinical data, differential diagnosis and management and pathophysiology, appropriate use of technology and prevention. The fellow then presents a definitive discussion of some aspect of the case, and this discussion is accompanied by a formal handout. Two such cases are usually presented at each meeting. Cases are regularly presented from the Pediatric Infectious Disease Service and are occasionally presented by extramural fellows or faculty. A third, management case, is a patient currently being followed by the consultation service. This case is presented in its entirety, and the audience is asked for advice regarding management. A clinical microbiologist is present weekly at the conference and contributes to the discussion of the cases and provides slides, preparations and cultures from the clinical laboratory on an occasional basis to illustrate cases. Surgical pathology is presented at the conference at a regular basis. The Didactic Conference takes place at noon on Tuesdays three out of four weeks. Lectures are presented by faculty. The topics are selected by the third year fellows and usually cover the spectrum of infectious disease over a two-three year interval. Lectures specifically devoted to issues in tropical medicine are included. Research Conference takes place on the first Tuesday of each month at noon. Fellows and graduate students present their research in progress which is then open to critical discussion by faculty. Research in Progress Seminar takes place one evening each month. One senior and one junior investigator present work in progress. Fellows are exposed to much of the research in the Infectious Disease Group and in our affiliated basic science departments. Clinical Journal Club takes place at noon on the first and third Fridays of each month. Fellows and faculty are assigned responsibility for specific journals. Each fellow reviews the journal and presents articles of interest. A small handout is usually provided. The discussion focuses on critical evaluation and interpretation of the infectious disease literature. Microbial Pathogenesis Journal Club meets the second and fourth Fridays of each month and discusses articles related to the basic science aspects of microbial pathogenesis and interaction with host defenses. Topics from this year's program included: HIV Viral replication
Infectious Disease Faculty Research Day: The faculty present research. Internal Medicine Research Day is a departmental event occurring each spring. Each of the fellows gives an oral or poster presentation. These venues provide formal instruction in: 1. The factors that determine the outcome between host and parasite, including microbial virulence factors and host defense mechanisms. 2. The basic concepts of immunology. 3. The epidemiology, clinical course, manifestations, diagnosis, treatment, and prevention of major infectious agents including viruses, chlamydiae, mycoplasma and ureaplasma, rickettsioses, bacteria including spirochetes and mycobacteria, mycoses, protozoa, and helminths.
Faculty evaluate the fellows on all of the inpatient rotations. Evaluations of outpatient activities are obtained annually. Fellows are assessed for competence in patient care, medical knowledge, practice-based learning, interpersonal skills and communication, professionalism and systems based practice. Charts are audited daily by the attending physician and daily feedback to the fellow provided. Concerns of the faculty or fellows are addressed immediately by the Program Director and/or the Chair of the Clinical Competency Committee when brought to their attention. Research supervisors provide evaluation of the research activities. The Program Director meets with each fellow per year, and the Chair of the Clinical Competency Committee meets with each fellow once per year to review these evaluations. The progress of the fellows is followed by the Clinical Competency Committee, which meets several times each year. Research mentors evaluate the fellows quarterly. Fellows evaluate faculty on the inpatient rotations at the end of each rotation and the outpatient attendings on an annual basis. These anonymous evaluations are summarized for individual faculty and for the program director and are used to counsel faculty and to assign faculty to specific teaching rotations. Fellows evaluate the program on an annual basis (anonymously) and these evaluations are used to develop programmatic changes. A written evaluation of the clinical competence of each fellow is prepared annually by the the Chair of the Clinical Competency Committee and Program director.
Fellows have extensive clinical experience or formal instruction in the prevention, evaluation, and management of the following disorders: 1.The febrile patient; specifically presenting in association with rash or as fever of unknown origin Areas in which the fellows are expected to develop expertise are listed on the following chart. The areas principally responsible for these exposures are defined. Fellows gain practical and instructional experience with the following: 1. Mechanisms of action and adverse reactions of antimicrobial agents; the conduct of pharmacologic studies to determine absorption and excretion of antimicrobial agents; methods of determining antimicrobial activity of a drug; techniques to determine concentration of antimicrobial agents in the blood and other body fluids; the appropriate use the hospital, ambulatory practice, and the home |