Pulmonary and Critical Care Medicine Fellowship

The primary training site, BMC Brighton, is a modern facility that includes inpatient and ambulatory care, as well as clinical and research laboratory resources.

Our Community

The population served at BMC Brighton is multiethnic and multilingual, comprising individuals who live in proximity to BMC Brighton, Boston residents referred from other hospitals, and residents of suburban communities in Massachusetts.

We see patients from a variety of groups and national backgrounds, including those who identify as Black, Hispanic, east and south Asian, Irish, and Russian. Appropriate translators are available as needed. Our residents and fellows benefit from caring for those who may experience and express their needs differently and who may have different expectations regarding appropriate treatment.

Academic Affiliation

Almost every BMC Brighton pulmonary, critical care, and sleep medicine specialist is a board-certified faculty member of the Tufts University School of Medicine or the Boston University Chobanian & Avedisian School of Medicine.

Year One: Foundations

The first year of fellowship is divided equally between two core experiences, in 2-week blocks.

• Inpatient Pulmonary Consult Service
• Medical Intensive Care Unit (MICU)

Additionally, fellows complete rotations in Sleep Medicine and, in the ventilator weaning unit, Long-Term Acute Care.

(Additional information regarding these rotations is also provided in the Pulmonary Disease/Critical Care Medicine division goals and objectives policy.)

Diseases and Conditions

During these rotations, our trainees acquire clinical experience with a spectrum of pulmonary and critical care diseases and conditions, including:

• Acute lung injury, acute respiratory failure, and ventilator management
• Genetic and developmental disorders involving the lungs
• Iatrogenic and drug-induced lung disease
• Infectious disease, including fungal lung disease, tuberculosis, and management of infection in the immunocompromised patient
• Interstitial lung disease, including idiopathic pulmonary fibrosis, sarcoidosis, and disease related to vasculitis and collagen vascular disease
• Multisystem critical illness, including sepsis, metabolic, and hematologic emergencies
• Neurologic conditions, including intracranial hemorrhage, ischemic stroke, meningoencephalitis, and respiratory failure due to degenerative and neuromuscular diseases
• Obstructive lung diseases, including asthma, bronchiectasis, bronchitis, chronic obstructive pulmonary disease (COPD), cystic fibrosis (CF), and emphysema
• Occupational lung diseases, including occupational asthma, COPD related to environmental exposures, interstitial lung diseases of occupations, and hypersensitivity pneumonitis
• Pleural and mediastinal disorders, including management of pleural effusions and empyema
• Pregnancy complications, such as preeclampsia, amniotic fluid embolism, and pregnancy-related cardiomyopathy
• Pulmonary hypertension and pulmonary hemorrhage syndromes
• Pulmonary malignancy, including primary lung tumors and metastatic disease
• Sleep disorders, including obstructive sleep apnea, narcolepsy, and central hyperventilation syndromes

Procedures

During the first year of clinical training, fellows gain experience in the following procedures related to the care of pulmonary and critical care patients:

• Establishment and maintenance of an open airway in non-intubated, unconscious patients and intubation of the airway with an endotracheal tube
• Management of mechanical ventilation, including noninvasive mechanical ventilation and methods of ventilator weaning and liberation
• Use of masks and devices to deliver oxygen, nebulized medications, and incentive spirometry
• Management of pneumothorax
• Arterial puncture and blood sampling and insertion of central venous, arterial, and pulmonary artery balloon catheters
• Basic and advanced cardiopulmonary resuscitation and cardioversion
• Pleural drainage via thoracentesis, chest tube, and tunnel pleural catheter placement
• Pulmonary function testing and interpretation, including spirometry, lung volumes, diffusion capacity, blood gas analysis, exercise testing, and measurement of central respiratory drive
• Diagnostic and therapeutic procedures, including thoracentesis and fiber optic bronchoscopy
• Calibration of hemodynamic monitoring systems and the utilization, zeroing, and calibration of transducers
• Examination of samples of sputum, pleural fluid and tissue, and lung tissue for culture and histology
• Appropriate utilization and application of enteral and parenteral nutrition

Through didactics and clinical experience obtained during both the critical care and consult rotations, trainees are also exposed to and gain experience in the management of:

• Non-pulmonary critical care issues, including electrolyte management and acid-base physiology as well as metabolic effects of critical illness
• Critically ill patients with multi-organ diseases, including hematologic, oncologic, immunologic, and anaphylactic disorders
• Unique aspects of drug metabolism and effect, plus the use of sedation and paralytic agents in pulmonary and critical care patients
• Ethical, economic, and legal aspects of critical care, including the administration of an intensive care unit (ICU), effective communication, and the emotional and psychosocial effects of critical illness on patients

Throughout the first year, each fellow also attends a one half-day general pulmonary continuity clinic weekly. They will continue attending the same clinic over the three years, supervised by a faculty member.

Year Two: Advanced Procedures and Critical Care

In the second year, fellows expand their procedural expertise and broaden their critical care experience. During the first half of the second year of training, each fellow’s responsibilities increase by rotating on the Pulmonary Procedure Service and in a general surgical critical care unit.

These rotations afford the trainee with additional experience in the areas of pulmonary function testing, inhalation challenge testing, cardiopulmonary exercise testing, management of pleural disease by pleural drainage procedures, and fiberoptic bronchoscopy.

Pulmonary Procedure Service

During the pulmonary procedure rotation, each fellow is able to develop expertise in the monitoring and supervising of pulmonary function testing, respiratory physical therapy, and pulmonary rehabilitation services, as well as respiratory care techniques and services.

Procedures that fellows gain proficiency in performing include:

• Cardiopulmonary exercise testing and interpretation
• Chest drainage catheter placement under ultrasound guidance
• Endobronchial biopsy
• Endobronchial brush biopsy, protected brush technique
• Endobronchial ultrasound-directed biopsy (EBUS)
• Exercise bronchoprovocation tests
• Fiber-optic flexible bronchoscopy
• Fine needle aspiration (FNA)
• Foreign body extraction technique
• Induction of sputum (hypertonic saline) for diagnosis
• Methacholine challenge testing
• Navigational bronchoscopy
• Six-minute walking test
• Thoracentesis
• Transbronchial biopsy

Surgical Intensive Care Unit (SICU)

During a one-month block rotating at the BMC Brighton Surgical Intensive Care Unit (SICU), fellows manage general surgical cases as well as complex postoperative patients, including cardiothoracic, neurosurgical, and urological cases.

Under the supervision of a member of the surgical critical care division, they obtain additional exposure and practical experience with pericardiocentesis, transvenous pacemaker insertion, peritoneal dialysis, and intracranial pressure monitoring.

Research

The second half of the second year is spent in research. The goals of the rotation are to expose the fellow to several aspects of clinical research.

The Tufts CTSI Graduate Program Summer Institute

Fellows begin their efforts by enrolling in Tufts Clinical and Translational Science Institute (CTSI) Graduate Program Summer Institute at the beginning of their second year of training. This four-week course, specific to professionals with advanced biomedical degrees, teaches fellows to formulate and develop a clinical research hypothesis and clinical research project. The course includes an introduction to the fundamentals of clinical epidemiology and biostatistics and also surveys topics in the other core concentrations, including health services research, bench-to-bedside translational research, systematic review, and decision analysis.

Fellows are required to develop a research proposal and present this proposal in class to the other class participants and faculty preceptors for scientific review. These proposals and presentations serve as the framework from which their actual research projects are based. The goal is for fellows to be able to summarize basic and advanced principles of study design and challenges commonly faced when conducting biomedical research involving human subjects.

By the end of the course, fellows are expected to be able to:

Describe and assess basic study designs used in clinical research including case-control, cross-sectional, observational cohort, and experimental studies.

• Discuss the strengths, limitations, and use of different study designs and their applications.
• Apply research methods across the spectrum of clinical studies, including early phase, genetic association, and stakeholder-engaged studies.
• Define the role of outcome research, health economics, systematic reviews, and clinical decisionmaking in clinical and translational research.
• Interpret statistical results including p-values, confidence intervals, and formal statistical test results.
• Develop a research protocol.

The development of a research protocol during the Tufts CTSI Graduate Program Summer Institute will perpetuate the fellows’ learning to execute their project for institutional review board (IRB) approval and implementation. All projects are mentored by one or more attending physicians within the division, and the expectation is for completed projects to be submitted and presented at an international pulmonary/critical care conference such as the American Thoracic Society (ATS) International Conference, American College of Chest Physicians (CHEST), etc.

Year Three: Leadership and Clinical Mastery

The final year focuses on consolidating clinical skills and cultivating leadership and teaching abilities.

Research

During the first half of their third year of training, our fellows continue their research activities. This allows an uninterrupted period to focus on research project development, IRB submission, conducting the research, analysis of data, and preparation of manuscripts for publication.

Advanced Rotations and Electives

The second half of the third year is devoted to clinical activities and electives. Fellows rotate:

• On the procedure service
• Through a focus on pulmonary hypertension, including interpretation of right heart catheterization and level 3 cardiopulmonary exercise testing (one-month block)
• At a lung transplantation center (one-month block)
• In the cardiopulmonary and PFT lab
• Through electives tailored their interests (for example, additional outpatient rotations, sleep medicine, or procedural training)

For those with an interest in telemedicine, opportunities exist to participate in the electronic ICU in Westwood, Massachusetts.

Pre-Attending MICU Rotation

Finally, senior fellows return to the medical ICU for a one-month block of “pre-attending” time. Under careful supervision, senior fellows lead rounds, giving each fellow a chance to hone their own style while developing autonomy, teaching, and leadership skills.

We believe that learning should be interactive, inclusive, and clinically grounded. Our conference series integrates evidence-based medicine, procedural expertise, and multidisciplinary collaboration—preparing fellows to become outstanding clinicians, educators, and leaders in pulmonary and critical care medicine.

Didactics

Our fellows take part in a comprehensive lineup of recurring conferences. Our Didactic Lecture Series is led by faculty and covers core curriculum (essential pulmonary and critical care topics).

Conferences

In addition to the introductory didactic lectures, educational conferences are provided on a regular schedule:

Weekly

• Thoracic Oncology Conference (Tumor Board). Collaborative case review with pulmonary, oncology, thoracic surgery, radiology, and pathology teams.

Monthly

• Board Preparation Conference. Regular sessions reviewing high-yield material for ABIM certification.
• Clinical Conundrums. Case-based problem-solving sessions tackling unique or challenging scenarios.
• Pulmonary/CCM Journal Club. Critical review of recent literature with focus on study design, interpretation, and clinical relevance.
• Research Work-in-Progress. Fellows share ongoing projects and receive feedback from peers and mentors.
• Thoracic Radiology Conference

Monthly (September to June)

• Clinical Case Conference. Interactive case discussions emphasizing diagnostic reasoning and evidence-based management.
• ICU Morbidity & Mortality (M&M). Multidisciplinary reflection on complex cases to enhance patient safety and systems improvement. With residents.

Every Other Month

• Physiology Conference. Application of pulmonary and cardiovascular physiology to bedside care.
• Sleep Conference. Discussion of sleep-related disorders and their management.

Quarterly

• Pathology Conference

Other

• ATS Book Club. Guided discussions of landmark papers and key topics from the ATS Core Curriculum.
• Procedural Conference. Review and hands-on learning of pulmonary and critical care procedures.
• Program Director Rounds. Open forum for discussion of clinical experiences, education, and fellow wellbeing.
• Professional Development Series for Fellows. Longitudinal workshops on communication, leadership, and career growth.
• Ultrasound Conference. Focused training in point-of-care ultrasound (POCUS) for pulmonary and critical care practice.

Fellows are provided with feedback on an ongoing basis by our faculty, both face-to-face and through the New Innovations website.

Clinical Competency Committee

Every six months, the Clinical Competency Committee meets to judge the fellows’ performance and provide guidance for improvement. At this meeting, the CCC opines on the progress of each fellow in each of the ACGME Milestones of Training. This is followed by a face-to-face meeting with the Program Director in order to discuss the positives and negatives of a given fellows’ progress.

Program Evaluation Committee

In addition, the Program Evaluation Committee meets every other month. This committee consists of representative faculty as well as a fellow from each year of training and reviews the division’s specific rotations and curriculum along with any concerns from the faculty or trainee viewpoint.

In-Service Examinations

Every year, the first- and second-year fellows take an in-service exam in pulmonary and critical care medicine, and the third-year fellows take an in-service exam in critical care medicine. These exams allow for pinpointing areas of weakness in fellows’ knowledge that may be strengthened during board exam preparation.

Open Channels of Communication with the Program Director

The Program Director meets with all fellows each month and as the need arises to collect feedback on their experience with the program and discuss potential changes.