We select three fellows per year for training. This is a three-year fellowship. The core fellowship lasts for two years with a third year of research and clinical specialty training. The third year position is a "transition year" with qualified fellows selected as either as a Clinical Associate (a junior staff position), or as a Limited Clinical Practitioners (a post-graduate fellow position).
Both positions are beyond the two years of the basic ACGME fellowship training program, and qualified candidates will have full clinical privileges to the Cleveland Clinic Foundation. Both positions allow continuation of research activities started during the first two years of fellowship along with several months of clinical practice. These third year positions are competitive positions which will be offered to selected senior fellows at the end of training who have demonstrated an aptitude in both clinical work as well as a focused area of research. The Clinical Associate position is open to U.S. citizens and those on an H-1 visa.
We emphasize clinical training in our program, and our program is best suited for physicians seeking a career as clinician-educators or clinician-investigators. We emphasize clinically-based research and translational research. Many of the fellows who have graduated from our program have a "hybrid" career characterized by clinical work in infectious diseases, applied research, and house staff education.
We have a number of components to our training program, which is a mixture of didactic learning, learner-centered exercises, and directed clinical experiences:
- Problem based learning curriculum (4 hours per week)
- High volume general ID consultation services
- Subspecialty services, each with specific curricula and competency testing (endocarditis service, bone and joint, solid organ transplantation, hematology and bone marrow transplantation, ICU, Pediatric ID)
- Evidence-based medicine clinical rotation with the Program Director, with multiple observed CEX exercises
- International rotation in Mexico City
- Off-site subspecialty rotations in Tuberculosis Clinic and with focused in-patient consultations (OB/GYN, burns), at Cleveland MetroHealth Medical Center
- HIV clinic (longitudinal clinic)
- Subspecialty outpatient clinics (Mycobacterial clinic, Travel Clinic)
- Course work: SHEA- IDSA 20 hour infection control course, CDC STD advanced training course (Cincinnati, OH)
- STD experience at Cleveland Free Clinic
- Traditional conferences: ID-Microbiology Grand Rounds, Journal Club, Morbidity and Mortality conference
- Additional conferences: weekly multidisciplinary HIV conference, ID City-Wide Rounds, weekly Infection Control rounds (when on ICU rotation)
- Microbiology laboratory training
- Formal training in Research Methodology with pre-tests (Fresno test) and post-tests
- Attendance at the annual antibiotic formulary meeting
In addition, fellows engage in several self-learning exercises:
- Infection control outbreak project, as part of ICU rotation
- Formal lectures given by fellows to the internal medicine residents (e.g. as part of the Heme-Onc/Bone marrow rotation, fellows prepare a 1 hour lecture on anti-fungal agents and invasive mold infections)
- Case presentations (e.g. as part of the bone and joint service, fellows formally present 1-2 cases from the service with literature review)
- Portfolio development
The goal of the Infectious Diseases fellowship training program at the Cleveland Clinic is to train clinician-educators and clinician-scholars using the latest in educational techniques and adult learning theory.
We train fellows who are deeply committed to excellence in clinical medicine, who wish to contribute significantly to the field of infectious diseases as scholars, and who plan busy practices in complex tertiary (and quaternary) care centers in the United States and globally.
The secret to patient care is to first care about the patient.
There are many models for training in medicine, and in infectious diseases. Our program is not for everyone. We place the highest priority for fellowship training in the clinical months at the bedside. We do not consider the clinical months as "necessary evils" to be grouped together for 12 straight months, so that the real business of bench research can be performed uninterrupted. The clinical months are the show case of our program. We consider the physician-patient interaction to be the heart of learning and the essence of what it means to be a clinician.
Problem Based Learning for Graduate Medical Education
One of the unique features of our program is the use of a problem based learning (PBL) format as the main Core Curriculum. This format has been widely used for medical student teaching, but is unique in fellowship training. Research studies in adult learning have repeatedly shown that the PBL format is superior to a standard lecture format on a number of outcome measures. This has also been called "learner-based learning."
The PBL sessions are based on actual Cleveland Clinic cases which are selected by the Program Director, and then presented as unknowns to the fellows, who work through the case with textbooks and articles at hand, with little or no “interference” by a faculty member. There are also specific questions regarding the case written by the Program Director, to highlight important issues. We also integrate some of the PBL cases with the microbiology laboratory, and sometimes we go to the laboratory as part of the session. Interpretation of radiographs is an important skill for the I.D. specialist and may not be covered in a didactic curriculum. In the PBL sessions we include numerous plain films, MRI scans, and CT scans (with identifiers blinded due to HIPAA regulations), and review the films as a group. We feel the PBL format represents a major educational advance for the program, and fits in well with the ACGME core competency project. The PBL format lends itself particularly well to assessment of competency, particularly with respect to medical knowledge and patient care.
The PBL sessions are held 3 hours per week (equivalent classroom time to a college course). The Core Curriculum is also supplemented by standard lecture series given by the faculty, board review simulations and videotapes, and a weekly didactic and PBL course in HIV medicine.
Clinical Examinations for Competency (CEX)
Although the mini-CEX examination is given routinely during internal medicine training, this form of teaching/learning is seldom used at the fellowship level. In our training program, we make extensive use of the FULL CEX examination, where fellows of all levels are evaluated from “start to finish” on a case with the Program Director present throughout. This has yielded valuable insights into the fellows’ approach to the patient which would not otherwise be uncovered during the more traditional bedside rounding approach. Although this is a time consuming process, we feel this is a key element of medical education that is missing in most fellowship training programs.
The Mentor Model
Starting in 2007 we instituted a “Mentor Model”, where a fellow is assigned to a single faculty mentor for 6-8 weeks. Fellows and staff see patients together on the general consult service, specialty consult services and outpatient clinic. This model addresses several of the problems of fragmentation in medical care and medical education. Due to high patient turnover in the hospital, trainees often see only “snapshots” of patients and their diseases and rarely see the patients again in clinic. Fellows ordinarily do not see hospital follow-up patients in clinic, and frequently do not know the outcome or consequences of their treatment recommendations. Fellows do not know how to “close out a case” or when it is safe to stop antibiotics.
Similarly, rotation cycles for faculty are getting increasingly shorter, and with other commitments for both the faculty and the trainees, the contact time between the two groups has become increasingly limited. We also feel that after two years of training, a graduating fellow (or resident) may not have a good feel for what an attending physician actually does day-to-day. The Mentor Model has allowed the faculty to evaluate the fellow in a variety of different settings, instead of only a single setting (e.g. high pressure inpatient consult service) to better appreciate the fellows abilities and consistency. The fellows have already shown major increases in the number of hospital follow-up visits to the outpatient setting compared with prior years. We feel this will lead to a better understanding of the course of an infection over time. Fellows also share in some of the non-clinical experiences of the faculty. For example, fellows are assigned to one of the infection control group faculty for 2 months, and during that time attend the same meetings, field the same phone calls regarding infection control, and participate in an outbreak investigation.
The main mentor blocks are as follows:
Bone and joint infection
ICU infections and infection control
Mycobacteria and Granuloma Clinic
Hematology and Bone Marrow Transplantation
Solid Organ Transplantation
Evidence Based Medicine Rotation
During the second year of training, fellows have a special rotation with the Program Director for 2 weeks, specifically to develop competence in practice based learning and improvement (PBLI), one of the key ACGME competencies. The rotation is structured such that the fellow sees relatively few patients compared with the general ID consult rotation (about 2 consults/day). For each new consult, fellows are required to identify at least one scientific study, review the study in real time, evaluate the quality of the study, and present all of this the next day. Fellows complete a special form for each encounter. This combination of patient note/article/evaluation form becomes part of their portfolio. During this rotation, the “User’s Guide to the Medical Literature” by Gordon Guyatt et al. and the accompanying exercises is reviewed by the fellow and program director. In essence this is a clinical experience in evidence based medicine.
Multiple Subspecialty Services and the "Crash Course"
Because of the wealth of clinical material at the Cleveland Clinic, the training program has been restructured through the years to incorporate an increasing number of focused clinical experiences in the curriculum. The clinical portion of the program has changed from an experience consisting of 12 months on the general ID consult service to more than half of clinical time on focused subspecialty rotations. Currently we have six specialty hospital services (endocarditis, bone and joint, program director rotation, ICU x 2 services, bone marrow-leukemia, solid organ transplant) in addition to a rotation at MetroHealth Medical Center specifically for trauma, burns, and OB/GYN. A limited number of faculty supervise these specialty services, ensuring that the fellow is working with an expert in the particular disease syndrome. Fellows receive an intense clinical experience in a focused area, which we feel is superior educationally to the more “hit or miss” distribution of diseases on large general consult services. This model lends itself well to tracking of patient volume in specific diseases and assessment of competency. We have additional specialty services under development including a neurologic infection service.
There is a specific academic curriculum which accompanies each of these subspecialty rotations. For several of the rotations, fellows will have an intensive review in the topic area for 1 week prior to starting the clinical block with their mentor. For example, beginning with the class of 2008, fellows will have a 1 week “crash course” in ICU infections and infection control prior to their 6 week block of combined ICU clinical rotations and general consults. The “crash course” will consist of a mixture of a faculty lectures, webcasts, reviews of CTs of the chest and abdomen, patient simulations and PBL exercises. During this intensive review, the fellow will have no clinical responsibilities except for longitudinal clinic and routine on-call responsibilities. The week will culminate with a short test to ensure mastery of the medical knowledge portion. The fellow will then enter the 7 week mentor block well prepared for success and ready to integrate the knowledge into clinical practice.
Clinical Microbiology Laboratory: Innovations and Competency Testing
Starting in 2007 fellows rotating through the microbiology laboratory will be required to demonstrate laboratory skills more than laboratory knowledge. As an example, rather than memorizing the various biochemical reactions necessary for identification of Pseudomonas aeruginosa, the fellow will need to identify Pseudomonas aeruginosa when presented as an unknown organism growing on a culture plate. The fellow will need to use multiple laboratory techniques in an independent, hands-on fashion. A number of specific laboratory benchmarks have been developed by the microbiology laboratory staff specifically for the ID fellows, including identification of common bacteria and mycobacteria, determination of resistance and MIC values for organisms using broth dilution techniques, identification of malaria smears, and others.
Elective in Tropical Medicine
In 2006 we developed a new 4 week rotation with Dr. Juan Sierra in Mexico City, an alumnus from the Cleveland Clinic ID training program. ID fellows can rotate at Nutricion Hospital in Mexico (Instituto Nacional de la Nutricion) for 4 weeks, which is fully funded by the Department of Infectious Diseases at the Cleveland Clinic. Fellows can choose other international sites for an elective using the same funds. In 2008, fellows have chosen sites such as the Philippines and Tel Aviv.
Granuloma Clinic: A Unique One-on-One Experience
This is a unique outpatient experience supervised by Dr. J. Walton Tomford, one of the key clinical faculty. He conducts a busy outpatient clinic consisting of complicated cases of patients with a variety of granulomatous diseases, many of which are from mycobacterial infections. Expertise in mycobacterial infection is important for the infectious disease practitioner but is only sporadically encountered in the inpatient setting. The high volume of cases helps the fellow understand the many nuances of managing this difficult disease. This experience has attracted fellows in other disciplines (pulmonary) and other institutions, and we have Dr. Tomford mentor each first year fellow for 6 weeks, including 4 weeks in the Granuloma Clinic.
HIV Specialist Credentialing Program
Our training program provides two hours of teaching dedicated to HIV each week (9 months/year). On Thursday afternoons, the HIV section holds a small group seminar exclusively for the fellows which emphasizes basics in HIV medicine, pharmacology and resistance testing. The problem based learning format is also used frequently during this hour, and fellows try their hand at patient simulations. On Friday afternoons there is another hour devoted to HIV topics in a larger, multidisciplinary group, which includes members of the ID faculty, fellows, interested students and residents, Microbiology faculty, and basic science researchers from the Lerner Research Institute. This conference is a mixture of outside speakers, case presentations and Journal Club reports by the fellows, and some research presentations.
Fellows in their second year are eligible to take the HIV specialist credentialing examination put forth from the American Association of HIV Medicine (AAHIVM). This is an increasingly important measure of competence in HIV medicine, and is being looked at by prospective employers. Because of the fellows extensive educational-CME credits in our training program, they are eligible for the credentialing examination as early as the fall of the second year.
Research Course: Valuable Training for New Fellows
First year fellows are enrolled in a 14 week course entitled “Introduction to Clinical Research and Proposal Development.” This is a graduate-level course from Case Western Reserve University, which takes place at the Cleveland Clinic campus. During this research course, fellows learn the basics of biostatistics and study design, and finalize a research proposal which is presented to the group later as the “final exam.” The course is funded by the fellowship training program.
Other Educational Experiences
First year fellows attend the Sexually Transmitted Disease Advanced Training Program, sponsored by the Centers for Disease Control. This is a 5 day course held in Cincinnati through the Cincinnati STD/HIV Prevention Training Center. This includes a combination of state of the art lectures, laboratory evaluations, and direct patient contact. This meeting is also fully funded by the fellowship program.
We continue to emphasize scholarly activities as an important aspect of training. We define research as "the production of new knowledge" and emphasize original research projects over other activities such as book chapters and topic reviews. We realize that I.D. fellow candidates have a wide variety of research backgrounds, some who already have a Ph.D. background and others who have never worked on independent research before.
To meet this challenge, we hold a weekly research meeting devoted solely to fellows' projects. During this 1-1 ½ hour session infectious disease fellows who are on their research module present their ongoing research with the program director and several key faculty.
We have a core group of faculty who attend the meeting regularly and are actively interested in supporting the fellows' projects (whether or not they are authors on the project). During this meeting there is both formal and informal teaching of research methods, particularly as it applies to a specific research problem.
This constant "peer review" of ongoing projects has led to an increase in the number and quality of fellow-authored manuscripts submitted to nationally recognized journals. On the average, our fellows publish 1-3 first-authored original papers during the course of their training.
A sampling of recent fellow publications is provided below. A full bibliography of the fellows publications in the past 5+ years will be provided at time of your interview.
Fellow Publications: Spring 2008-December 2010
Problem Based Learning Conference
The fellows actively participate in all of the weekly conferences conducted by the Departments of Infectious Diseases and Microbiology. The Problem Based Learning conferences are written by the program director. Fellows are aware of the general topic (e.g. central nervous system infections), but are not aware of the specifics of the PBL cases beforehand. Cases are presented to the fellows as unknowns, with directed questions related to the case. Fellows review the cases and the accompanying questions in an open-book fashion, and are expected to write their answers on a worksheet during the PBL session itself, not afterwards. Fellows are expected to also search for relevant articles and distribute them to the group during the PBL session itself. Worksheets are not graded per se, but are periodically reviewed by the Program Director for accuracy and to be sure the medical knowledge goals are being met. Fellows are frequently asked by the peer group to present short talks (5-10 minutes) to answer questions brought up by the PBL case
Infectious Diseases-Microbiology Grand Rounds
Infectious Diseases/Microbiology Grand Rounds is held 3 times per month (the remaining monthly sessions are Research Meetings and Journal Clubs). This consists mainly of formal lectures by the I.D. faculty, Microbiology faculty, and guest speakers. The schedule for this is made by the Chief I.D. fellow.
Fellows are also responsible for presenting their research at the Infectious Diseases Grand Rounds once per year. This is a formal one-hour lecture to I.D. staff, internal medicine residents and students, Microbiology staff, infection control staff, and others. Fellows present their original research, completed or ongoing, and is considered part of the research meeting requirement.
The Department of Rheumatic and Immunologic diseases conducts a multidisciplinary course on clinical immunology. This course is targeted towards fellows in training in several specialties including ID, allergy/immunology, and rheumatology. This course is repeated each year and is . The I.D. fellows were responsible for preparing and presenting selected basic science chapters from the textbook Immunobiology (Janeway CA, ed).
Fellows’ Case Conference
An important conference is the Fellows Case Conference, which is 1- 1 1/2 hours in length each week. This is a multidisciplinary conference which includes member of the Department of Pathology, and is coordinated by Steve Schmitt, M.D. About 3 cases are presented each session to the fellows as unknowns. The presenter can be a staff physician, pathologist, fellow, resident or medical student. The fellows are selected at random to analyze the case and generate a differential diagnosis and treatment plan. Fellows are asked to discuss the case prior to any comments from the faculty. This is followed by a discussion of the case by the presenter with a review of the literature. A number of cases include slides of Gram stains and biopsy specimens and fellows are expected to comment on these findings. Usually one case per week is presented by a staff or resident from Pediatric infectious diseases.
City Wide Infectious Diseases
Fellows also attend the Infectious Disease City Wide Conference which is held every 2 weeks (except during summer months). This conference involves a number of teaching hospitals in the greater Cleveland area and is coordinated by Steven Schmitt, M.D., one of the key teaching faculty.. A host hospital presents a series of unknown cases to guest infectious disease attendings, fellows, and residents. Only the hosting hospital is required to prepare and present cases. Twice yearly the case conference is held at the Cleveland Clinic, and fellows are expected to present their best cases of the year with a short review of the relevant medical literature.
Reverse" Journal Club.
In 2006 the monthly Journal Club format was changed to emphasize Evidence Based Medicine in a unique way. Following the method of Hartlaub et al. (Acad Med, 1999) the conference was changed such that the article is kept as an "unknown" and presented at the end of the hour. First, the research question is posed to the audience (who usually has no knowledge of the study). The fellows are then challenged to design the study “from scratch” to answer the research question, a process mediated by the Program Director or key faculty. Staff in the audience contribute to the discussion as well. Once a consensus has been reached in the audience regarding details of the study design including biostatistical considerations, one of the fellows then presents the scientific study in a standard fashion including his/her own analysis. The groups’ study proposed design is compared with the design of the authors, and the pros and cons of the article are discussed in light of the groups’ prior discussion. We feel this “reverse journal club” better highlights the challenges of study design and application of biostatistics.
A number of patients who come to autopsy have been evaluated at some point by infectious diseases. The Department of Pathology has instituted an electronic system for reporting autopsy schedules to the program directors. We have now replaced most of our traditional Morbidity and Mortality conferences (which tended to be sit-down classroom style case presentations) with autopsy rounds 1-2 times per month. When the medical record numbers of autopsied patients are released to the program directors, the ID education coordinator determines if that patient was ever seen by an ID fellow, using our electronic medical record and our consult tracking record. If this is the case, all of the fellows and the program director meet at the autopsy suite, where the clinical case is presented and the findings reviewed with staff from Pathology. We attempt to attend the autopsies on all patients seen by an ID fellow as well as selected cases seen by ID faculty. This experience has been well-received by our fellows.
Cleveland Clinic is a regional, national, and international academic referral center. It is consistently ranked among the top 3 hospitals nationwide. This 1,100 bed tertiary care facility attracts patients with a wide variety of surgical and non-surgical illnesses. It is the second largest group practice in the world and the largest hospital in Ohio.
In July 2004, Cleveland Clinic also established the first new U.S. medical school in over two decades, the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University.
The Infectious Disease Department at Cleveland Clinic Foundation is a 17-member group actively dedicated to clinical care, education, and research. More than 3,700 inpatient consultations were done in 2005. The staff members have a variety of clinical and research interests, complementing each other to form a cohesive unit that has traditionally been and continues to be well respected by other departments and divisions. In addition, we have a strong working relationship with doctors Johanna Goldfarb, MD, Charles Foster, MD, Lara Danziger-Isakov, MD, MPH, and Camille Sabella, MD in the Pediatric Infectious Disease Division. Finally, our microbiology laboratory is one of the premier clinical laboratories in the country and a reference laboratory for several states and many ACTG trials. Faculty from the microbiology laboratory attend our conferences and are actively involved in fellow education and mentorship of research projects.
While many infectious diseases programs across the country are in the process of redefining their identity, we continue to expand and find ourselves at the forefront in the changing environment of healthcare delivery. We are thus able to offer an ideal training environment for fellows with state-of-the-art clinical expertise and clinically oriented research. Furthermore, fellows in the first two years of training are not required to obtain grant money to fund their training as they are fully supported by the institution.