Primary Care Residency Program

Inpatient Education

The two major sites where residents obtain their inpatient experience are Yale-New Haven Hospital and Waterbury Hospital Health Center.

Subspecialty Wards
There are three subspecialty ward services at YNHH, the Oncology Firm, the Atkins/Donaldson (HIV) Firm, and the Klatskin (liver disease) Firm. The goals of training on the medical subspecialty inpatient wards are to prepare residents to diagnose and treat the more acute manifestations of common oncologic conditions, HIV-related illnesses, and liver disease including assessment of patients being considered for hepatic transplantation. While these topics are also encountered during general medicine rotations, the subspecialty rotations provide a complimentary intensive and focused experience in each of these areas. In addition, residents work closely with subspecialty attendings and fellows, a dedicated geographically localized nursing staff, social workers and care coordinators who have expertise in working with patients with oncologic, HIV, and liver related care needs.

Resident working.

Oncology Firm
The Oncology Firm consists of an Oncology attending, a Hematology attending, an Oncology fellow, four PGY-II or III residents, four PGY-I residents and third-year medical students. The inpatient oncology service provides exposure to a wide variety of cancer patients, both those with solid and liquid tumors, including those with oncological emergencies, neutropenic fever and graft vs. host disease. Pain management and end of life issues are also a focus on this service. Dr. Edward Chu is the Chief of Medical Oncology.

Atkins/Donaldson Firm: HIV & General Medicine
The Atkins/Donaldson Firm consists of two attendings with a specialty in Infectious Diseases/HIV disease, or a Generalist with an interest in HIV-related diseases, an ID fellow, four PGY-II or III residents, four PGY-I residents, and third year medical students.

The Atkins Team is named after Dr. Elisha Atkins, Professor of Medicine and Infectious Diseases. Dr Atkins was a pioneer in understanding the mechanisms underlying fever in infectious and inflammatory diseases and together with his protégée, Dr Phyllis Bodell he did the initial studies describing the existence and mechanism of action of “endogenous pyrogen”. Dr Atkins was a remarkable individual, as much at ease with the humanities and the natural habitat of birds as he was with infectious diseases. The team name after him admits patients with HIV/AIDS.
The other team that admits patients with HIV/AIDS is the Donaldson Team, named after Dr. Robert M. Donaldson Jr. Dr. Donaldson was not an infectious diseases specialist, but an eminent gastroenterologist, having been an editor of the best known journal on the subject, Gastroenterology, a former President of the American Gastroenterological Association and a recipient of its most prestigious award, the Julius Friedenwald Medal for his seminal research in gut flora and cobalamin absorption. He served the Department of Medicine at Yale in many capacities, as Chief of Medicine at the affiliated Veterans Administration Medical Center, as Vice Chairman and later Acting Chairman of Medicine and then as Acting Dean of the Medical School. Why is it that a team which cares for patients with HIV/AIDS is named after a gastroenterologist? It was because during the latter phase of his professional career, the AIDS epidemic had peaked and resulted in devastation of the lives of those whom it affected and the lives of their loved ones. Dr. Donaldson could not remain on the sidelines, and well into his mid sixties, he began to attend outpatient clinics that cared for patients with AIDS, learned about the disease from faculty colleagues who were experts in the disease and devoted that part of his life to the cause of patients with AIDS.

Klatskin Firm
The Klatskin Firm consists of two attendings; one with a specialty in Hepatology/Gastroenterology and the other a Hospitalist, a subspecialty fellow, two PGY 2 or 3 residents, two interns and physician assistants.

The Klatskin Team is named after Dr. Gerald Klatskin, identified by many in the field as the father of hepatology in America and one of the pioneers of the subspecialty of liver disease in the world. Dr Klatskin was the recipient of the American Gastroenterological Association’s highest award, the Julius Friedenwald Medal. A master clinician, he maintained detailed records on index cards of the thousands of patients that he saw over the years. His collection of many thousand Kodachromes of liver biopsies of every kind of liver disease known at the time, to the understanding of many of which he had made substantial contributions to, is legendary. It is fitting that the team named after Dr. Klatskin will focus on evaluation and treatment of patients with liver disease.

Resident working.

General Medicine Wards
There are three general medicine Firms at Yale-New Haven Hospital and two general medicine Firms at Waterbury Hospital. Admissions to the general medicine firms at both hospitals come from the emergency department, outpatient practices and clinics as well as transfers from the intensive care units. Attending rounds occur three times weekly and the team attending also rounds with the team on all post-call days as well as at other times during the week emphasizing bedside teaching.

The General Medicine Firms at YNHH consist of one attending, two PGY II or III residents, two PGY 1 residents, and third year medical students. Each intern: resident pair admits patients every fourth day and functions as the “day float” for their “sister team” pair on that team's post-call day.

The Peters Team is named after a giant in American Medicine, Dr. John Punnett Peters, who joined the Yale faculty in the 1920s, who developed laboratory medicine and contributed greatly to metabolic diseases, from which in time emerged the subspecialties of nephrology and endocrinology. Dr. Peters was also a man with a deep sense of social commitment who ruffled many feathers in the political system of his time in the U.S. by being a champion for the poor and complaining bitterly about the quality of health care they received, initially during the Great Depression, but also thereafter. His liberal views on this and similar issues landed him in a great deal of trouble in the political climate of the early years of the Cold War.
The Kushlan Team is our acute care geriatric service where the Attending Physicians are all geriatricians and rotation on this team provides a wonderful experience on the care of the elderly hospitalized patient. The team is named after Dr. Samuel Kushlan, the first gastroenterologist in New Haven, who was also first one to introduce gastroscopy at Yale. For many years he was the Assistant Chairman of Medicine at Yale, a position that made him the main liaison person for the private faculty with the Department of Medicine. His generosity towards the Department of Medicine is well known. When you come to Yale, you will meet Dr. Kushlan, now in his early nineties, at Morning Report almost every day. His presence in the Department is truly unique.
The Fitkin Team, is a general internal medicine team and is named after Mr. Abram Fitkin, a major benefactor of the medical school in the 1930s.

Resident working.

The General Medicine Firms at Waterbury Hospital consist of two attendings, two PGY II or III residents, three PGY 1 residents, and third year medical students. One of the three interns for each Firm functions as a day float for the Firm and assists with patient care on all post-call days. After two weeks as day float this intern rotates onto the team call schedule and one of the other interns becomes the day float. The day float intern works six days per week with one weekday off each week. They are always in on the weekend to provide care to the patients that belong primarily to the intern: resident pair that has a day off. This model has allowed for much greater continuity of care for patients on the weekends and we believe has benefited patient safety. In addition, because the day float role is provided by an intern who is not doing overnight call, all members of the team are able to attend their weekly continuity clinic on the assigned day and thereby maintain fidelity with their patients and preceptor which is a major educational and patient care goal of the Program.

Critical Care Rotations
The goals of medical training in the intensive care units are to educate residents in the diagnosis, evaluation and management of patients with a wide range of critical illnesses. The resident is expected to become knowledgeable about and trained in certain procedures, including Swan-Ganz management and interpretation; performance of arterial puncture and arterial blood gas interpretation; arterial line placement; central venous line placement; paracentesis; lumbar puncture; and naso-gastric tube placement. The resident is expected to learn the indications for cardiac catheterization, PTCA, thrombolysis, cardiac bypass surgery, and intra-aortic balloon pump placement. Residents also become proficient in ventilator management. Inherent in this situation is the management of psychiatric, social and family concerns. Admissions to the intensive care units come from the emergency department and as transfers from the wards. Patients are transferred to the medical ward teams when discharged from the intensive care units.

Primary Care Housestaff rotate through the combined Medical Intensive Care/Coronary Care Unit at Waterbury Hospital and the Coronary Care Unit at YNHH. The teams consist of Cardiology attendings (CCU) or Pulmonary/Critical Care attendings (MICU) senior residents and interns.

Coronary Care Unit: The resident team in the CCU at YNHH is comprised of three upper level residents and four interns with each intern taking overnight call every fourth night. Rotations in the CCU provide for the care of acutely ill patients with heart disease under careful supervision of an Attending Physician. Not only do residents see patients belonging to the interventional cardiology service, but also to patients from the heart failure service. This results in a very well rounded experience under close supervision of an Attending Physician with help from the Cardiology Fellow. The Director of the coronary Care Unit is Dr. Henry Cabin, Professor of Medicine.
Medical Intensive Care Unit: The resident team in the combined MICU/CCU at Waterbury Hospital is comprised of four upper level residents and three interns. PGY 2 and PGY 3 residents work a rotating series of 10 – 12 hour shifts and the interns take overnight call every third night. Attending rounds in all intensive care units occurs three times weekly and there is a structured case-based curriculum that is implemented in the MICU. The Director of the MICU is Dr. Jock Lawrason, Clinical Associate Professor of Medicine.

Consult Rotation
Preoperative risk assessment and inpatient consultation to non-internal medicine services (e.g., surgery, OB.GYN, psychiatry) represents an essential aspect of internal medicine. PGY III residents have a one month consultation rotation at Waterbury Hospital that incorporates weekly preop evaluation clinic and daily inpatient consultation to other services in the hospital. There is an assigned consult attending and a structured curriculum. The consult resident provides ongoing follow up for patients they have seen in consultation and they also participate in morning report daily. The consult resident is also a member of the multidisciplinary Rapid Response Team and participates in the assessment of inpatients with acute deterioration in clinical status. The rapid response team consists of an attending physician, a nurse, and a respiratory therapist. The consult resident also works with the interventional radiologists to develop further expertise in thoracentesis, lumbar puncture, and paracentesis. ON addition, the consult resident has an important peer teaching opportunity by leading resident morning report with faculty mentorship once weekly.

Night Float
A night float system is in place at YNHH and Waterbury Hospital to assist in coverage of admitted patients and to admit patients after the teams have reached their daily admission cap. Residents assigned night float at YNHH are from the Yale “Traditional” Internal Medicine Residency while night float rotations at Waterbury Hospital are staffed by residents from the Primary Care Program.

Resident working.

Teaching on Inpatient Rotations on the Yale Beeson Service and at Waterbury Hospital
A great deal of learning occurs, as it appropriately should, at the bedside while admitting and caring for patients under the supervision of senior residents and Attending Physicians. Teaching also occurs on daily Work Rounds each morning, during Attending Rounds, Firm Chief’s Rounds, Morning Report and didactic conferences.

Attending Rounds: Attending rounds occur three times weekly on every inpatient rotation. Occasionally, the Attending Physician of Record might invite a subspecialist, often a clinician scientist, to take Attending Rounds, one of many ways in which our housestaff are exposed to basic and clinical scientists.
Firm Chiefs' Attending Rounds: In addition to the Attending Rounds held by each team’s Attending of Record, there is a once a week Firm Chiefs’ Attending Rounds. The major emphasis of these Firm Chiefs’ Attending Rounds is to teach housestaff through example how data gathered from the patient’s history and physical examination can be analyzed in order to arrive at a diagnosis and management plan. Frequently, the firm Chiefs will invite an “expert” on the patient’s disease, again often a clinician scientist, to discuss pathophysiology or answer questions on evidence based management.
Morning Report: Morning report occurs six days weekly at all inpatient sites. This important interactive educational conference is organized and administered by the chief residents and is an opportunity for residents to discuss diagnostic strategies and management decisions regarding patients on the medical service. Core faculty of the residency program and faculty attending on the medical service attend morning report to provide expert insights and information as needed. This is a setting in which residents are encouraged to “think out loud” and develop their clinical acumen with the assistance of their peers. Morning report once each week is specifically for the interns.
Teaching Conferences: There is a full spectrum of teaching conferences that include noon conferences, professors rounds, peer teaching, etc. These are described in the “Didactic Education” section of this website.