“To study the phenomenon of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all”.
–Sir William Osler
This often quoted aphorism of Osler’s truly describes our emphasis on the primacy of the patient in the process of learning medicine. We believe passionately that the learning of medicine has to be an active process at the bedside and to that end our residents find themselves in a supportive environment ministering to an ethnically diverse population of patients and encountering as wide a spectrum of illness as can be encountered anywhere. We supplement these clinical experiences and “hands-on” learning with a didactic curriculum that covers important facets of internal medicine and pediatrics and that allows for in-depth discussion with our faculty. There is a comprehensive inpatient didactic curriculum that occurs in both departments and at all clinical training sites. Similarly, there is a comprehensive ambulatory didactic curriculum that occurs during ambulatory block rotations and in the weekly continuity clinic.
Inpatient Didactic Curriculum
The inpatient didactic curriculum in both internal medicine and pediatrics consists of morning report, noon conferences, journal clubs, and weekly grand rounds. The medicine department also sponsors a variety of special conferences such as Firm Conferences and the pediatrics department sponsors a weekly discharge conference that is one of the most popular didactic experiences of the program. A description of the didactic curriculum for residents while on the medical service and while on the pediatrics service follows.
Teaching Programs & Conferences During Internal Medicine Rotations
Morning report occurs Monday through Saturday. One report each week is specifically for interns and report on Saturday is for all housestaff in the hospital that day. It is a Yale tradition that report is run by the Chief Resident with core faculty always present to provide input when needed. On occasion an “expert” may also be invited.
Report frequently begins about a brief inquiry about codes, errors or near errors the previous day, often followed by a very short “teaser”, such as a blood smear, a picture of a skin rash, urine sediment, an imaging study or EKG, projected on the screen by the Chief Resident. The reports are run using one of two different formats. Occasionally short discussions are held on a number of patients admitted to the teams during the previous night. However, more frequently, after the patient’s houseofficer has presented pertinent clinical details about a patient pre-selected by the Chief Resident, a lively and interactive discussion ensues between the Chief Resident and the housestaff in attendance, with faculty only interjecting when they feel they have something of importance to add. The initial emphasis is on using clinical information in order to arrive at a differential diagnosis and then asking for further investigative data. At this point, as relevant, copies of EKGs may be distributed and blood smears, imaging studies, echocardiograms, etc. projected on the screen in order to enable the housestaff to arrive at a diagnosis. Thereafter, time permitting; evidence is sought from the patient’s resident in support of the treatment the patient received, or, about the pathophysiology of the disease in question.
Medical Grand Rounds
Medical Grand Rounds occurs weekly. The Department of Medicine prides itself in the quality of its Medical Grand Rounds that are put together through the efforts of Dr Asghar Rastegar, the Associate Chair for Clinical Affairs. The following are broad categories of subjects generally selected:
- Patients admitted to housestaff teams in the recent past whose problems lent themselves to discussions by clinical faculty, chief residents or clinician scientists of:
- Dilemmas in diagnosis or management
- Science underlying the disease (often discussed by faculty whose scientific work is in that area)
- Ethical issues
- Issues related to access to Health Care in the U.S.
- Faculty experiences with clinical work or research in the developing world, often but not exclusively, with problems related to HIV
- Faculty experiences in disaster areas
- Medical errors and quality improvement – by local or visiting faculty
- Annual lecture given by a well known physician writer given on the same morning as the residents’ presentations of their work for the Writer’s Workshop
- Annual Ralph Horwitz lecture delivered by a young Yale faculty member who is a funded clinical investigator. The lecture is given on the morning of Resident Research Day, when residents present their research done in the Research-in-Residency Program.
- Other Annual Named Lectures:
- Paul Beeson Visiting Lectureship
- Samuel Their visiting Lectureship
- John Peters Lecture: given by an eminent visiting endocrinologist or nephrologists in alternate years
- Massimo Calabresi Lecture given each year by an eminent visiting cardiologist
- Paul Calabresi Lecture in Medical Oncology given by an eminent visiting endocrinologist
- Gerald Klatskin Lecture given each year by an eminent hepatologist
- Samuel Kushlan Lecture given each year by an eminent gastroenterologist
Summer Teaching Conferences
These lectures are given three times a week at noon and occur at both hospitals. They are open to all housestaff but are specifically focused on the needs of new interns. They cover a vast array of topics which cover the nuts and bolts of subjects that it is felt new interns should become familiar with soon. These subjects include a talk of how to present patients during Work Rounds, important topics in every subspecialty in Internal Medicine including critical care medicine, problems in neurology, dermatology, psychiatry, medical ethics, legal aspects of medicine, quality assurance issues etc.
Noon Teaching Conference
These lectures are held two to three times weekly at both hospitals from September through June and they cover a series of core internal medicine topics.
Professors Weekly Conference
These conferences are given at Yale once a week and provide yet another opportunity for housestaff to meet with physicians who are engaged in either basic science research or clinical investigation. The goal is to expose housestaff in relatively small groups to such faculty and to make the discussion interactive. To make that possible, two such sessions are held simultaneously in order to achieve “small group” teaching possible. Patients on the housestaff service are generally chosen, and the “Professor” talks about the patient presented by the housestaff; may touch upon diagnostic aspects, but concentrates as far as possible on pathophysiology, basic science aspects underlying the patient’s disease, epidemiology etc. as relevant. A fair bit of the curriculum is covered in this fashion.
Lectures in a larger forum include those on a number of different topics such as those related to:
- Laboratory medicine
- Adolescent Medicine
- Monthly ethics and end-of –life conferences
- Quality Improvement Curriculum
- Medical Errors – “matrix” presentations
- Legal aspects of Medicine
- Morbidity and mortality conferences (including some using the Matrix format)
- Autopsy conferences
- Peer teaching conferences: These are seminars given by third year residents on a subject of their choice as a part of their scholarly activity
- Journal Club: These journal clubs are focused mainly to teach housestaff to evaluate an article critically and a variety of different types of studies are chosen e.g. randomized control trials, longitudinal cohort studies, case control studies, cross sectional studies etc., quite apart from the subject the article deals with.
Teaching Programs & Conferences During Pediatric Rotations
The Yale Pediatric Residency Program is designed as a continuing and progressive educational experience. While bedside teaching and learning is of the essence, a core of didactic and interactive conferences form the basis to solidify your educational experience. Currently, emphasis is being placed on a case management approach. Our core teaching curriculum is evaluated on an annual basis and is closely coordinated and integrated among all three of the teaching hospitals. This year, computer teleconferencing links have been established between the Yale-New Haven Children's Hospital and the Bridgeport Hospital so that all of the Yale pediatric housestaff can observe and participate in the core lecture series.
In all of the patient care areas, the attending physician makes rounds with the housestaff on a daily basis, including weekends. The attending physician has the responsibility for coordination of patient care activities as well as teaching on all patients. This includes daily bedside examination and teaching for the housestaff. In addition, the attending physician for each ward team at the Children's Hospital are responsible for a didactic teaching conference weekly. An innovative conference series including Journal Club, daily inpatient as well as outpatient conference series, morning report, and mock codes are provided for the house staff. Pediatric subspecialists provide additional teaching conferences for the Yale pediatric housestaff two days per week as well as every morning as part of the Outpatient Conference Series. Finally, Pediatric Grand Rounds is the highlight of the weekly teaching schedule. All of these conferences are specifically directed to patient care problems and housestaff education. Daily conferences also occur in Radiology, Continuity Clinic, Newborn Special Care Unit, Pediatric Intensive Care Unit, and various subspecialty sections.
Each Thursday afternoon, patients who have been discharged with diagnostic dilemmas or unusual diagnoses are discussed in a multidisciplinary literature-based conference which provides further opportunity for interaction between the housestaff and the faculty. This Discharge Conference provides opportunity for detailed discussion of intriguing and diagnostically difficult patients. Once monthly, the conference is devoted to a morbidity and mortality discussion to evaluate the issues of medical management, practitioner communication, and overall patient care. Discharge Conference also allows for both the housestaff and faculty to hear from world experts on various issues in pediatrics, as well as learn the latest clinical and basic laboratory information in the continuing effort to bring the bench to the bedside.
Ambulatory Medicine Lectures
The ambulatory medicine didactic curriculum includes didactic conferences during pediatric outpatient rotations and during combined Medicine/Pediatrics ambulatory block rotations. During ambulatory block rotations, in addition to topics developed specifically for the medicine/pediatrics residents, we take advantage of the ambulatory curriculum developed by the Yale Primary Care Residency which is among the most comprehensive and effective seminars offered in any training program. In addition, during weekly continuity clinic sessions, each resident participates in a 20 minute interactive seminar discussing outpatient evaluation and management of common pediatric and internal medicine topics.