Traditional Internal Medicine Residency Training Program
Inpatient Education
The two major sites where residents obtain their inpatient experience are Yale-New Haven Hospital and the Connecticut Veterans Administration Healthcare Center in West Haven.
- Inpatient Education on the Beeson Service at Yale
- Team Structure and Call Schedule
- The Firm Structure
- Teaching on Inpatient Rotations on the Yale Beeson Service
- Inpatient Education at the Hospital of the Connecticut Veterans Administration Health Care System
Inpatient Education on the Beeson Service at Yale
- 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.
- Dr. Gerald Klatskin, after whom the Klatskin Team is named, was 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. The Klatskin team preferentially admits patients with liver disease and is lead by a liver attending.
- 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
- 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 nineties, at Morning Report almost every day. His presence in the Department is truly unique. In order to experiment with new models and paradigms of care, the structure of the Kushlan team will be different from the other medical teams. The team will admit a small number of patients daily and will not take overnight call.
- 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.
- The Generalist Team is a very special service designed specially to provide a unique continuity inpatient-outpatient experience to interns and senior residents and admits patients whose primary physicians are the residents who have their Continuity Clinic at Yale (for more details see section on Yale Ambulatory Block.)
- HIV Teams: The Atkins and Donaldson teams are the two teams that admit patients with HIV related diseases and at any given time the census of HIV patients on each team varies from 40 to 75%. The focus of the learning experience while on these rotations is HIV and AIDS.
- Oncology Service: 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.
- Medicine Intensive Care Unit: The Yale MICU rotation provides for an wide and very well supervised experience to intensive care unit patients in an outstanding learning environment. The learning extends to beyond the management of these intensely ill patients to exposure to discussions on end of life issues, palliative care and code status. The Director of the MICU is Dr. D. Siegel, Associate Professor of Medicine.
- Coronary Care Unit: 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.
- Medicine Consultation Service: Second year residents spend a 2-week rotation on the Medicine Consultation Service at Yale. Residents are taught to evaluate a variety of acute medical problems that arise on patients admitted to other services such as surgery, neurology, psychiatry and obstetrics and gynecology. Evaluation of work-ups for preoperative patients is also stressed during this rotation. Literature in this area of medicine is made available to the residents during the rotation.
|
Team Structure and Call Schedule
- Each team at Yale, with the exception of our Geriatrics team (the Kushlan team), has two residents (two PGY-2 or two PGY-3 residents or one of each) and two interns (or 1 intern and 2 sub interns). These four-person medical teams allow the interns and residents to have one-to-one pairing of intern and resident while on call, but also enables the exchange of ideas among the supervising PGY-2 or PGY-3 residents both on work rounds and at other times and of shared responsibility when an intern or resident is home post call, in clinic or on the day off. The Kushlan team structure is different consisting of 2 residents and 3 interns. Each resident admits every other day with 2 interns assuring 4 patients are admitted to the service daily during a working day shift and all team members go home in the evening signing out to a night float for coverage overnight.
- Call is every fourth night on all rotations on the medical floors and in the MICU. The Kushlan service will admit a small number of patients every day and will not take overnight call. The CCU service will have call every third night.
The Firm Structure
For purposes of teaching some of the above teams are organized into firms.
- Internal Medicine Firm: consisting of the Fitkin and Peters teams, Firm Chiefs are Dr. Fred Kantor, Paul Beeson Professor of Medicine, Dr. Thomas P. Duffy, Professor of Medicine and Director of the Program for Humanities in Medicine and Dr. John N. Forrest Jr., Professors of Medicine and Director, Yale School of Medicine, Student Research. Dr. Francis M. Lobo is the Associate Firm Chief.
- Generalist Firm: Dr. Michele Barry, Professor of Medicine and Public Health and Director Office of International Health and Dr. Patrick G. O’Connor, Professor of Medicine and Section Chief, General Internal Medicine are the Firm Chiefs. Dr. John Moriarty is the Associate Firm Chief.
- Atkins/Donaldson Firm: Firm Chief is Dr. Gerald Friedland, Professor of Medicine and Epidemiology & Public Health. Dr. Krystn Wagner is Associate Firm Chief.
- Kushlan Team: Chief is Dr. Leo M. Cooney, Jr. Humana Foundation Professor of Geriatric Medicine and Chief of Section of Geriatrics
Teaching on Inpatient Rotations on the Yale Beeson Service
A great deal of learning occurs, as it appropriately should, at the bedside while admitting and caring for patients under the supervision of supervising residents and Attending Physicians. Teaching in invaluable small bites happens as well on Work Rounds each morning. However, the other forms of teaching on inpatient rotations occur on Attending Rounds, Firm Chief’s Rounds, Morning Report and Teaching conferences.
- Attending Rounds by Attending of Record: Attending rounds are held 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, at Yale, once a week Firm Chiefs’ Attending Rounds are held on the Internal Medicine Firm and the Atkins/Donaldson Firm by the firm chiefs of those firms, on cases admitted to those teams. 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. The Generalist Firm also has a weekly Firm Conference at which time the inpatient team is joined by the ambulatory members of the team to discuss cases as they transition between the inpatient and outpatient arenas.
- Morning Report
- Teaching Conferences
Inpatient Education at the Hospital of the Connecticut Veterans Administration Health Care System
- Medical Teams at the V.A. There are 4 General Internal Medicine Teams and an Intensive Care Unit that admits both general medical and cardiac patients in need of intensive care.
- Team Structure and Call Schedule:
- General Internal Medicine Teams: Each team consists of 1 PGY-2 or PGY-3 resident and two interns (or 1 intern and two sub interns). The call schedule on the general internal medicine teams is different from that on medical teams at Yale described above. The call cycle operates as a 4-day cycle and for purposes of understanding of the call schedule the two Interns will be termed Intern1 and Intern2. On Day 1 of the cycle Intern2 is on Short Call helped by the Resident on the team. No one stays overnight. On the next day, Day 2 of the call cycle, the Resident takes overnight night call with Intern1. On Days 3 and 4 of the call cycle that team does not admit patients. During the next 4-day call cycle the Resident will take long call with Intern2. Thus, in this schedule the Resident takes long cal, staying overnight, every 4th day and the intern only every 8th day.
- Intensive Care Unit rotation: The ICU rotation provides excellent experience, by the very nature of its structure it being a one intern, one resident, one fellow and one Attending Physician team and admits both general and cardiac intensive care unit patients.
- Medicine Consultation Service: Third year residents spend a 2 week rotation on the Medicine Consultation Service at the V.A. Residents are taught to evaluate a variety of acute medical problems that arise on patients admitted to other services such as surgery, neurology, psychiatry and obstetrics and gynecology. Evaluation of work-ups for preoperative patients is also stressed during this rotation and residents attend a preoperative medical clinic. Literature in this area of medicine is made available to the residents during the rotation.
- Teaching on the V.A. Inpatient Rotation: This is very similar to that described for the Beeson service a Yale, including Resident and Intern Reports run by the Chief Resident at the V.A. with core faculty always present.