Currently, we have two training tracks for fellows entering our Program: a traditional three year track for fellows interested in an academic research career, and a clinical track (2 year training program) for fellows interested in a career as a clinician-educator in Infectious Disease.
There are three institutions utilized in the Yale Infectious Disease Program that participate in the fellows' inpatient consultation experience. These are Yale-New Haven Hospital (New Haven), the VA Connecticut Health Care System (West Haven campus), and the Hospital of St. Raphael (New Haven). Each institution provides a very different patient population, which adds to the general experience of Infectious Disease Fellows in our program.
Yale-New Haven Hospital (YNHH) is a 825 bed tertiary care facility that also functions as a community hospital to greater New Haven and southern Connecticut. It provides both an urban community and tertiary medical care experience, with strong emphasis on immunosuppressed populations (including granulocytopenic cancer patients, organ and bone marrow transplant patients, HIV/AIDS patients), critical care unit infections, and training in Clinical Microbiology.
The VA Connecticut Health Care System (West Haven campus) is a 120 bed primary and tertiary care facility and provides a strong general infectious disease experience including patients with HIV infection, critical care unit infections, and ambulatory infectious disease problems (including ambulatory clinics in general infectious diseases issues, HIV, and hepatitis C. The presence of both a reference laboratory for Tuberculosis and a reference laboratory for Virology, in addition to an outstanding Microbiology laboratory in the VA CT program are added benefits.
The Hospital of St. Raphael is a 491 bed community hospital that also serves New Haven and southern Connecticut. It provides a strong experience in community acquired and nosocomial infectious diseases, HIV and critical care unit infections, ambulatory infectious disease problems, as well as Clinical Microbiology.
These three hospital experiences complement, rather then duplicate, the various educational experiences for Infectious Disease Fellows.
The average number of inpatients that each trainee is responsible for following is approximately 10- 20 patients at any one time while on the Infectious Disease Consultation Service at each of the three hospitals. These are not patients for whom the trainee has direct care responsibility; in all cases, the trainee serves as a consultant.
The difference between the responsibilities of the subspecialty fellow and Internal Medicine residents are that the Infectious Disease subspecialty trainee is responsible for a consultative and educational role within the medical center, with a strong emphasis on the educational role in relation to the residents in the Internal Medicine Programs. The Internal Medicine residents are involved in the day-to-day management of patients in conjunction with their attending, whereas the Infectious Disease trainee performs a consultative and educational role in the management of specific patients with Infectious Disease and HIV-related problems. This includes recommendations for diagnostic testing, antimicrobial selection/dosing/duration, and other infectious disease management issues. Infectious Disease trainees have a role which is distinct from that of residents at all levels.
The responsibilities of the resident for acute and continuing care of inpatients for Infectious Disease trainees on the Consultation Services are to respond to requests for consultation from any service within the hospital, including internal medicine, to correlate the microbiological and clinical data, to present this material to the ID attending and to communicate recommendations to the house staff and attending caring for these patients. Following the initial consultation, these patients are generally followed daily until they are discharged from the hospital.
Trainees are directly involved in the education of Internal Medicine house officers in the Yale program at YNHH and the VA CT, as well as house officers in the Hospital of St. Raphael program. This includes direct consultative advice on diagnostic and management issues for patients with infectious disease problems, choice and dosing of antimicrobial agents, and infection control issues.
Trainees rotate through the VA CT where they interact with house officers in the Yale categorical programs and the Hospital of St. Raphael where they interact with Hospital of St. Raphael house officers. At the VA CT, fellows are supervised by predominantly full-time faculty members of the Infectious Disease section (10 months of the year) as well as part-time faculty members (2 months of the year). All faculty members are board certified in Infectious Diseases.
Relationship to the Internal Medicine Program
Trainees are involved in teaching and/or supervising medical students and house officers in many capacities. First, students and house officers rotate on the Infectious Disease Consultation Service as one month elective experiences and are taught and supervised on a daily basis by trainees. Specifically, the bedside exam, data collection, diagnostic and therapeutic decision making of all new consults is discussed by the trainees with the students/house officers who are also assigned to those patients. Additionally, trainees provide daily informal consultative advice and teaching to houseofficers and students at all three hospitals in diagnostic/ therapeutic decisions in infectious disease issues as well as choice and dosing of antimicrobial agents.
Patients are assigned to the Internal Medicine service through the Emergency Room where they are admitted to general Medicine housestaff firm teams. Infectious Disease Consultation service patients are assigned by consultative request only and are requested from all services in the respective hospitals (e.g. Internal Medicine, Surgery, Ob-Gyn, etc. with the notable exception of Pediatrics which have a separate Infectious Disease training program and consultation service).
Other Aspects of Training
Instruction in the basic sciences is achieved during the second year and beyond by involving our trainees in an extensive research project. In their second year, fellows are required to take coursework relevant to their research project. Multiple courses are available, focusing on both laboratory and non-laboratory-based research, and organized under the auspices of the Investigative Medicine Program (Dr. Joseph Craft, Director) and the Robert Wood Johnson Clinical Scholars Program (Dr. Harlan Krumholtz, Director). Research Conferences within the section, small laboratory conferences, preparation for presentation at national meetings, statistical analysis of data under supervision, all contribute to instruction in the basic sciences.
There are three venues in which trainees gain knowledge in the evaluation of medical literature, clinical epidemiology/study design, relative risks of disease, medical statistics and decision-making. First, in their clinical training year, all trainees are required in our weekly Infectious Disease Clinical Conference to present and discuss relevant published literature as they pertain to specific patient related infectious disease issues. This requires that they develop practical experience in evaluating study designs, results of comparative diagnostic/therapeutic maneuvers, and in formulating conclusions in medical decision making. Second, trainees also participate in a monthly Clinical Journal Club in which two contemporary articles are discussed/critiqued by trainees as well as faculty each meeting. Emphasis is placed on fundamental strategies in hypothesis generation, study design, analytical methodology, as well as practical conclusions. Specific discussion is given to the advantages and pitfalls of randomized trials, observational cohorts, case-control studies, diagnostic marker studies and descriptive studies. Third, upon entering their Research Training years, all trainees are required to attend the course "Introductory Course in Biostatistics" given at the Yale University School of Medicine.
Trainees receive practical experience in the processes of quality assessment/improvement through their experience in the Microbiology Laboratory in which diagnostic testing modalities for pathogen identification/antimicrobial susceptibilities are evaluated and discussed. Additionally, trainees are instructed in the Didactic Lecture Series as well as their Infection Control/Hospital Epidemiology rotation regarding aspects of antimicrobial use/resistance patterns, hospital and outbreak surveillance, quality assessment and risk management issues.
Trainees acquire experience in cultural, behavioral and economic issues in all aspects of their inpatient consultative care in which these issues are discussed regarding the feasibility and duration of outpatient IV antibiotic therapy. These are complex, but daily issues that trainees acquire experience in through the multidisciplinary care required for patients with HIV and non-HIV related infectious disease.
Trainees are on call approximately every fourth night and one weekend per month. Trainees take calls at home via a long range beeper system and return to the hospital to evaluate all new consult requests as well as major clinical changes in patients already on the service. By nature of the call schedule, trainees have two weekend days off every two weeks, averaging out to one and a half days per week free from hospital duties.