Inpatient Education

Our residents obtain their inpatient experiences at Yale-New Haven Hospital and Waterbury Hospital Health Center.  On September 12, 2012, Yale-New Haven Hospital merged with the Hospital of St. Raphael to form one hospital with two campuses located just 0.5 miles apart; the “York Street” campus and the “Chapel Street” campus of Yale-New Haven Hospital. This 1500 bed institution is the fourth largest hospital in the United States and brings a unique opportunity for our Department and Academic Medical Center to positively impact the care of our community in an integrated and coordinated manner.  Because of this merger, the inpatient rotations for the Primary Care and Medicine-Pediatrics residency programs at Waterbury Hospital will shift to the Chapel Street Campus of Yale-New Haven Hospital over a two-year period where we will replicate the general medicine service with a similar educational structure as described below.  Inpatient training includes a mix of subspecialty Firms and general medicine Firms providing trainees with a broad exposure to the breadth and depth of internal medicine.

The five subspecialty medical services at YNHH are the Oncology Firm (consisting of a solid tumor Firm and a Hematology malignancy Firm), Donaldson (HIV) Firm, Klatskin (liver disease) Firm, Peters (renal disease) Firm and Goodyer (non-CCU cardiology) Firm. The goal of training on the medical subspecialty inpatient Firms is to provide an intensive and focused interdisciplinary experience caring for patients with both common and less common conditions in these specialty areas of medicine. While these topics are also encountered during general medicine rotations, the subspecialty rotations provide a complimentary in-depth experience working directly with attending physicians from the respective specialty sections of the Department. The specialty Firms are geographically localized and the Firm Chiefs oversee both the clinical and educational experiences of the Firm integrating quality of care, systems-based improvement and interprofessional care.

Oncology Firm
The Oncology Firm consists of two parallel Firms, one focusing on the care of patients with solid tumors and the other focusing on patients with hematologic malignancies. Each is staffed by an Oncology or Hematology attending, an Oncology fellow, PGY-II and III residents, interns, students and integrated mid-level providers. The inpatient oncology service provides exposure to a wide variety of cancer patients 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. Cancer care at YNHH is centralized in Yale’s state of the art Smilow Cancer Center.

Donaldson (HIV) Firm
The Donaldson Firm consists of two attendings with a specialty in Infectious Diseases/HIV disease, PGY-II and III residents, interns and students.  This Firm is named after Dr. Robert M. Donaldson Jr. Dr. Donaldson was not an infectious diseases specialist, but an eminent gastroenterologist who served the Department of Medicine at Yale in many capacities, as Chief of Medicine at the Veterans Administration Medical Center, Vice Chairman and later Acting Chairman of Medicine and then Acting Dean of the Medical School. In 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 Donaldson Firm is also staffed by a dedicated nursing staff with added expertise in HIV care, a dedicated case manager and social worker and is linked with the outpatient HIV service at Yale.

Klatskin (Liver) Firm
The Klatskin Firm consists of an attending with expertise in Hepatology/Gastroenterology, a subspecialty fellow, PGY-II and III residents, interns and students as well as integrated mid-level providers who have added expertise in the care of patients with end-stage liver disease and technical expertise in paracentesis. This Firm 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. With the largest liver transplant program in New England at Yale, the breath of liver disease encountered on the Klatskin Firm is broad and in addition to diagnostic assessment and management of liver disease, there is a focus on assessing and managing quality of life and end of life care issues.

Peter (Renal) Firm
The Peters Firm consists of a Nephrology attending and a general medicine attending, a nephrology fellow, PGY-II and III residents, interns and students as well as integrated mid-level providers who have added expertise in the care of patients with end-stage renal disease. In addition to the care of patients on the inpatient service, trainees have the opportunity to attend a variety outpatient nephrology clinics. This Firm is named after a giant in American Medicine, Dr. John Punnett Peters, who joined the Yale faculty in the 1920s, 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 such as universal healthcare while politically unpopular at the time, spoke to his commitment to the social contract of medicine, a core value of medicine at Yale.

Goodyer (Cardiology) Firm
The Goodyer Firm consists of a Cardiology attending, a cardiology fellow, PGY II and III residents and integrated mid-level providers. The Firm cares for patients admitted to the telemetry unit with a wide range of cardiac conditions. In addition to the care of patients on the Firm, residents spend afternoons in the cardiac diagnostic labs (e.g., echocardiography, nuclear cardiology, the cardiac cath lab, the exercise stress test lab). The focus of these sessions is on the appropriate selection of patients for various cardiac diagnostic tests, the sensitivity and specificity of the tests and the role of the cardiologist consultants in the collaborative care of patients. This Firm is named after Dr. Allan V.N. Goodyer, the first full time faculty member to serve as chief of cardiology. He joined the Department of Internal Medicine at Yale as an instructor in 1948 and was promoted to professor in 1966. His early research was in the field of fetal electrocardiography, which provided the background for this technique in modern obstetrics. His subsequent research was in the elucidation of the mechanisms relating electrolyte and water disturbances to cardiac failure. He then became involved with the evaluation of left ventricular function by computer analysis of the left ventricular pressure curve. Dr. Goodyer was recognized for his teaching skills and the Yale inpatient cardiology service proudly bears his name.

General medicine firms exist at both Yale-New Haven Hospital and Waterbury Hospital. These firms are geographically localized like the subspecialty firms. Admissions to the general medicine firms at both hospitals come from the emergency department, outpatient practices, clinics and transfers from the intensive care units.

Fitkin Firm
This Firm, located at YNHH, is a general internal medicine team named after Mr. Abram Fitkin, a major benefactor of the medical school in the 1930s.  This Firm consists of attending physicians from all Sections of the Department, PGY III residents, interns and students.

Kushlan Team
This Firm, located at YNHH, is our Advanced Care of the Elderly (ACE) service and consists of an attending geriatrician and a general medicine attending, a geriatrics fellow, PGY-II and III residents, interns and students. The intern rotation includes three weeks on the inpatient service and one week in various outpatient settings. Outpatient experiences include working alongside a geriatrician to provide hospital discharge follow up, ongoing care and assessment of acute issues at nursing homes and assisted living facilities. This Firm is named after Dr. Samuel Kushlan, the first gastroenterologist in New Haven, who introduced 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. His commitment to all members of the New Haven community and in particular, the elderly members of our city was remarkable.

Podell and Renda Firms
Located at Waterbury Hospital, these general medicine Firms consist attending physicians from the Section of General Medicine who are members of the core faculty of the Primary Care Residency, PGY-II and III residents, interns and students. These Firms are named after Drs. David Podell and Joseph Renda, master clinicians who embody the very best of medicine from clinical excellence to the highest standards of professionalism and devotion to patients. Areas of particular emphasis of the general medicine Firms at Waterbury Hospital include bedside rounding, the role of the physical examination in clinical care and transitions of care.

The goal of medical training in the intensive care units is to educate residents in the diagnosis, evaluation and management of patients with a wide range of critical illnesses, most commonly sepsis, chronic disease related multi-organ failure, and respiratory failure. The resident is expected to become knowledgeable about the indications, contraindications, risks and benefits of common ICU level procedures. Residents have the opportunity to be trained in a variety of procedures such as arterial puncture and arterial blood gas interpretation, arterial line and central venous line placement, paracentesis, lumbar puncture, and naso-gastric tube placement. In the Cardiac Intensive Care Unit, 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 the care of critically ill patients is the management of psychiatric, social and family concerns which are heightened in these intensive care settings and are addressed by residents as part of a multidisciplinary team. Patients are transferred to the medical ward teams when discharged from the intensive care units.

• Cardiac Intensive Care Unit: The Cardiac Intensive Care Unit team is comprised of Cardiology attendings, cardiology fellows, PGY II and PGY III residents, interns and midlevel providers. Trainees learn to provide care for acutely ill patients with heart disease under careful supervision of the cardiology and heart failure services. Clinical care is complimented with daily case discussions and a core cardiology curriculum.
• Medical Intensive Care Unit: The Medical Intensive Care Unit team is comprised of Pulmonary/Critical Care attendings, PGY II and PGY III residents, interns and midlevel providers. Clinical care is complimented with daily case discussions and a core intensive care unit curriculum.

Consult Medicine
Preoperative risk assessment and inpatient consultation to non-internal medicine services (e.g., surgery, OB.GYN, psychiatry) represents an essential aspect of internal medicine. Residents gain this valuable experience during the PGY III year during a rotation at Waterbury Hospital that incorporates a structured curriculum and daily inpatient consultation to other services in the hospital. The consult resident provides ongoing follow up for patients seen in consultation and participates in morning report daily. The consult resident also participates in the assessment of hospitalized patients with acute deterioration in clinical status as a member of the multidisciplinary Rapid Response Team, consisting of an attending physician, a nurse, and a respiratory therapist.

Night Float
A night float system is in place at all hospitals to provide care for patients on the teaching service when members of the primary team are not in-house. The roles of the night residents are to both provide coverage of patients on the medical service and to admit new patients to the hospital who they will sign out to the day team in the morning. Interns and residents have 4-6 weeks of dedicated night rotations per year.