Inpatient Education

“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 passionately believe that learning of medicine is an active process at the bedside and, to that end, our residents find themselves in a supportive environment caring for 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 that allows for in-depth discussion with our faculty. A comprehensive inpatient didactic curriculum is used at each of our inpatient training sites. Similarly, a comprehensive ambulatory medicine didactic curriculum occurs during ambulatory block rotations and in the continuity clinic.

Morning Report

Report takes place Monday through Friday at noon at Yale New Haven Hospital Saint Raphael Campus (SRC). This interactive case-based discussion led by the chief residents with guidance and participation by faculty. We emphasize clinical reasoning and pathophysiology of disease in these discussions. Indications and accuracy of diagnostic testing, medical management and the literature supporting the most appropriate options are reviewed, and key concepts are summarized as “take home” learning points. Case-based reports will periodically be interwoven with more traditional lectures such as case-based Firm conferences, Morbidity and Mortality conferences and topic based lectures.

Intern Didactic Series

Each Monday interns on the inpatient services at SRC participate in an intern only two-hour case-based lecture series delivered by our core faculty. These interactive leaning sessions focus on common inpatient topics experienced by interns.

Medical Grand Rounds

Medical Grand Rounds takes place weekly. The Department of Internal Medicine prides itself in the quality of its Medical Grand Rounds and the diversity and range of speakers. The following are broad categories of subjects generally selected:

• Dilemmas in diagnosis or management
• Interdisciplinary discussions of patients on the medical service
• Scientific advances and implications for patient care, current and future
• Clinical updates
• Medical ethics
• Healthcare Policy and Healthcare access
• Global health
• Medical errors and quality improvement
• A writer’s workshop
• Clinical epidemiology

Firm Rounds

Daily on the inpatient services at SRC, residents from the night team present patients to the day team for a warm hand-off and teaching encounter at the patient’s bedside. Our core faculty participate in this activity to highlight physical findings, historical clues to diagnosis and diagnostic reasoning. Residents provide brief teaching points for their peers.

Core Conference Series

A series of noon conferences are interspersed with noon report at SRC. These conferences cover a wide range of common internal medicine topics using a variety of formats. The emphasis is on core clinical concept, evidence-based care and clinical reasoning. Sample conferences include:

• Core topic seminars led by faculty (e.g., common conditions in all areas of medicine for example, atrial fibrillation, acute kidney injury, COPD exacerbations)
• Master Clinician Rounds
• Peer teaching led third-year residents returning from Global Health Electives
• Firm conferences and Morbidity and Mortality conferences led by the Firm chiefs. These conferences are held twice monthly depending on the service and focus on a recent case from the inpatient teaching service. Firm conference is centered on interesting and complicated cases, while Morbidity and Mortality conference focuses on medical errors, near-misses and systems-related issues in an attempt to identify these and prevent them from happening again. Both conferences enlist the active participation of the medical teams and specialists involved in the patients' care. A resident involved in the care of the patient is asked to prepare and present the case, under the supervision and guidance of the Firm chiefs.

A noon conference series and report are also available at Yale New Haven Hospital York Street Campus for residents rotating at these sites.

Ambulatory Medicine Lectures

The ambulatory medicine didactic curriculum of the Yale Primary Care Residency is among the most comprehensive and effective seminar series offered in any training program. Details regarding the weekly Yale office-based medicine curriculum (now used by over 100 internal medicine residency programs nationally) and the ambulatory block core seminar series is described in the ambulatory medicine section of the website. These interactive seminars cover all major topics in outpatient general internal medicine with an emphasis on standard of care, clinical decision making, communication skills, physical examination skills, and psychosocial aspects of medicine.

Our residents’ rotations in General Medicine will occur primarily at Yale New Haven Hospital's Saint Raphael Campus. This is the site where the core faculty of the Residency Program have their academic offices and serve as attendings for the teams thus providing the opportunity for all housestaff to work with and be mentored by this highly talented and devoted group of outstanding academic general medicine faculty.

These firms are geographically localized and the majority of admissions come from the emergency department, providing the opportunity for housestaff to manage patients throughout the course of their hospitalization. Attendings are all members of the Yale full-time faculty and there is an added focus on the patient’s experience, educational innovation, inter-professional care, quality, safety and transitions of care. Included among the general medicine Firms is an Advanced Care of the Elderly (ACE) Unit, or the Cooney Firm. This Geriatrics Firm is part of a larger initiative to develop a Center of Excellence in Elder Care at Yale New Haven Hospital.

The inpatient medical service at the SRC is developed around three main principals: outstanding patient care, excellent attending and peer teaching, and the fostering of strong relationships with other medical services as well as nursing and ancillary staff.

We pride ourselves on our inpatient Firm system where, localized to one general medical unit, we work to deliver true multidisciplinary and team-based care. Our Firms honor the long history of master clinicians from Yale who embody the very best of medicine from clinical excellence to the highest standards of professionalism and devotion to patients. Each Firm is comprised of two teams and each team as dedicated day and night team components working under the supervision of a single attending. There is one PGY 2 or PGY 3 resident with an intern and medical student on each day team and one PGY 2 or PGY 3 resident and an intern on the night team. There are no ”Day Floats” or “Night Floats”, no “holdovers” as all patients are admitted and cared for by physicians who have ongoing responsibility for their care. Within each Firm, faculty, nurses, residents, interns and students work together in a system designed to maximize peer teaching as well as faculty teaching, guidance, and continuity of care. All night and day team members (housestaff and faculty) round together for one hour every morning during “Firm rounds”, where patients admitted to the Firm by the night team are presented at the bedside. These rounds assure a “warm handoff” of the patients and are critical for teaching and learning, as well as for maximizing the patients’ awareness of who their team members are and for patients to gain insight into their illness and to participate in discussion of the proposed plan of care.

Our medical service is designed to maximize collaboration with other hospital staff. This floor is the first unit in the entire Yale New Haven Health that has been designated an Accountable Care Unit (ACU). One hallmark of the ACU model is Structured Interdisciplinary Bedside Rounds (SIBR). In SIBR, all members of the care team including physicians, nursing, pharmacy, physical therapy, social work etc. come together for daily structured bedside rounds. We also have a weekly floor meeting, attended by the medical and nursing staff and led by one of the physician Firm chiefs, where the focus is on collaboration and communication. As a result of these meetings, many initiatives to improve patient care have been designed and implemented.

We view our Firm system as a model for innovation in patient care and education, we welcome new ideas and we are committed to continuous improvement. There are numerous patient-care enhancements, education innovations and academic projects that result each year from collaborative house-staff/faculty/nursing initiatives.

There are six subspecialty firms at Yale New Haven Hospital's York Street Campus that housestaff will rotate through over the course of training. These firms include the Oncology Firm, the Duffy Firm (hematologic malignancies), the Donaldson (HIV) Firm, the Klatskin (liver disease) Firm, the Peters (renal disease) Firm and the 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 of Medicine. 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 inter-professional care into the daily experiences of the Firm.

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, hemodynamic instability, myocardial infarction, congestive heart 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, thoracentesis, paracentesis, lumbar puncture and naso-gastric tube placement. Residents will rotate through the Cardiac Care Unit at York Street Campus and the Medical Intensive Care Unit at Saint Raphael Campus.

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. Residents learn the indications for cardiac catheterization, PTCA, thrombolysis, cardiac bypass surgery, intra-aortic balloon pump placement, left ventricular assist devices, etc.. Clinical care is complimented with daily case discussions and a core cardiology curriculum.

The Medical Intensive Care Unit team is comprised of Pulmonary/Critical Care attendings and fellows, PGY II and PGY III residents, interns and midlevel providers. Residents learn to provide care to critically ill patients with a wide range of conditions and become proficient in hemodynamic monitoring and 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. In addition to becoming proficient in critical care, residents in the ICU, are often given graduated responsibility in leading conversations around goals of care with patients and their families. Clinical care is complimented with daily case discussions and a core intensive care unit curriculum.