Clinical Training Program
Our fellows complete a minimum of 18 months of clinical training during their fellowship. The first year of fellowship is all clinical and the remaining 6 months of clinical training occur during the second and third years. Throughout the 36 months of PCCSM fellowship, fellows participate in a continuity clinic.
Several hospitals participate in the clinical training of PCCSM fellows including: Yale-New Haven Hospital (YNHH), a tertiary care hospital which has two campuses-York Street Campus (YSC) and St. Raphael Campus (SRC), The West Haven Veteran's Administration Hospital (WHVAMC), Bridgeport Hospital, a community hospital with specialty burn intensive care unit, and Gaylord Hospital, a comprehensive rehabilitation hospital specializing in ventilator dependence, weaning and respiratory rehabilitation.
Clinical Rotations
- Medical Intensive Care Unit
The Medical Intensive Care Unit (MICU) at YSC is under the directorship of Dr. Shyoko Honiden. This ICU is regarded as one of the region's elite units. The YSC MICU is housed in the state-of-the-art facility on the 9th and 10th floors in the Smilow Cancer Hospital. There are 40 ICU beds alongside 16 step-down beds. The MICU team cares for an average daily census of 30-36 critically ill patients with a wide range of life threatening disorders, such as septic shock, acute respiratory distress syndrome, and acute liver failure. There are over 4500 admissions per year in this busy unit with approximately 50% requiring mechanical ventilation and a median length of stay of 3 days. We receive 400 transfers annually from hospitals in the region for second opinions and specialized care that cannot be offered locally. Four teams cover the MICU, each led by a PCCSM faculty member supported by fellows, residents, and advanced practice providers. In addition to PCCSM fellows and Internal Medicine residents, the MICU is a major training site for medical students, as well as residents and fellows from several departments, including Surgery, Emergency Medicine, Maternal Fetal Medicine, Anesthesia Critical Care, Interventional Radiology and Obstetrics-Gynecology. PCCSM faculty as well as fellows in the MICU lead work rounds and conduct teaching conferences. The MICU is a haven for clinical research, with multiple faculty conducting studies in acute lung injury, sepsis, cognitive impairment, sleep, diabetes, liver failure, and end-of-life care. As a first year PCCSM fellow you will spend 3-3.5 months in the YSC MICU. The MICU at YSC is staffed by in-house intensivists overnight ensuring supervision, quality care and education 24 hours a day. There is no in-house night call for fellows, except when they are on a MICU nights rotation as an upper year for 2 weeks.
- Coronary Care Unit (CCU)
The Coronarry Care Unit (CCU) is a 14 bed unit that cares for patients with myocardial infarction, post-cardiac catheterization, congestive heart failure, LVADS and heart transplant. The unit is staffed by attending cardiologist, cardiology fellows and medical housestaff. During this rotation the critical care fellow will round with the team, learn about the advanced management of heart failure, echocardiography and participate in right heart catheterizations.
- Neurosciences Intensive Care Unit (NICU)
PCCM fellows rotate through the Neurological Intensive Care Unit (NICU) at Yale-New Haven Hospital, typically for 4 weeks, during their first year of fellowship. The goals of this rotation are broad and include learning all of the skills required to evaluate and manage critically ill patients with neurologic and neurosurgical diseases, including but not limited to subarachnoid hemorrhage, intracerebral hemorrhage, ischemic stroke, traumatic brain injury, status epilepticus, Guillain-Barre Syndrome, brain tumors, diseases of the spinal cord and CNS infections. Fellows are expected to attend neurology and neurosurgical conferences and are afforded the opportunity to join Neurosurgeons in the operating room. NICU work rounds are conducted with highly skilled neurointensivists. Dr. Kevin Sheth is the medical director, and Dr. Guido Falcone, Dr. Emily Gilmore, Dr. David Hwang and Dr. Nils Peterson are the other faculty. There is no in-house call during this rotation.
- Surgical Intensive Care Unit (SICU)
The overall goal of the SICU rotation is for PCCSM fellows to gain experience and competence in managing critically ill patients in the unique environment of the surgical intensive care unit. The SICU at Yale New Haven Hospital is a multidisciplinary unit that includes patients from multiple surgical services including obstetrics and gynecology, general surgery, gynecologic oncology, trauma, orthopedics, ear, nose and throat surgery, thoracic surgery, transplant surgery including liver and renal transplant. In addition, the SICU team manages trauma cases runs the emergency general surgery/trauma service. Therefore, PCCM fellows have a unique opportunity to experience the full range of surgical intensive care from trauma, pre-operative and post-operative management. While the PCCM fellows are rotating on the service they function as a surgical intensive care unit fellow providing direct patient care to all of the critically ill patients. The service is led by critical care trained faculty from trauma/general surgery, anesthesiology as well as emergency medicine. Fellows will rotate on this service for 1 month typically during the 2nd year of their fellowship. There is no overnight call during this rotation.
- Interventional Pulmonary Rotation
Interventional Pulmonary Rotation offers the most advanced diagnostic and therapeutic approaches to various diseases in the chest, including lung nodules and masses, enlarged lymph nodes (mediastinal adenopathy), complex airways and pleural effusions. Our trained interventional pulmonologists are leaders in the field and have more experience than anybody in the state and surrounding area. The TIP service at Yale-New Haven Hospital is under the directorship of Dr. Jonathan Puchalski. Our fellows spend one month on the TIP service during their fellowship where they get exposure to advanced bronchscopic procedures, pleural procedures and percutaneous tracheostomies. Dr. Erin DeBiasi serves as the Fellowship Procedural Education Director for the IP service. Fellows who are interested in a career in interventional pulmonology can apply to the accredited fellowship program for additional training.
- Pulmonary Consult Service
- The pulmonary consult service at Yale-New Haven Hospital is run by our PCCM faculty and is an active consultative service. Our fellows see patients on the medical and surgical floors as well as in the non-medical ICU’s. It is a busy service with 2 teams with a dedicated fellow and attending on each. PCCM fellows typically spend about four months on the consult service during their first year of training. There is tremendous breadth and depth in the clinical cases that fellows encounter. Examples include lung nodules, interstitial lung disease, pulmonary hypertension, pulmonary infections, cystic fibrosis and pulmonary manifestations of rheumatologic illnesses. Fellows gain experience in diagnosing and managing common pulmonary diseases as well as rare diseases, and uncommon presentations of pulmonary disease There is ample opportunity for procedural skill development in this rotation as well, with procedures such as thoracentesis and bronchoscopy. The pulmonary consult service is a sought after elective for Yale IM residents and affiliate residents, and thus provides fellows an opportunity to hone their teaching and leadership skills. While on the consult service they care for some of the patients in the Progressive Pulmonary Care Unit which is comprised of 16 beds where stable ventilated patients can be managed. Here, in addition to their time at Gaylord Hospital (a long-term acute care facility-see below) as a 2nd or 3rd year, fellows learn about long-term ventilator weaning, tracheostomy management as well as care of the chronically critically ill.
- West Haven VA Connecticut Health Care System
The Section of Pulmonary and Critical Care Medicine at the WHVA is directed by Dr. Hilary Cain. The WHVA has a six bed medical ICU, a pulmonary consultation service, pulmonary function lab and outpatient pulmonary clinics. Our fellows spend one or two months of their inpatient training during their first year at the WHVA where they round with faculty and housestaff in the ICU, see pulmonary consult patients, perform bronchoscopies and read PFTs. The WHVA also has an active sleep program under the directorship of Dr. Brian Koo.
- Pulmonary Rehabilitation
Fellows spend two to three weeks during 2nd or 3rd at Gaylord Hospital, which is a premier long-term acute care facility in the region, specialized in the care of patients with chronic respiratory failure. There, they round on chronically ventilated patients with a multidisciplinary team. Fellows round with an ENT consultant to manage tracheostomies and assess for decannulation. Fellows additionally learn how to assess patient suitability for pulmonary rehabilitation, observe rehabilitation in both inpatient and outpatient settings, and participate in QI meetings to review weaning and decannulation rates.
- St. Raphael Campus (SRC)
YNHH SRC is a 500-bed community hospital located in New Haven about 5 minutes from the YSC. It is the 4th largest hospital in Connecticut and has a 16 bed ICU. Dr. Aydin Pinar is the site ICU director. PCCSM fellows spend two to three months during their training at the SRC. Residents on this service are from Yale Internal Medicine Primary Care program, and faculty are Pulmonary and Critical Care attendings. As with the YSC MICU, there are in-house night intensivists for this unit overnight to ensure supervision, quality care and education 24 hours a day. There are no in-house overnight responsibilities for fellows. During the SRC rotation fellows round with attending and housestaff in the ICU and see pulmonary consult patients on the medical and surgical floors. They are responsible for performing bronchoscopies and thoracentesis. In addition, the YNHH cardiopulmonary exercise testing (CPET) program is based out of the SRC campus and fellows spend two weeks learning pulmonary physiology as well as supervising and interpreting CPET during their CPET/physiology rotation during their first year.
- Sleep Medicine
Training in Sleep Medicine occurs during rotations through the Yale Center for Sleep Medicine and the VACHCS sleep laboratory. Our fellows spend two weeks on the sleep medicine rotation. The curriculum for this sleep rotation includes: fundamentals of the neurobiology and structure of sleep, fundamentals of the effects of sleep on organ system physiology, pharmacology of drugs affecting sleep and wakefulness, classification of sleep disorders, basics of polysomnography, knowledge about ambulatory techniques for the monitoring of sleep disordered breathing, obstructive sleep apnea syndrome and related conditions, nocturnal hypoventilation management, and the basics of the differential diagnosis of excessive daytime sleepiness. Fellows who are interested in a career in sleep medicine can apply to our ACGME accredited Sleep Medicine Fellowship.
- Pulmonary and Critical Care Electives
Cardiothoracic ICU
The CTICU at YNHH is an 18-bed multidisciplinary unit. The patient population consists of a robust general cardiac and thoracic surgery experience, a cardiac transplantation program, and a rapidly growing extracorporeal life support (ECLS) and mechanical circulatory support program. Fellows will participate in multidisciplinary work rounds (which includes surgery housestaff, advanced practise providers, pharmacists and dieticians), and will help manage patients with complex physiology alongside CTICU (anesthesia critical care) attendings.
Hospital for Special Care
Hospital for Special Care has 200 beds and is licensed as a Long-Term Acute Care Hospital (LTAC). The Hospital services patients with chronic respiratory diseases from spinal cord/neuromuscular disorders, COPD, chronic ventilator dependency and long term weaning from mechanical ventilation. Acute rehabilitation is also provided. Our fellows have the option to spend time at HSC as an elective during their training.
Bridgeport Shriner's Burn unit/SICU
The burn unit is a unique and highly specialized care environment and is the only burn center in the state of Connecticut The burn center is an outstanding model of interdisciplinary care including occupational & physical therapy, dietary, respiratory & pulmonary services, social work and chaplain services. Fellows learn about critical care of patients with severe burns including fluid management, inhalational injuries, and nutrition in these complex patients.
Chest and Critical Care Radiology
As radiographic studies are a critical part of our pulmonary and critical care medicine, learning how to interpret radiographic studies of the thorax is critical. Fellows meet on a daily basis in the thoracic radiology suite and read films with the thoracic radiology service.
Anesthesiology
Fellows can rotate through the operating room with anesthesiology either at Yale-New Haven Hospital or the West Haven VA and learn the technical skills of intubation, vascular access and difficult airway management.
Tele-ICU
From 7PM to 7AM, experienced intensivists and nurses support ICU patients in area affiliated hospitals from the secure InSight Clinical Center. The tele-ICU team collaborates with the bedsite care team, reviews the EMR, monitors vital signs and laboratory data to identify concerning trends. Specialized audio and video equipment allows for a seamless interface. Given that tele-ICU has become a reality in many parts of the country, PCCM fellows with interest are given the opportunity to spend some nights at the 'bunker' to learn about how care is delivered and participate in QI projects.
Away Electives
Our fellows have the opportunity to spend a month doing an away elective in a field of their choosing Our previous fellows have spent time learning lung transplant at specialized centers, learning about bronchiectasis and MAI, spending time in an underserved location as part of the Yale/Stanford Johnson and Johnson Global Health Scholars Program. The latter program has established program rotations sites for 2018-19 in locations such as South Africa, Uganda, Rwanda and Colombia.
- Continuity Clinic
All of our first year fellows have weekly continuity clinic at the West Haven VA under the guidance of our faculty (Hilary Cain, Carly Rochester, Kathleen Akgun, Charles Dela Cruz, Christine Won, Klar Yaggi and Meir Kryger). The VA clinic population includes a large cohort of COPD, asthma, lung nodules and obstructive sleep apnea.
During their second and third years the fellows alternate their weekly clinic between the West Haven VA and Winchester Chest Clinic at Yale-New Haven Hospital. Winchester Chest Clinic serves the local community as well as a wide referral population. The addition of Winchester Chest Clinic in the second and third year of fellowship not only gives the fellows exposure to a wider range of pulmonary disease but also teaches them the art of outpatient consultative medicine. The faculty who supervise in Winchester include Jennifer Possick, Margaret Pisani, Shyoko Honiden, and Maor Sauler.
Subspecialty Clinics
Our fellows have a wide variety of subspecialty clinics to choose from. Clinics are customized for each fellow based on interest and career development. Subspecialty clinics include TB, adult cystic fibrosis, ILD, asthma, COPD, thoracic oncology, pulmonary vascular disease, interventional pulmonary, occupational medicine, sarcoidosis, and sleep. Our fellows spend 6 months doing ½ day/week in subspecialty clinics during the course of their fellowship.