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Ambulatory Medicine

Developing the skills and expertise necessary for the practice of outpatient medicine is an essential component of residency training in both internal medicine and pediatrics. There is also growing recognition that essential aspects of office practice, such as doctor-patient-family communication, evidence-based decision-making, preventive medicine, and office-based procedures, should be taught to residents in training. An extensive ambulatory curriculum has been developed to meet these needs, and is learned in a variety of venues and rotations.

Med-Peds Continuity Clinic

Med-Peds housestaff have their continuity practices in a modern clinic built by St. Mary's Hospital in Waterbury specifically for this purpose. It is a combined clinic, caring for both adult and pediatric patients at all times. Resident practices are supervised by full-time Med-Peds faculty who are free from other scheduled responsibilities while precepting housestaff. Faculty also care for their own patient panels, drawn from the same local population, in the same clinic during separate sessions. New patients, ranging from newborns to nonagenarians, are recruited by faculty and housestaff from St. Mary's newborn nurseries, pediatric and adult in-patient wards, and from a growing panel of satisfied, ethnically diverse families. Referrals from the Waterbury area are also referred to the Med-Peds clinic from the nursery and subspecialty services at Yale. Within clinic the faculty has developed clinical programs in HIV, neonatal HIV, hepatitis C, substance use disorder, refugee health, and the care of chronically ill children. These clinical enterprises further expand our residents' clinical training.

A nationally recognized pre-clinic conference series, developed by Yale faculty, addresses topics in both internal medicine and pediatrics. A local chapter of the nationally acclaimed Reach Out and Read program helps Med-Peds providers promote literacy amongst their patients. Additionally, initiatives to improve the quality of care in the clinic are routinely spearheaded by residents with faculty support and supervision. These resident initiatives are often the focus of our monthly Med-Peds noon conferences, which are organized by the Med-Peds chief resident.

Med-Peds Ambulatory Blocks

Med-Peds residents rotate through protected ambulatory blocks during all four years of training. These blocks are custom-crafted to help residents meet their individual educational needs. Residents work with faculty in advance of the rotations to determine the best use of the time. Early on in training, the ambulatory blocks are designed to help residents deepen their skills as outpatient physicians, develop familiarity with the critical roles that non-physicians play on the ambulatory care team, spend concentrated periods of time in continuity clinic, and begin working on a scholarly pursuit. Residents also spend time in the private offices of community-based internists, pediatricians, family physicians, and Med-Peds practitioners, where they gain exposure to the business and logistical aspects of practice management. As residents advance in training, the ambulatory blocks are increasingly customized to provide additional training in areas of personal interest and to lay the groundwork for life after residency. Great flexibility exists in developing the Med-Peds ambulatory blocks. Residents benefit from knowledge of the creative things their predecessors have done with the time, but ultimately no two resident schedules are identical given the broad range of resident interests and available opportunities.

Other Ambulatory Clinical Sites

Essential primary care skills are also taught during outpatient block rotations and electives. Throughout the four years, acute ambulatory care is learned alongside pediatric housestaff at Yale's Primary Care Center, and through adult and pediatric Emergency Medicine rotations. Pediatric and medicine outpatient electives include time in subspecialty outpatient clinics. Rotations in adolescent medicine, developmental pediatrics, and geriatrics also expose residents to core skills for outpatient Med-Peds practice.

Residents also have the opportunity to work in the VA Connecticut Healthcare System (VACHS) Center of Excellence (COE) in Primary Care Education which trains future health care professionals in a team-based, patient-centered care teaching model. Through an innovative curriculum of inter-professional clinical care months, interactive leadership seminars, and health policy classes, the COE offers trainees a unique, transformative approach to post-graduate medical education.

Ambulatory Education Lecture Series

The didactic component of the ambulatory curriculum includes the pre-clinic conferences, which provide practical, case-based reviews of common outpatient topics. During the ambulatory block, residents also participate in an Ambulatory Core core Curriculum curriculum that includes a resident/faculty-taught evidence-based medicine series, and workshops on physician-patient communication skills, minor office procedures, and physical diagnosis. Also included are seminars in preventive medicine, psychosocial medicine, women's health, preoperative consultation, and outpatient management of common chronic diseases. There is a weekly ambulatory morning report in medicine, and a weekly series of outpatient pediatrics conferences which housestaff can attend when on outpatient rotations.

Residents also have an opportunity to participate in community projects including a medical clinic established by Program program faculty in a homeless shelterfor people experiencing homelessness, a free-care van for the uninsured in Waterbury, and community health promotion and disease prevention projects. Residents may also contribute to an annual month-long basic science review/career counseling course for minority collegeunderrepresented in medicine students who will be applying to medical school that is sponsored by the Primary Care Residency Program and the Office of Multicultural AffairsOffice of Diversity and Inclusion.

There are several other educational activities of relevance to ambulatory medicine and pediatrics. Some examples include high quality journal club series in both the Medicine and Pediatrics departments, a quarterly ethics series in Pediatrics, and a monthly Med-Peds noon conference.

Inpatient Medicine

A Med-Peds residency is particularly challenging given the expectation for a resident to function at the same level as her peers in the single-track programs. Mindful of this challenge, we have found that our residents perform well on the wards, as they draw from their experiences on complementary rotations: their PICU experience informs their approach in the MICU. Geriatrics and newborn care often share similar issues of self-care and independence.

Tertiary inpatient training occurs primarily in two facilities: Yale New Haven Hospital (adult medicine) and Yale New Haven Children's Hospital (pediatrics). Important to inpatient education is the community hospital experience which takes place at affiliated hospitals with dedicated Yale faculty, usually one to two months a year.

Yale New Haven Hospital (YNHH) is the flagship hospital of Yale New Haven Health and has 1,541 total beds across two campuses in New Haven. In addition to serving the metropolitan New Haven area, YNHH is a regional referral center and has patients with less commonly seen medical problems as well as patients with undiagnosed and complicated problems. Residents care for patients being treated with a wide range of advanced medical technology, including bone marrow,cardiac transplantation and experimental oncology regimens. Since YNHH is part of Yale School of Medicine, residents learn from leading experts in a wide range of fields. The basic science,clinical, and translational research facilities provide an opportunity for residents to pursue questions that arise from patient care experiences into the laboratory or clinical research center.

The Medical Service of YNHH includes a 22-bed Coronary Care Unit, a 15 bed Medical Intensive Care Unit with adjacent “step down” unit, Oncology Service with a Bone Marrow Transplant Unit, a Cardiology Service, the Atkins Firm which manages patients with HIV-related diseases, and five general medicine teams.

The Yale New Haven Children's Hospital (YNHCH) is composed of 208 licensed beds and consists of two neonatal intensive care units, a pediatric cardiac intensive care unit, a pediatric intensive care unit, a pediatric psychiatry unit, an adolescent psychiatry unit, 24-hour Level 1 Pediatric Emergency Trauma Center and a pediatric surgery center.

YNHCH is completely integrated with respect to medical and surgical cases as well as private and staff patients. The patients are assigned to pediatric care units according to their age. Housestaff have the full and complete responsibility for the care of all children. The patients admitted by the pediatric surgical service or surgical subspecialties are cared for in coordination with surgical colleagues. The housestaff are supervised by members of the full-time faculty as well as pediatricians of the greater New Haven area who constitute an active part-time faculty. The inpatient service is divided by age: an infant and toddler unit, a school age unit, and an adolescent unit. Full-time faculty is responsible for coordination of all teaching activities and for maintaining a high level of patient care for all patients. The Department of Pediatrics has available extensive and excellent support services including diagnostic imaging, blood bank, laboratory medicine and other contemporary diagnostic modalities.

The Department of Pediatrics maintains a close collaboration with the Yale Child Study Center which is devoted to teaching and research in child development and child psychiatry. Also, the faculty of the Department of Genetics is involved in many aspects of patient care and teaching.

Didactic 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 believe passionately that the learning of medicine has to be an active process at the bedside and to that end our residents find themselves in a supportive environment ministering to 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 pediatrics and that allows for in-depth discussion with our faculty. There is a comprehensive inpatient didactic curriculum that occurs in both departments and at all clinical training sites. Similarly, there is a comprehensive ambulatory didactic curriculum that occurs during ambulatory block rotations and in the weekly continuity clinic.

Inpatient Didactic Curriculum

The inpatient didactic curriculum in both internal medicine and pediatrics consists of morning report, noon conferences, journal clubs, and weekly grand rounds. The medicine department also sponsors a variety of special conferences such as Firm Conferences and the pediatrics department sponsors a weekly discharge conference that is one of the most popular didactic experiences of the program. A description of the didactic curriculum for residents while on the medical service and while on the pediatrics service follows.

Teaching Programs & Conferences During Internal Medicine Rotations

Morning Report

Morning report occurs Monday through Saturday. One report each week is specifically for interns and report on Saturday is for all housestaff in the hospital that day. It is a Yale tradition that report is run by the chief resident with core faculty always present to provide input when needed. On occasion an expert may also be invited.

Report frequently begins about a brief inquiry about codes, errors or near errors the previous day, often followed by a very short teaser, such as a blood smear, a picture of a skin rash, urine sediment, an imaging study or EKG, projected on the screen by the chief resident. The reports are run using one of two different formats. Occasionally short discussions are held on a number of patients admitted to the teams during the previous night. However, more frequently, after the patient’s houseofficer has presented pertinent clinical details about a patient pre-selected by the chief resident, a lively and interactive discussion ensues between the chief resident and the housestaff in attendance, with faculty only interjecting when they feel they have something of importance to add.

The initial emphasis is on using clinical information in order to arrive at a differential diagnosis and then asking for further investigative data. At this point, as relevant, copies of EKGs may be distributed and blood smears, imaging studies, echocardiograms, etc. projected on the screen in order to enable the housestaff to arrive at a diagnosis. Thereafter, time permitting; evidence is sought from the patient’s resident in support of the treatment the patient received, or, about the pathophysiology of the disease in question.

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

Summer Teaching Conferences

These lectures are given three times a week at noon and occur at both hospitals. They are open to all housestaff but are specifically focused on the needs of new interns. They cover a vast array of topics which cover the nuts and bolts of subjects that it is felt new interns should become familiar with soon. These subjects include a talk of how to present patients during Work Rounds, important topics in every subspecialty in Internal Medicine including critical care medicine, problems in neurology, dermatology, psychiatry, medical ethics, legal aspects of medicine, quality assurance issues etc.

Noon Teaching Conference

These lectures are held two to three times weekly at both hospitals from September through June and they cover a series of core internal medicine topics.

Professors Weekly Conference

These conferences are given at Yale once a week and provide yet another opportunity for housestaff to meet with physicians who are engaged in either basic science research or clinical investigation. The goal is to expose housestaff in relatively small groups to such faculty and to make the discussion interactive. To make that possible, two such sessions are held simultaneously in order to achieve “small group” teaching possible. Patients on the housestaff service are generally chosen, and the “Professor” talks about the patient presented by the housestaff; may touch upon diagnostic aspects, but concentrates as far as possible on pathophysiology, basic science aspects underlying the patient’s disease, epidemiology etc. as relevant. A fair bit of the curriculum is covered in this fashion.

Lectures in a larger forum include those on a number of different topics such as those related to:

  • Laboratory medicine
  • Psychiatry
  • Adolescent Medicine
  • Monthly ethics and end-of –life conferences
  • Quality Improvement Curriculum
  • Medical Errors – “matrix” presentations
  • Legal aspects of Medicine
  • Morbidity and mortality conferences (including some using the Matrix format)
  • Autopsy conferences
  • Peer teaching conferences: These are seminars given by third year residents on a subject of their choice as a part of their scholarly activity
  • Journal Club: These journal clubs are focused mainly to teach housestaff to evaluate an article critically and a variety of different types of studies are chosen e.g. randomized control trials, longitudinal cohort studies, case control studies, cross sectional studies etc., quite apart from the subject the article deals with.

Teaching Programs & Conferences During Pediatric Rotations

The Yale Pediatric Residency Program is designed as a continuing and progressive educational experience. While bedside teaching and learning is of the essence, a core of didactic and interactive conferences form the basis to solidify your educational experience. Currently, emphasis is being placed on a case management approach. Our core teaching curriculum is evaluated on an annual basis and is closely coordinated and integrated among all three of the teaching hospitals.

In all of the patient care areas, the attending physician makes rounds with the housestaff on a daily basis, including weekends. The attending physician has the responsibility for coordination of patient care activities as well as teaching on all patients. This includes daily bedside examination and teaching for the housestaff. In addition, the attending physician for each ward team at the Yale New Haven Children's Hospital are responsible for a didactic teaching conference weekly. An innovative conference series including Journal Club, daily inpatient as well as outpatient conference series, morning report, and mock codes are provided for the house staff. Pediatric subspecialists provide additional teaching conferences for the Yale pediatric housestaff two days per week as well as every morning as part of the Outpatient Conference Series. Finally, Pediatric Grand Rounds is the highlight of the weekly teaching schedule. All of these conferences are specifically directed to patient care problems and housestaff education. Daily conferences also occur in Radiology, Continuity Clinic, Newborn Special Care Unit, Pediatric Intensive Care Unit, and various subspecialty sections.

Each Thursday afternoon, patients who have been discharged with diagnostic dilemmas or unusual diagnoses are discussed in a multidisciplinary literature-based conference which provides further opportunity for interaction between the housestaff and the faculty. This Discharge Conference provides opportunity for detailed discussion of intriguing and diagnostically difficult patients. Once monthly, the conference is devoted to a morbidity and mortality discussion to evaluate the issues of medical management, practitioner communication, and overall patient care. Discharge Conference also allows for both the housestaff and faculty to hear from world experts on various issues in pediatrics, as well as learn the latest clinical and basic laboratory information in the continuing effort to bring the bench to the bedside.

Ambulatory Medicine Lectures

The ambulatory medicine didactic curriculum includes didactic conferences during pediatric outpatient rotations and during combined Medicine/Pediatrics ambulatory block rotations. During ambulatory block rotations, in addition to topics developed specifically for the medicine/pediatrics residents, we take advantage of the ambulatory curriculum developed by the Yale Primary Care Residency which is among the most comprehensive and effective seminars offered in any training program. In addition, during weekly continuity clinic sessions, each resident participates in a 20 minute interactive seminar discussing outpatient evaluation and management of common pediatric and internal medicine topics.

Resident Research and Scholarship

Yale School of Medicine is one of the preeminent centers for biomedical, technological, and behavioral research. The principal sponsor of research for YaleSchool of Medicine is the federal government through the National Institutes of Health (NIH) which continually ranks within the top 10 nationwide.

Aims of the Resident Scholarship Requirement

The primary goals of the resident scholarship requirement are to enhance the critical thinking skills of the residents as bedside clinicians, to facilitate scholarly thinking, creativity, and appreciation of the excitement in creating new knowledge in medicine at an early stage in clinical training, and to broaden the scholarly sophistication of all elements of the residency program (i.e., morning report, peer teaching, work rounds, attending rounds, etc.).

Structure of the Resident Scholarship Opportunities

PGY 1 and PGY 2 residents work with their faculty advisor to identify a mentor for their scholarly project and residents typically begin their project in the PGY 2 or PGY 3 year. Residents pursuing hypothesis driven research or those developing an educational curriculum can spend one half-day per week during their PGY 3 ambulatory block rotation to work on their projects and all residents can elect up to 3 months of elective time during training to pursue research and still meet training requirements. In addition, residents can integrate their research project into their PGY 4 ambulatory block rotation.

Presentation of Results

All residents present their work either as oral presentations or as posters at our annual Primary Care and Medicine/Pediatrics Residency Research Day each May. Those who have completed hypothesis driven research projects also present their work at the Department’s “Annual Research in Residency Day Symposium” also held each May. Residents are encouraged to submit their research to regional and national scientific meetings (e.g., Society of General Internal Medicine, American College of Physicians, American Academy of Pediatrics, etc.) and funding is available to support residents to attend these meetings in order to present their work. Below are some examples of the abstracts our residents have presented.

Primary Sites of Training

Ambulatory Training occurs in a variety of sites as described in the Ambulatory Education section of the website.

Inpatient training occurs at two sites:

  • Yale New Haven Hospital (the Beeson Service)
  • Yale New Haven Children’s Hospital: Yale New Haven Hospital's York Street Campus contains Yale New Haven Children’s Hospital, the Yale New Haven Psychiatric Hospital and Smilow Cancer Hospital. The 1,541-bed flagship hospital of Yale New Haven Health System is one of the largest in the United States and brings a unique opportunity for the department and academic medical center to positively impact the care of our community in an integrated and coordinated manner.

Yale New Haven Hospital - Beeson Service

Yale-New Haven Hospital

The Internal Medicine service at Yale is named after Dr. Paul Beeson, one of the most illustrious figures in American medicine in the latter half of the 20th century, who was chair of Medicine at Yale from 1952 until 1965.

The Beeson Service occupies the fifth, eighth, ninth, and tenth floors of the East Pavilion, the fifth floor of the South Pavilion (Medical Intensive Care Unit and Coronary Care Unit), and the ninth floor of the West Pavilion (Medical Oncology). Most of the services are now fairly well localized geographically.

Yale New Haven Children's Hospital

Yale New Haven Children’s Hospital functions both as a community hospital for a population in excess of 400,000 and as a tertiary care center for the referral of patients from throughout Connecticut, New England and other states as well as foreign countries. This dual role assures a variety of clinical experiences including common pediatric disorders as well as a more complex, rare,and tertiary type of pediatric cases. Furthermore, in addition to this tremendous diversity of pediatric disease pathology, the Yale resident is exposed to a wide variety of patient diversity.

The Yale New Haven Children's Hospital (YNHCH) is composed of 208 licensed beds and contains two neonatal intensive care units, a pediatric cardiac intensive care unit, a pediatric intensive care unit, a pediatric psychiatry unit, an adolescent psychiatry unit, 24-hour Level 1 Pediatric Emergency Trauma Center and a pediatric surgery center.

The patients are assigned to pediatric care units according to their age. There are also dedicated units for respiratory step-down, hematology and oncology, and patients on research protocols. The pediatric housestaff has the full and complete responsibility for the care of all children admitted to the hospital. The patients admitted by the pediatric surgical service or surgical subspecialties are cared for in coordination with our surgical colleagues.

The housestaff are supervised by members of the full-time faculty as well as pediatricians from the greater New Haven area who constitute an active part-time faculty. The Department of Pediatrics has available extensive and excellent support services including diagnostic imaging, blood bank, laboratory medicine and other contemporary diagnostic modalities.

The Department of Pediatrics maintains a close collaboration with the Yale Child Study Center which is devoted to teaching and research in child development and child psychiatry. Also, the faculty of the department of genetics are involved in many aspects of patient care and teaching.

The pediatric primary care center (PCC) is a major community resource for the care of children with approximately 15,000 visits per year. The PCC is oriented to continuity of care and dedicated to intensive houseofficer and medical student teaching. Weekly continuity clinics are held and are given the highest priority among resident responsibilities. In addition, senior level residents participate in an office practice rotation. This experience has been extremely well received by our housestaff, as it has afforded them the opportunity to observe firsthand how patient care is provided in the community setting as well as to learn how an office practice is conducted.