Currently, we have two training tracks for fellows entering our program: a traditional three-year track for fellows interested in pursuing an academic research career, and a clinical/clinician educator track (two-year training program) for fellows interested in a career as a clinician-educator in Infectious Disease.
The Yale Infectious Disease Program utilizes three sites to provide fellows with inpatient consultation experience: Yale New Haven Hospital's York Street and Saint Raphael campuses along with the VA Connecticut Healthcare System in West Haven. YNHH's York Street Campus has three ID consult services: General ID, Transplant ID and Smilow (oncology) ID. One fellow is assigned to each of these three services, one fellow is assigned to the VA, and one fellow is assigned to the Saint Raphael Campus. All five services are staffed by one first-year fellow and one attending physician. Second year fellows only perform inpatient ID consultation when covering first year fellow vacations, in-service exams or maternity/paternity/sick leave.
Each site provides a very different patient population, broadening the experience of Infectious Disease fellows in our program. Yale New Haven Hospital is a two campus, 1,541-bed tertiary care facility that also functions as a community hospital for greater New Haven and southern Connecticut. It provides both an urban community and tertiary medical care experience with a 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 Saint Raphael Campus 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.
The VA Connecticut Healthcare System 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). Reference laboratories for Tuberculosis and Virology and an outstanding Microbiology laboratory in the VA CT program provide added benefits. Experiences at these three hospital sites complement, rather than duplicate, the various educational experiences for Infectious Disease fellows. Trainees are responsible for following an average number of 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 and is supervised by an attending physician.
In contrast to Internal Medicine residents, Infectious Disease subspecialty trainees play a consultative and educational role. Where Internal Medicine residents are involved in the day-to-day management of patients in conjunction with their attending, the Infectious Disease trainee consults on the management of specific patients with Infectious Diseases and HIV-related problems. This includes recommendations for diagnostic testing, antimicrobial selection/dosing/duration, and other infectious disease management issues. The role of Infectious Diseases trainees is distinct from that of residents at all levels.
The responsibilities of the Infectious Diseases fellow 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 at YNHH's Saint Raphael Campus 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 (two 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 and physician assistant students and house officers in many capacities. First, students and house officers rotate on the Infectious Disease Consultation Service as two-week or 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 for 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 house officers 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 Department where they are admitted to General Medicine house staff firm teams. Infectious Diseases 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). Pediatrics has a separate Infectious Disease training program and consultation service.
Other Aspects of Training
Clinical/clinician educator fellows can choose to focus their training in the second year in one of the following areas: HIV, HIV/Hepatitis C co-infection, transplant ID, or hospital epidemiology/antimicrobial stewardship. They will attend specific clinics related to their areas of interest, develop a research project and attend relevant local and national meetings. They have the opportunity to apply for the Fellows as Medical Educators (FAME) program to further develop their skills as clinician educators. All clinical fellows rotate through a weekly fellows ID clinic where patients are seen for hospital follow-up visits.
Academic/research fellows obtain instruction in the basic sciences or in clinical investigation during the second year and beyond by engaging 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 (Joseph Craft, MD, director) and the National Clinician Scholars Program (Cary Gross, MD, director). Coursework is available through the Yale School of Public Health (YSPH). Tuition for all of these courses is supported through the ID T32 Training Grant. Research conferences within the section, small laboratory conferences, preparation for presentation at national meetings, and statistical analysis of data under supervision all contribute to instruction in the basic sciences or in clinical investigation.
There are three venues where 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 to present and attend our weekly Infectious Disease Clinical Case Conference where they present and discuss relevant published literature pertaining to specific patient-related infectious disease issues. This requires that they develop practical experience in evaluating study designs, comparing diagnostic/therapeutic maneuvers, and 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 in 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, most trainees attend the course "Introductory Course in Biostatistics" at Yale School of Medicine unless trainees enroll in more intensive courses through YSPH.
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 four days per week. Additionally, trainees are instructed in the Didactic Lecture Series as well as their Antimicrobial Stewardship two-week rotation in the second year regarding aspects of antimicrobial use/resistance patterns, hospital and outbreak surveillance, quality assessment and risk management issues. At all stages of their training in inpatient consultative care, trainees acquire experience in cultural, behavioral and economic issues related to 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 fifth night and two weekends per month. The Smilow ID fellow has every Thursday off but works every weekend for duration of the assigned month. Trainees take calls at home and only return to the hospital to evaluate new consult requests as needed. Trainees on average have one day off in seven from hospital duties.