Nephrology / Critical Care Fellowship
Yale Department of Internal Medicine’s Sections of Nephrology and Pulmonary, Critical Care Medicine, and Sleep Medicine are offering a combined three-year Nephrology / Critical Care Medicine Fellowship.
The fellowship is aimed at highly motivated applicants who desire formal nephrology training with subspecialty training in critical care medicine. The fellowship is a combined three-year track, with the applicant applying for both programs simultaneously. Applicants will be interviewed by faculty from both Nephrology and Pulmonary and Critical Care Medicine on interview day.
All potential candidates must have completed a three-year internal medicine residency by start of fellowship.
The first year consists of twelve months of inpatient nephrology. Time will be divided among three different sites.
Yale New Haven Hospital’s York Street Campus (YNHH-YSC): A teaching hospital with 1000+ medical and surgical beds. Time will be divided between rotations focused on transplant nephrology, end stage renal disease, and nephrology consults. There is also a night float system, and fellows will be periodically on evening night call during time at YNHH-YSC.
In addition to consultative care covering all aspect of inpatient nephrology consultation, inpatient time will expose fellows to the following:
- Continuous renal replacement therapy, intermittent hemodialysis, and peritoneal dialysis
- Training to perform ultrasound guided native and transplant kidney biopsies
- Insertion of non-tunneled dialysis catheters
- Point of care ultrasound, focused on volume assessment and acute kidney injury
- Urine microscopy
- Exposure to donor and recipient transplant surgeries
Yale New Haven Hospital’s Saint Raphael Campus (YNHH-SRC): A 500-bed hospital where fellows will be exposed to inpatient nephrology consults. Procedures are generally not performed while on service at YNHH-SRC.
VA Connecticut Healthcare System: A 200-bed hospital in West Have where fellows will be exposed to inpatient nephrology consults and both inpatient and outpatient end stage renal disease care. Fellows will have the opportunity to perform dialysis catheter insertions and ultrasound guided native kidney biopsies.
In addition to the above inpatient time, during the first year, fellows will have an outpatient general nephrology continuity clinic either at YNHH-YSC or the VA’s West Haven location.
Approximately 80% of inpatient time will be spent at YNHH-YSC, with 10% of time at YNHH-SRC and 10% at the VA Connecticut Healthcare System.
Approximately 4-6 months of time will be spent on inpatient rotations at any of the three sites (YNHH-YSC, YNHH-SRC, or the VA Connecticut Healthcare System).
The remaining 6-8 months of second year will be spent in the outpatient setting. Outpatient learning will include the following:
- Continuity on an outpatient hemodialysis shift
- Weekly exposure to home hemodialysis and peritoneal dialysis at an outpatient home dialysis unit consisting of 75 patients
- Outpatient clinics including kidney stone, onco-nephrology, glomerular disease, hypertension, and transplant
- Opportunity for outpatient native kidney biopsies
- Opportunity for exposure to pediatric nephrology, interventional nephrology, palliative care
- Electives and procedures focused on critical care medicine are possible
In addition, fellows will be responsible for inpatient coverage while co-fellows are on vacation and rotating through the night float schedule.
During the second year, fellows will also have a yearlong general nephrology continuity clinic either at YNHH-YSC or the VA Connecticut Healthcare System.
During the first two years, didactics and conferences will be focused on nephrology. These include fellows nephrology conference, hypertension conference, transplant conference, kidney pathology conference, fellows physiology seminar series, nephrology grand rounds, and nephrology journal club.
The third year will focus on critical care. Fellows will rotate through a broad mix of ICUs in a schedule that it is integrated with the three-year Pulmonary Critical Care fellowship.
Critical Care fellows split their time between YNHH-YSC and YNHH-SRC. They also rotate to Bridgeport Hospital, which has the only specialized burn ICU in the state of Connecticut. In addition, there is elective time that is customized to the fellow’s career goals and prior training.
Yale New Haven Hospital-York Street Campus (YNHH-YSC) YNHH-YSC provides advanced services such as solid organ and bone marrow transplantation, trauma care, and complex cardiovascular surgery. Fellows have the opportunity to work within several distinct ICU services:
- The York Street Campus Medical ICU (MICU) Service: This ICU is regarded as one of the region's elite units. The York Street Campus (-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 15 step-down beds. The MICU team cares for an average daily census of 36 critically ill patients with a wide range of life-threatening disorders, such as septic shock, acute respiratory distress syndrome, and acute liver failure. The MICU at YSC is staffed by in-house intensivists overnight ensuring supervision, quality care and education 24 hours a day. Critical Care fellows will have both daytime (~ 12 weeks) and night rotations (~eight weeks total, in two-week blocks, Mon-Thurs only with Fr-Sun off) in the YSC MICU. On day rotations fellows serve as visible leaders and are responsible for running work rounds, teaching the housestaff and performing procedures under the guidance of the attending. During the overnight rotation they are responsible for supervising the housestaff and reviewing admissions with them and performing procedures under the guidance of the nocturnal intensivist. As the year progresses, there will be increasing responsibilities such as assisting with ICU triage.
- The Saint Raphael’s Campus Medical ICU Service is housed within the 500-bed Saint Raphael’s campus. There are 16-beds in the MICU on this campus. There are two teams, each led by a Pulmonary and Critical Care Attending, alongside fellows and primary care residents. As with the York Street campus, there is an on-site intensivist every night with backup support from our tele-ICU team to ensure supervision, quality care and education 24 hours a day. While there are residents overnight, there are no in-house overnight responsibilities for Critical Care fellows at this campus.
- The Coronary 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, use of mechanical circulatory assist devices, echocardiography and participate in right heart catheterizations.
- The Surgical ICU (SICU) Service is a 21-bed unit. The overall goal of the SICU rotation is for CCM fellows to gain experience and competence in managing critically ill patients in the unique environment of the surgical intensive care unit. While the CCM fellows are rotating on 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 one month typically during their fellowship. There is no overnight call during this rotation.
- The Cardiothoracic ICU (CT ICU) Service 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 practice providers, pharmacists and dieticians), and will help manage patients with complex physiology alongside critical care faculty on this service who are dual-trained in Anesthesiology and Critical Care, or in Cardiothoracic Surgery and Critical Care. There is overnight call one night a week on this service.
- The Neurocritical Care Service (NICU) is a 14-bed unit with overflow into the surgical ICU. CCM fellows rotate through the Neurological Intensive Care Unit (NICU) at Yale New Haven Hospital, typically for four weeks, during their 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.There is no overnight call on this service.
- Interventional Pulmonary Rotation (IP) The Interventional Program (IP) 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. CCM fellows spend one month on the IP service during their fellowship where they develop basic bronchoscopy skills, and learn about chest tube management. They get exposure to advanced bronchscopic procedures, pleural procedures and percutaneous tracheostomies.
- Bridgeport Hospital is a community hospital affiliated with Yale New Haven Health, with the only burn center in the state of CT. The fellows will rotate through in the Burn ICU where they will learn about critical care of patients with severe burns including fluid management, inhalational injuries, and nutrition in these complex patients.
Critical Care Electives (not all inclusive sample list)
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.
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.
Fellows can rotate through the operating room with anesthesiology at Yale New Haven Hospital and learn the technical skills of intubation, vascular access, and difficult airway management.
From 7 p.m. to 7 a.m., experienced intensivists and nurses support ICU patients in area affiliated hospitals from the secure InSight Clinical Center. The tele-ICU team collaborates with the bedside 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, CCM 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.
A number of didactic opportunities are available to fellows. Fellows present cases (in rotation with fellows from Pulmonary Critical Care) to faculty discussants at the weekly State Chest Conference. Weekly core content lectures on a variety of topics relevant to critical care medicine follow. Conference time is protected for fellows, unless extreme clinical circumstances mandate otherwise. Each of the individual ICUs have educational lectures for the fellows.
A variety of other educational opportunities occur at the various teaching sites. These include daily teaching rounds in all ICUs (which are regularly led by either the fellow or attending physician), YNHH-YSC Multidisciplinary monthly journal club, Medical Grand Rounds.