Clinical Training

Our fellows receive clinical exposure and learn the clinical science of rheumatology at three principal training locations: Yale-New Haven Hospital (YNHH), York Street Campus, the main teaching hospital of Yale University School of Medicine, YNHH - Saint Raphael's Campus (SRC), and the VA Connecticut Healthcare System, West Haven Campus. These venues, which are leading medical centers in southern New England, provide state-of-art clinical care and education. The clinical training spans two years during which fellows participate in the diagnosis and management of patients with a wide variety of rheumatic diseases and other diseases with rheumatologic manifestations. Participation in musculoskeletal ultrasound training and subspeciality clinics bolster the clinical experience. Fellows become part of a team comprised of residents and students headed by faculty who supervise the practical aspects of patient care and provide didactic teaching in the scientific disciplines that underlie the clinical practice of rheumatology.

During the first and second years in the program, fellows are assigned to the inpatient consultation service interspersed with elective months. The fellow on service for each training location responds to calls and consults during weekdays, whereas weekend coverage is divided equally among first and second year fellows. All fellows are provided a cellular phone with Mobile Heartbeat, a smartphone app that enables HIPAA-compliant texting, telephone communications, and patient-specific alerts as well as ease of communication with attending physicians and as-needed consultants.

In additions to inpatient consultations, fellows attend selected outpatient clinics throughout their training. Outpatient clinics are held weekly and include:

• Fellows' General Rheumatology Clinic at YNHH North Haven at the Interventional Immunology Center and YNHH Orchard Street Clinic at SRC where fellows see a diverse range of patients with rheumatic diseases;
• Bone and Joint Clinics at the VA Connecticut Healthcare System in West Haven, with a large number of patients with inflammatory and mechanical arthritis, and training in joint injections, arthrocentesis, and musculoskeletal ultrasound;
• Subspecialty clinics at YNHH Interventional Immunology Center and YNHH Orchard Street YNHH-SRC campus offering specialized care (including specialty clinics) for patients with lupus and related autoimmune diseases, rheumatoid and other inflammatory arthritis, systemic sclerosis, spondyloarthropathies, and osteoporosis.

Subspecialty elective opportunities in the second year will allow fellows to develop skills needed for their individualized career paths including but not limited to rotations in hand surgery, radiology, and pediatric rheumatology. Fellows will also learn bone densitometry from experts in its performance and assessment.

Wellness mentors will be assigned to each fellow. Mentors are selected from faculty that are not directly involved with the fellow supervision. Fellows are expected to meet with their wellness mentors in July, and then quarterly thereafter. Sectional wellness activities will occur throughout the year where fellows and faculty can interact in a social setting.

Educational conferences sponsored by our program include weekly Rheumatology Grand Rounds on Wednesdays and monthly combined conferences with Allergy & Immunology on Fridays, presented by Yale faculty members and/or other nationally or internationally recognized speakers.

Fellows manage the Post Grand Rounds Conference. These are teaching forums usually in the form of a case presentation or relevant Journal Club. This is an opportunity for fellows and faculty to gather and discuss challenging clinical cases in depth. Each fellow is expected to present and participate in a clinical pathology conference as well as a mortality and morbidity (M&M) conference at least once during their 2 years of clinical training. These are mentored activities designed to improve clinical acumen and quality of care. Once a month, the post grand conference is dedicated to a basic immunology review that is relevant to a case presented by the trainee. Select scientific faculty will work with the fellow to build the scientific foundation necessary to develop rheumatology scholars.

The Summer Lecture Series is held weekly and consist of both clinical and basic science lectures, as well as physical exam practicals for all fellows. These lectures are normally held on Wednesdays and Fridays in July and August. The summer lecture series culminates in a rheumatology focused Objective Structured Clinical Examination (OSCE).

All fellows participate in a weekly interdisciplinary lunchtime conference with orthopedics and physiatry at the VA Bone and Joint clinic. The schedule alternates between journal club, case presentations, and musculoskeletal radiology review. During the summer months, the noontime sessions are focused on musculoskeletal exam skills. Each month, the rheumatology fellow will present a rheumatology topic as a 30-minute review to the group. Journal club topics are focused on sports medicine, relevant orthopedics, rehabilitation, and related disciplines.

These conferences are designed to supplement materials and knowledge learned on rounds and in the clinic, following ACGME Review Committee guidelines for training in rheumatology and the ACR core curriculum standard. Medical image mystery, board review questions, and difficult case scenarios are presented and used as teaching tools during the exercise.

Interdisciplinary conferences are held quarterly with Rheumatology and other subspecialties:

• Rheumatology-Dermatology Comprehensive Conference - The rheumatology-dermatology conference brings together faculty members from rheumatology, dermatology, and dermatopathology, along with their trainees, to discuss the diagnosis and management of challenging cases seen in consultation. The conference details cases that have dermatologic and rheumatologic overlap, and covers key clinical and pathologic findings followed by group discussion. The cases are co-presented by the dermatology resident and rheumatology fellow, supervised by Drs. Koumpouras and Ramachandran (dermatology). The conference occurs quarterly.
• Rheumatology-Renal Comprehensive Conference - The rheumatology renal conference is an intra-departmental conference devoted to review cases of patients who have systemic inflammation with renal involvement. Cases range from lupus nephritis to amyloid and from vasculitis to TTP. The conference is attended by nephrology and rheumatology faculty and trainees. The conference is co-presented by the rheumatology and nephrology fellow, supervised by Drs. Dong and Luciano (nephrology).
• Rheumatology-Pulmonary Comprehensive Conference - Conferences are held quarterly and include interstitial lung disease experts, a chest radiologist, and the rheumatologist. A rheumatology fellow presents an interesting case and experts discuss their approach to the patient in terms of diagnosis, treatment, and prognosis. The conference is supervised by Drs. Hinchcliff and Gulati (pulmonary).
• Musculoskeletal Radiology Conference - The MSK radiology conference occurs quarterly, where a dedicated MSK radiologist join the rheumatology faculty and trainees for a themed case-based review of different radiographic changes in rheumatology. These include sessions dedicated to rheumatoid and other inflammatory arthritides, crystalline arthritis, and metabolic bone disease. Drs. Hsiao and Wang (radiology) supervise the conference.

Research in Progress (RIP) seminars are a monthly forum for both faculty and research fellows to present fundamental laboratory studies in the rheumatic diseases. This didactic and interactive seminar series is aimed at defining key questions in the biology of rheumatic diseases, the approaches to studying these questions in the laboratory, and discussing experimental results. The program is designed to provide constructive criticism and research direction to the speaker with an emphasis on establishing research interactions among investigators in rheumatology. The topics presented range from basic research including animal models of disease, molecular and cellular immunology, pathology, and mechanisms of disease, to translational research including studies using human tissue, computer and data science, as well as imaging to better understand rheumatic diseases, and patient-reported outcome instrument studies.

Musculoskeletal Ultrasound (MSUS) is an important diagnostic and therapeutic tool that many rheumatologists use in daily practice. A longitudinal course for the fellows begins in September, and consists of a monthly Wednesday afternoon 4-hour didactic and hands-on scanning session. There are a total of 8 sessions per year. 75 % attendance is required for fellows. Ultrasound directed joint injection clinic at the VA occurs weekly and is managed by the VA attending and the VA fellow on call.

For successful completion of the fellowship, all fellows are required to participate in basic, translational, or clinical scholary activity under the supervision of a faculty member(s). Research within the Section of Rheumatology encompasses basic, translational, and clinical investigation, with provision of training in these. During the first year of training, fellows meet with Dr. Richard Bucala, Director of Research, and Dr. Monique Hinchcliff, Director of Clinical and Translational Research, to discuss their research interests and to develop a plan for research education and project completion suited to the trainees' career goals. Fellows are encouraged to take the initiative and meet with other faculty members to discuss possible research topics, and to take formal courses in clinical and laboratory research, available through the Investigative Medicine Program at Yale.

All academic fellows will be advised to take courses in the summer following their first year/start of second year including Introduction to Biostatistics in Clinical Investigation (IMED 645), Principles of clinical Research (IMED 625) and Ethical Issues in Biomedical Research (IMED 630). These short 2-week courses or weekly seminars are designed to provide trainees with fundamentals of statistical analysis (e.g., analysis of clinical and research studies, and/or performance of same), tools for clinical investigation and robust clinical care, and fundamentals of ethics in clinical care and clinical investigation. Completion of these courses can also be used in part for completion of the M.H.S. degree from the Yale School of Medicine, with the latter also requiring completion of in-depth clinical investigation over 1 year.

Scholars at all levels (e.g., Clinical Fellows, Residents, Post-doctoral Fellows, Students) and faculty who are interested or involved in clinical or translational research are encouraged to participate in Research and Evaluation Support Core Unit (RESCUE) meetings. Each week scholars present their research project (e.g., draft abstract/poster presentation, aims for a research grant, or an idea for developing a new research project), and faculty respond with constructive suggestions in a supportive environment. Sometimes, a topic of general interest (e.g., accessing and analyzing aggregated data from the electronic health record) is discussed. Faculty include experts in epidemiology, biostatistics, and different laboratory, translational and clinical disciplines. The goal is to support and promote the career development of rheumatic disease investigators by providing constructive feedback for projects at all stages of development.

As evidence for a successful scholarship project, submission and/or presentation of an abstract at the annual meeting of the American College of Rheumatology or its equivalent based upon the original research project, is expected before fellowship completion.

Preparation and submission of an original research manuscript will help ensure that fellows emerge from training with the skills necessary to be contributing members to the scientific body of knowledge throughout their careers. While not a requirement, fellows are encouraged to prepare and submit original research for publication during fellowship, with close faculty support and guidance.