Curriculum

Residents learn to manage common ambulatory problems under the supervision and guidance of faculty preceptors. After residents have matched into the Traditional Medicine Program, they will have the opportunity to rank their preference for a primary continuity clinic at one of the following sites.

1. New Haven Primary Care Consortium at 150 Sargent Drive: The majority of residents will care for patients in the New Haven Primary Care Consortium (NHPCC). The NHPCC is an innovative collaboration between Yale School of Medicine, Yale New Haven Hospital, the Cornell Scott-Hill Health Center, and Fair Haven Community Health Care, andwhere many of the local population of New Haven receive their primary care. Residents assigned to this location will have an equal balance of men and women patients with a variety of medical conditions. Residents here will have exposure to a highly ethnically diverse patient population, including refugees. In addition, residents will witness first-hand the impact of social and economic stressors on medical issues in this predominantly indigent patient population.
   
2. Yale Refugee Clinic: All residents rotate through the Yale Refugee Clinic as part of their ambulatory experience. The Yale Refugee Clinic, located within the PCC, is a resident-run clinic that provides medical care to newly arrived refugees from various countries including Afghanistan, Congo, Cuba, Eritrea, and Iran. We work in collaboration with Integrated Refugee and Immigrant Services (IRIS), a non-profit organization based in New Haven that resettles over 200 refugees every year. The refugee population offers a unique global health experience for residents which focuses on psychological trauma, tropical infectious diseases, and routine preventative care. All Yale internal medicine residents are encouraged to volunteer.
3. The VA Connecticut Healthcare System (VACHS) Primary Care Firm System: A significant number of residents also care for patients in the VA Connecticut Healthcare System’s primary care clinics at the West Haven campus. In addition to the typical medical conditions seen in primary care, the VA clinics provide exposure to a population of patients with unique health issues related to their service in the military. To supplement the primarily male patient panel that residents care for at this site, residents also spend afternoons in the Women’s Clinic at the VA hospital, which cares for women veterans and a select number of male veterans’ spouses.
4. The VA Connecticut Healthcare System (VACHS) Center of Excellence (COE) in Primary Care Education : A handful of residents will participate in this team-based, patient-centered care teaching model. The COE is unique in that it involves dedicated clinical care months (in place of elective time) that include learning, implementing, and practicing inter-professional collaboration, health policy, leadership, and quality improvement, which are necessary skills to function in today’s health care system. The patient population served is identical to that in the VA Primary Care Firm System.
5. Fair Haven Community Health Center : The Fair Haven Community Health Center is a federally qualified health center serving a low-income population of New Haven located a 10-minute drive or bike ride from the main Yale campus. It is a patient-centered medical home with integrated medical, behavioral health, addiction and dental services that delivers team-based care to a predominantly Spanish-speaking, economically disadvantaged population. Our Spanish-speaking residents who want to serve the under-served, are interested in social medicine or healthcare reform, or just want to work with a great group of interdisciplinary colleagues may work at Fair Haven as their primary continuity clinic.

** Please see the Yale Office-Based Medicine Curriculum site for more details about the Ambulatory Resident Education.

The purpose of morning report is to teach residents how to think. This includes an emphasis on clinical reasoning, test characteristics, and cognitive bias. Some reports focus on diagnostic challenges, others focus on management decisions. Morning Report is run by the chief residents and attended by the program director, Mark Siegel, as well as a few core faculty members or invited consultants. Interns and residents volunteer to present a recent or current patient from their service. The presenter is expected to share the history, physical exam, and primary data including labs and imaging for the patient. We emphasize personal review of primary data (including chest X-rays, CT scans, ultrasound, and EKGs) to enhance housestaff interpretive skills. Then, as a group, we focus on summarizing the case into a succinct syndrome around which we build our differential diagnosis. Residents are expected to share their opinion about the "most likely" diagnosis and their estimation of pre-test probability of that diagnosis. The conversation is resident-run, with faculty interjecting only when they feel they have a pearl or tip to add. At the end, the presenter shares the hospital course of the patient and takes an active role in discussion some teaching points related to the case.

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

Noon conferences are lectures from faculty and chief residents on various topics. During the summer, noon conferences focus on high-yield topics in inpatient medicine to help interns triage the most common issues that arise in the hospital. They are open to all housestaff but are specifically focused on the needs of new interns. They are held at Yale and at the VA and posted online for review afterwards.

Outpatient didactics include case discussions from the Yale Office-Based Medicine Curriculum, and educational half-days. Residents get protected time to discuss cases from the Yale Office-Based Medicine Curriculum, which cover all topics in ambulatory medicine over the course of three years. Lastly, every Friday morning during clinic blocks is dedicated to educational half-days, in which focus on building skills and knowledge base. Themes for these half-days change every year and have included: health policy, women's health, musculoskeletal exams, pain management, geriatrics and palliative care in the outpatient setting, and mental health.

• Yale New Haven Hospital’s York Street Campus (YSC) – The Beeson Service
• VA Connecticut Healthcare Center in West Haven (VA) - VA Firm (General Medicine)
• Yale New Haven Hospital‘s Saint Raphael Campus (SRC) - The Cooney Firm (Geriatrics), Verdi-5-North (General Medicine) and MICU-SRC.

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.

The Beeson Service at Yale New Haven Hospital's York Street Campus (YSC) occupies several floors of the East Pavilion, the several floors of the North Pavilion/Smilow (Medical Intensive Care Unit, Medical Step-Down Unit, Medical Oncology and Hematology services), and the 5th floor of the South Pavilion (CCU and Cardiology services). All services are well localized geographically. See Firm Structure in this section for more information.

Yale New Haven Hospital Saint Raphael Campus (SRC)less than two miles from the York Street Campus. Internal Medicine-Traditional Residency Program house staff cover the Cooney Firm (Geriatrics) at SRC and can rotate on Verdi-5-North (General Medicine) and in the MICU-SRC, though the latter two services are primarily staffed by the Primary Care Residency Program and Yale Combined Medicine-Pediatrics house staff.

The VA Connectictut Healthcare System in West Haven, which is approximately five miles from our York Street Campus and accessible via shuttle, provides inpatient rotations for our house staff that are organized to take advantage of the breadth and depth of clinical care provided across these campuses in alignment with the distribution of clinical programs, centers of excellence, and faculty expertise.

Rotations in the CICU provide for the care of acutely ill patients with heart disease under careful supervision of an attending physician. Here, residents care for patients belonging both to the interventional cardiology service and the heart failure service resulting in a very well-rounded experience under close supervision of an attending physician with help from a cardiology fellow.

Firm Chief: Elliott Miller, MD, MHS

The Goodyer Service was named after Dr. Allan Goodyer who was the Chief of Cardiology at Yale School of Medicine in the 1960s. Dr. Goodyer graduated from Yale School of Medicine and was a resident at YNHH. His chief interests were electrocardiography, left ventricular function and congestive heart failure and he was uniformly recognized as an excellent teacher. The Goodyer Team, consisting of second- and third-year residents as well as physician assistants, cares for patients with acute cardiac complaints and diseases under the supervision of a cardiologist and often a cardiology fellow.

Firm Chief: Stephen Possick, MD, FACC

Fitkin is a general internal medicine service staffed by third-year residents and interns and is named after Mr. Abram Fitkin, a major benefactor of the medical school in the 1930's.

The Generalist Service is a very special service designed specially to provide a unique continuity inpatient-outpatient experience to interns and senior residents and admits patients whose primary physicians are the residents who have their Continuity Clinic at Yale and attendings at the New Haven Primary Care Consortium at 150 Sargent Drive or Yale Internal Medicine Associates (YIMA).

Our Geriatrics service is located at Saint Raphael’s campus, and consists of an attending geriatrician and/or general medicine attending, a geriatrics fellow, a senior resident and intern, and students. This Firm is named after Dr. Leo Cooney, a true “master clinician” who has been a leader in geriatric care at Yale-New Haven Hospital for several decades. This Firm provides an opportunity to focus on the unique needs of elderly patients with acute illnesses as well as the importance of multidisciplinary care and how to collaborate and coordinate outpatient services with various resources in our community.

Firm Chief: Jennifer Ouellet, MD

The inpatient hematology service provides in-depth exposure to a variety of patients with liquid tumors as well as other acute hematologic diseases, including those with leukemia, lymphoma, neutropenic fever, graft versus host disease, and bone marrow or stem cell transplant.

Firm Chief: Scott Huntington, MD, MHS, MSc, and Nikolai Podoltsev, MD, PhD

Dr. Gerald Klatskin, after whom the Klatskin Firm is named, was the father of hepatology in America and a world-renowned pioneer of the subspecialty of liver disease. Dr Klatskin was the recipient of the American Gastroenterological Association’s highest award, the Julius Friedenwald Medal. A master clinician, he maintained detailed records on index cards of the thousands of patients that he saw over the years. His collection of many thousand Kodachromes of liver biopsies of every kind of liver disease known at the time, many of which he had made substantial contributions to, is legendary. It is fitting that the team named after Dr. Klatskin will focus on evaluation and treatment of patients with liver disease. The Klatskin team is staffed by senior residents, interns, and students, with supervision by a liver attending and assistance of a gastroenterology fellow. The team preferentially admits patients with liver disease.

Firm Chief: Michael Nathanson, MD, PhD and Simona Jakab, MD

The Donaldson Team, named after Dr. Robert M. Donaldson Jr, admits patients with HIV/AIDS. Interestingly, Dr. Donaldson was not an infectious diseases specialist, but an eminent gastroenterologist, having been an editor of the best known journal on the subject, Gastroenterology, a former President of the American Gastroenterological Association and a recipient of its most prestigious award, the Julius Friedenwald Medal for his seminal research in gut flora and cobalamin absorption. He served the Department of Medicine at Yale in many capacities, as Chief of Medicine at the affiliated Veterans Administration Medical Center, as Vice Chairman and later Acting Chairman of Medicine and then as Acting Dean of the Medical School. Why is it that a team which cares for patients with HIV/AIDS is named after a gastroenterologist? During the latter phase of his professional career, the AIDS epidemic had peaked and resulted in devastation of the lives of those whom it affected and the lives of their loved ones. Dr. Donaldson could not remain on the sidelines and, well into his mid-sixties, he began to attend outpatient clinics that cared for patients with AIDS, learned about the disease from colleagues who were experts on the disease, and became devoted to the cause of patients with AIDS. At any given time, the census of HIV patients on the Donaldson team varies from 40 to 75%. The focus of the learning experience while on this rotation is HIV and AIDS.

Firm Chief: Merceditas Villanueva, MD

The Yale MICU rotation provides for a wide and very well supervised experience with intensive care unit patients in an outstanding learning environment. The MICU admits 3000 patients per year including 350 patients from regional hospitals. The MICU care for critically ill patients with a wide range of life-threatening disorders including septic shock, acute respiratory distress syndrome, and acute hepatic failure. The learning extends to beyond the management of these intensely ill patients to exposure to discussions on end-of-life issues, palliative care, and code status.

Firm Chief, York Street Campus: Shyoko Honiden, MD, MS

Firm Chief, Saint Raphael Campus: Aydin Pinar, MD

The medical Stepdown Unit rotation provides an opportunity for second- and third-year residents to provide care to a diverse array of relatively ill patients in conjunction with physician assistants and two attending physicians.

Firm Chief: Melissa Knauert, MD, PhD, and Sandhya Kanade, MBBS

The Peters Firm is named after a giant in American Medicine, Dr. John Punnett Peters, who joined the Yale faculty in the 1920s. Dr. Peters developed laboratory medicine and contributed greatly to metabolic diseases, from which later emerged the subspecialties of nephrology and endocrinology. He was also a man with a deep sense of social commitment who ruffled many feathers in the political system of his time in the U.S. by being a champion for the poor and complaining bitterly about the quality of health care they received, during the Great Depression and thereafter. His liberal views on this and similar issues landed him in a great deal of trouble in the political climate of the early years of the Cold War. The Peters Team preferentially admits patients with renal disease and is led by outstanding nephrologists.

Firm Chief: Ursula C Brewster, MD

The inpatient oncology service provides exposure to a wide variety of cancer patients, focusing on those with solid tumors, including those with oncological emergencies, neutropenic fever and new diagnoses. Pain management and end of life issues are also a focus on this service.

Firm Chief: Elizabeth Prsic, MD

• General Internal Medicine Teams: Each of the 4 teams consists of 2 residents (PGY-2 or PGY-3) and two interns (or 1 intern and two sub interns). The call schedule on the general internal medicine teams is different from that on medical teams at the York Street Campus at Yale. Resident-intern teams admit every fourth day. Senior residents stay in-house for a 24+4-hour call every fourth day, joined by a nighttime intern.
• Intensive Care Unit Rotation: The ICU rotation provides excellent experience, by the very nature of its structure being one intern, one resident, one fellow and one Attending Physician team and admits both general and cardiac intensive care unit patients.
• Medicine Consultation Service: Third year residents who have outpatient clinic at the VA spend 2-weeks covering the Medicine Consultation Service at the VA. Residents are taught to evaluate a variety of acute medical problems that arise on patients admitted to other services such as surgery, neurology and psychiatry. Resident will also see patients in clinic to perform preoperative evaluation and cardiac risk of stratification. Call residents cover the medicine consultation service overnight and on weekends.

• Teaching on the VA Inpatient Rotation: This is very similar to that described for the Beeson Service a Yale. Attending rounds are held two to three times per week. Resident and Intern Reports are run by the Chief Resident at the VA with core faculty present. In addition to case-based reports, there are also weekly reports that focus on literature review and incorporating evidence-based medicine into every-day practice. Daily noon conferences at the VA are held on a variety of topics led by our VA faculty who are faculty of one of the Yale Department of Internal Medicine Sections (i.e. General Medicine, Infectious Diseases, Nephrology, Pulmonary, etc.) or other Yale Departments (i.e. Neurology, Psychiatry, etc.).

The table shows rotations during the three years of training. Our academic year is divided into four-week blocks, thus there are 13 blocks in each year. A few rotations may be for two weeks and are therefore shown as "0.5" blocks. Please Note: the table below is an approximation for a house officer in a given year. The spectrum for individual house officer's in each year may vary somewhat, though not substantially.

* All PGY1 residents are scheduled for a total of two blocks of ICU time.

** ONLY Neurology preliminary interns rotate through the CCU. All other preliminary interns do not do CCU.

*** PGY-3 will do ED only if they do not rotate through the ED as interns.

^ All house officers receive a total of four weeks (one block) of vacation during each academic year: two weeks (0.5 block) in the first half of the academic year and two weeks (0.5 block) in the second half of the academic year.

• Most teams at Yale, with the exception of our Medical ICU teams, have two residents (two PGY-2 or two PGY-3 residents or one of each) and two interns (or 1 intern and 2 sub interns). These four-person medical teams allow the interns and residents to have one-to-one pairing of intern and resident while on call, and the structure enables both the exchange of ideas among the supervising PGY-2 or PGY-3 residents and sharing of responsibility when an intern or resident is post-call, off, or, rarely, in afternoon clinic. The Medical ICU teams are structured with one senior resident and 2 interns. At the York Street Campus, each resident admits every other day with their intern who can admit 2 holdovers and 4 new patients per day. All team members go home in the evening signing out to a night float or call resident for coverage overnight. At the West Haven VA, resident-intern teams admit every 4 days, and can take holdovers on non-admitting days if required by their sister team.
• Call for interns is limited to the Fitkin service and occurs one to two times per two-week block (no more frequent than every fourth night). For senior residents at the York Street Campus, call occurs one to two times per two-week block (no more frequent than every fourth night) on most services depending on the service.