Structure of Clinical Training
Overview: The First Year
Clinical training in the first year of the Infectious Diseases Training Program consists of a 2-month rotation on the Infectious Diseases Inpatient Consultation Service within the NIH Clinical Center, a 2-month rotation on the NIAID Inpatient Ward, and 7 months of rotations at four outside affiliated academic medical centers (Johns Hopkins University Hospital [JHH], Washington Hospital Center [WHC], George Washington University Hospital [GWU], and Georgetown University Hospital [GUH]). This blend of general and specialized infectious diseases experiences offers a unique and unmatched array of diverse infectious disease pathologies. These rotations are designed to provide fellows with both a broad case mix and comprehensive and well-rounded training in the pathophysiology of infectious diseases, including microbiology, mechanisms of pathogenesis and antimicrobial resistance, host immune response, and antimicrobial treatment.
Orientation
Prior to beginning the clinical rotations, all fellows attend a comprehensive 3-week introductory course taught by the Infectious Diseases and Microbiology faculty. These lectures cover a variety of disciplines in infectious diseases including common consultation questions and dilemmas that the fellows will encounter throughout the year, a thorough overview of bacterial, viral, fungal and parasitic microbiology, pharmacology of antimicrobial drugs, and key components of the immune response to various infectious agents.
The NIH Infectious Diseases Consultation Service Rotation
The Infectious Diseases Consultation Service oversees the infection management of immunocompromised patients undergoing allogeneic stem cell transplantation, intensive and investigational chemotherapy for solid tumors and hematological malignancies, or immunomodulatory treatment for cancer, autoimmunity, or immunodeficiency at the NIH Clinical Center, a 234-bed clinical research hospital. In addition, the Infectious Disease Service receives consultations from a large surgical service with patients undergoing intensive experimental chemotherapeutic, surgical, and immune therapies.
The consult team consists of the NIH fellow, often a visiting ID fellow from an area hospital, occasional visiting residents and/or students, and the attending physician. During this 2-month rotation, the fellows typically receive 40-60 consults per month on patients with neutropenic fever and a diverse array of opportunistic bacterial, viral and fungal infections. Through the integrated daily rounds with the stem cell transplant service, the fellows acquire superior training in transplant medicine and become familiar with concepts such as conditioning regimens, types of transplantation, graft-versus-host disease, and the mechanism of action and immunomodulatory effects of commonly used immunosuppressive agents.
Daily microbiology rounds in the NIH Clinical Center's outstanding research and diagnostic laboratory with the microbiology faculty enhance patient care and improve the fellows' knowledge of microbiology. On a daily basis, these 30-minute microbiology rounds review all pertinent patient microbiology data and include daily teaching presentations and quizzes prepared by the microbiology faculty that are designed for the fellows’ education. Hence, by the end of the 2-month rotation, fellows are able to recognize and identify common pathogens under the microscope by interpreting various microbiological stains and are familiar in some depth with the range of diagnostic assays and techniques used in the clinical microbiology laboratory. The Microbiology Service has an incredible array of in-house expertise, including extensive molecular diagnostic capabilities, mycology, and mycobacteriology.
A representative list of consults/cases that fellows typically see during this 2-month rotation is attached here for a more detailed description of entities that are encountered during this rotation.
The NIAID Inpatient Ward Rotation
The 2-month NIAID Inpatient Ward rotation at the NIH Clinical Center affords the unique opportunity to evaluate and manage patients with a range of inherited, acquired, and iatrogenic defects in immunity leading to infection susceptibility. The NIAID inpatient ward admits ~40-60 patients/month enrolled in various infectious diseases and allergy/immunology clinical research protocols. Fellows on the ward service supervise and teach 4 internal medicine residents from the George Washington University and Georgetown University Hospital Internal Medicine Residency Programs who have patient care and night call responsibilities.
Some of the entities that fellows typically see during this rotation include (but are by no means limited to): chronic granulomatous disease with a variety of invasive bacterial and fungal opportunistic infections; hyper-IgE (Job) syndrome; HIV/AIDS (with opportunistic infections or manifestations of immune reconstitution syndrome); disorders of the interferon-gamma/interleukin-12 axis that lead to heightened susceptibility to disseminated mycobacterial infections; bronchiectasis disorders that lead to increased susceptibility to pulmonary mycobacterial infections; primary ciliary dyskinesia with recurrent sinopulmonary bacterial infections; chronic active EBV infection; systemic mastocytosis; RAG mutations; monocytopenia disorders that lead to susceptibility to disseminated mycobacterial infections; idiopathic CD4 lymphocytopenia; leukocyte adhesion disorder (LAD); X-linked agammaglobulinemia; parasitic infections, and hyper-IgM syndromes.
Fellows also have the opportunity to evaluate patients admitted with opportunistic infections due to as-yet undefined immunodeficiency syndromes. Through exposure to the unique array of rare disorders and conditions, fellows acquire a comprehensive understanding of basic immunological parameters and are able to associate the susceptibility to specific infectious diseases to dysfunctions of specific arms of the immune system.
Outside Affiliated Hospital Infectious Diseases Rotations
Fellows rotate for 7 months at four affiliated academic hospitals; following is a brief outline of the structure and characteristics of these rotations.
The fellows spend 2 months at Johns Hopkins Hospital (JHH), a 945-bed tertiary care center. The JHH Infectious Diseases service typically receives ~100 consults per month and the consult team consists of 2 fellows (1 JHH and 1 NIH fellow), 1-2 medical residents, 1-3 students, and an attending physician.
The fellows spend 2 months at the Washington Hospital Center (WHC), a 926-bed hospital, the largest private hospital in Washington, D.C., and a major cardiovascular surgery center. The WHC Infectious Diseases service typically receives ~100 consults per month and the consult team consists of 2 fellows (1 WHC and 1 NIH fellow), 1 medical resident, 1 student, and an attending physician who is a full-time faculty member.
The fellows spend 1-2 months at the George Washington University Hospital (GWU), a 315-bed tertiary care center. The GWU Infectious Disease service typically receives 100-120 consults/month and the consult team consists of 2 fellows (1 GWU fellow and 1 NIH fellow), 1-2 medical residents, 1-2 students, and an attending physician.
In addition, the fellows may spend 1 month at Georgetown University Hospital (GUH), a 535-bed tertiary care center. The GUH Infectious Disease service typically receives ~100 consults/month and the consult team consists of 2 fellows (1 GTH fellow and 1 NIH fellow), 1-2 medical residents and 1-2 students.
Finally, there are opportunities for elective months in various inpatient and outpatient settings such as the solid organ and stem cell transplant consultation service at JHH, the Pediatric Infectious Diseases Service at Children’s National Medical Center, an outpatient rotation at a bustling Infectious Diseases private practice, and an inpatient month at Inova Fairfax Hospital, a 833-bed tertiary care hospital and solid organ transplant center in Northern Virginia. Other electives can be arranged on a case-by-case basis.
The rotations at the four outside hospitals provide superb and complementary infectious diseases training experiences that, in aggregate, expose fellows to a broad spectrum of cases spanning most disciplines of Infectious Diseases:
- Solid organ transplantation – renal at WHC, small bowel, liver and kidney at GUH; JHH elective for liver, kidney, heart, pancreas, and lung transplantation
- Advanced HIV/AIDS patients with opportunistic infections and AIDS-associated malignancies/other pathologies at all 4 affiliated hospitals
- Large volume of “bread-and-butter” infectious disease cases such as community acquired pneumonia, bacteremia, endocarditis, acute and chronic osteomyelitis, cellulitis and soft-tissue infections, necrotizing fasciitis, prosthetic joint infections, diabetic foot infections, septic arthritis, meningitis, brain abscess, post-surgical infections, wound infections, urinary tract infections, intraabdominal infections, fungemia, neutropenic fever, at all 4 outside hospitals.
- Tropical infections in the returning traveler at GUH
- Burn-related infections at WHC, whose burn unit cares for all burn patients in the metropolitan Washington DC area.
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