Infectious Diseases Clinical Training
Overview: The First Year
Clinical training in the first year consists of rotations at the NIH Clinical Center and four outside affiliated academic medical centers (Johns Hopkins University Hospital, Washington Hospital Center, George Washington University Hospital, and Georgetown University Hospital), as well as at private practice and hepatitis C clinics. This blend of general and specialized infectious diseases experiences offers a unique and unmatched array of diverse infectious disease pathologies, allowing fellows to gain comprehensive training in the pathophysiology of infectious diseases, including microbiology, mechanisms of pathogenesis and antimicrobial resistance, host immune response, and antimicrobial treatment.
Orientation Month
First-year fellows spend the month of July building their knowledge base in preparation for their clinical rotations. Following an orientation to NIH, fellows attend the Johns Hopkins infection control and hospital epidemiology course. The remaining three weeks of July are spent in a comprehensive course taught by NIH infectious diseases and microbiology faculty. Interactive and hands-on sessions cover a thorough overview of bacterial, viral, fungal, and parasitic microbiology. Faculty give didactic presentations and case-based discussions on topics such as common consult questions and dilemmas, pharmacology of antimicrobial drugs, transplant infectious diseases, and host immune response to infection.
NIH Infectious Diseases Consultation Service Rotation
Fellows rotate for two to three months on the NIH Infectious Diseases Consultation Service, which serves adult and pediatric patients undergoing stem cell transplantation, intensive and investigational chemotherapy, surgery, or immunomodulatory treatment for cancer, autoimmunity, or immunodeficiency at the NIH Clinical Center. The service is also consulted for patients with ophthalmic, neurologic, endocrine, pulmonary, cardiac, and genetic disorders.
The consult team consists of an ID fellow, visiting residents and/or students, and an attending physician and typically receive 40 to 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. By the end of the rotation, fellows feel confident in their ability to manage infectious diseases in the setting of stem cell transplantation, malignancy, and other immunocompromised states.
Daily microbiology rounds in the Clinical Center's outstanding Microbiology Service are the highlight of this rotation. The rounds enhance patient care and bolster the fellows' knowledge of medical microbiology. On a daily basis, these 30-minute microbiology rounds review all pertinent patient microbiology data and include daily teaching presentations and demos prepared for the consult team. These clinically relevant and hands-on presentations teach fellows to recognize and identify common pathogens under the microscope by interpreting various microbiological stains and provide meaningful training in 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.
NIAID Inpatient Ward Rotation
The two-month NIAID Inpatient Ward rotation at the Clinical Center affords the unique opportunity to evaluate and manage opportunistic infections in adult and pediatric patients with a range of inherited and acquired immune defects. The NIAID inpatient ward admits 40 to 60 patients per month who are enrolled in various infectious diseases and immunology clinical research protocols. Fellows on the ward service supervise and teach four internal medicine residents from the George Washington University and Georgetown University Hospital who have patient care and night call responsibilities.
Some of the conditions that fellows see during this rotation include but are not limited to HIV/AIDS and immune reconstitution syndrome; parasitic infections; chronic granulomatous disease and hyper-IgE (Job) syndrome with invasive bacterial and fungal opportunistic infections; immune disorders that cause susceptibility to disseminated mycobacterial infections; bronchiectasis disorders that lead to increased susceptibility to pulmonary mycobacterial infections; chronic active Epstein-Barr virus infection; X-linked agammaglobulinemia; X-linked severe combined immunodeficiency, Leukocyte Adhesion Deficiencies; hyper-immunoglobulin (Ig)M syndromes; and GATA-2 mutations resulting in increased susceptibility to both infectious disease and hematopoietic complications.
The inpatient ward team also manages patients who have undergone stem cell transplantation for these immunodeficiencies and evaluates patients admitted with opportunistic infections due to as-yet-undefined immune defects. Through exposure to this unique array of conditions, fellows acquire an in-depth understanding of immunology and how dysregulation of specific arms of the immune system confer particular infection susceptibilities.
Outside Hospital Rotations
Fellows rotate for about seven months at four affiliated academic hospitals. The outside hospital rotations provide superb and complementary infectious diseases training experiences that expose fellows to a broad spectrum of cases spanning most disciplines of infectious diseases—from “bread and butter” to rare or specialized diseases, including transplant infectious diseases. The following is a brief description of the structure and characteristics of these rotations:
Johns Hopkins Hospital
Fellows typically spend two months at this 945-bed tertiary care center, which provides an excellent case mix and outstanding teaching conferences. Fellows gain experience managing complex infectious diseases in neurosurgical, cardiovascular, intensive care, and orthopedic patients, as well as challenging consults from the medical subspecialties. The ID consultation service receives approximately 120 consults per month, and the consult team consists of two fellows, residents, students, and an attending physician who is a full-time faculty member. There is also an optional Transplant Infectious Diseases rotation available at this institution, which provides additional training in infectious diseases in the immunocompromised host.
Washington Hospital Center
Fellows spend up to two months at this 926-bed hospital, the largest private hospital in Washington, DC, and a major cardiovascular surgery center. Fellows see a broad case mix, including infections related to cardiovascular procedures (including LVADs), heart and kidney transplants, orthopedic surgeries, trauma, and burns. The ID consultation service receives approximately 100 consults per month, and the consult team consists of two fellows, residents, students, and an attending physician who is a full-time faculty member.
George Washington University Hospital
Fellows spend up to two months at this 315-bed tertiary care center. Fellows see an excellent case mix, including tropical infections and complications of HIV. Interactive teaching rounds in the microbiology laboratory provide additional training in clinical microbiology. The ID consultation service receives 100 to 120 consults per month, and the consult team consists of two fellows, residents, and an attending physician who is a full-time faculty member.
Georgetown University Hospital
Fellows spend up to two months at this 535-bed tertiary care center. Fellows gain experience managing infections in solid organ transplant recipients (liver, kidney, small bowel) as well as infectious diseases in the returning traveler or patients with advanced HIV. The ID consultation service receives approximately 100 consults per month, and the consult team consists of two fellows, residents, and students.
Outpatient Rotations
Fellows may spend two weeks in a private ambulatory practice in order to gain exposure to the experience and challenges of managing infections in that setting. A hepatitis C clinic is also available to provide fellows with training in this rapidly changing field.
Electives
Finally, there are opportunities for elective rotations in various inpatient and outpatient settings, such as the sexually transmitted diseases clinic, tuberculosis clinic, solid organ and stem cell transplant consultation service at the pediatric ID service at Children’s National Medical Center, and the transplant service at Johns Hopkins. Other electives can be arranged on a case-by-case basis.
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