The Adolescent Medicine month is a favorite of many residents. During this month, house officers work with Dr. Oscar Taube, board certified in adolescent medicine, and spend time in a number of different locations. Residents gain experience in diverse settings such as college, high school and middle school based clinics, an eating disorder clinic, and a sports medicine facility. In addition, they participate in the provision of heath care for troubled youth in a group home setting. Dr. Taube's easy and eager teaching style makes this rotation a uniformly positive experience.
Behavior and Development
This month is coordinated through our staff behavioralist, Sharon Richter, D.O. The curriculum includes experiences in numerous different settings, including school and day care observations, office evaluations, clinics with outside developmentalists, and a NICU follow-up clinic. As part of the rotation, residents make school visits to patients who were previously evaluated in clinic and get a real-world sense of that child's problems. Residents find this perspective very useful in their evaluation of children with behavioral problems.
Continuity Clinic is one of the mainstays of any residency program because it provides experience in the work of the general practicing pediatrician. At Sinai, residents receive a panel of patients for which they are responsible. New patients are added to the panel as they come into the practice, both as new referrals and through the newborn nursery. House officers are responsible for examining their newborns in the hospital and providing the families with initial anticipatory guidance prior to discharge.
All residents are assigned one afternoon a week to follow their panel of patients. During this time, they are excused from all other clinical duties. Prior to each session, clinic attendings hold a short lecture on child development and anticipatory guidance, and address any issues regarding the residents' patients. House officers are scheduled for up to seven health maintenance visits, depending on their level of experience. Acute children are also managed by residents during clinic hours as their schedule permits.
For many residents, Continuity Clinic is the highlight of their week. Our patient population includes a wide diversity of patients; house officers quickly become "my doctor" to their patients and families.
Residents are scheduled five elective rotations during their training, in addition to Hematology-Oncology, Gastroenterology and Cardiology, which are already part of the 3-year curriculum. Many residents complete their elective rotations at either Sinai, Johns Hopkins Hospital or the University of Maryland Medical Center, but also have the opportunity to do electives outside of the Baltimore area. The program has recently began scheduling residents for international electives, in Hati and Honduras, and plans to explore additional international experiences to offer as part of the curriculum.
Sinai hospital has a Level II trauma center located in a new, state-of-the-art Emergency Center, with plans under development to expand the pediatric emergency department from the current eight beds to 16. Currently, Sinai has over 18,000 pediatric ER visits per year.
Each house officer spends five months in the pediatric emergency department. As might be expected, a large variety of cases are seen from the common (asthma, bronchiolitis and gastroenteritis) to the uncommon (brain tumors and rheumatic fever). A full-time emergency department staff including board-certified pediatric emergency medicine specialists supervises residents. House officers are an integral part of the ER team and have ample opportunities to master many procedures, including lumbar punctures, IVs, splinting and suturing.
In a typical month, each resident will have between 14 to 18 twelve-hour shifts in the ER.
This one-month rotation early in the first year of residency allows the new resident to have ingrained a strong sense of "normalcy" in the infant exam. Developing this sense is an important foundation for recognizing deviations from the norm, as might be seen in the septic or malformed child.
The house officer is responsible for examining all infants born in the hospital, daily and prior to discharge. In addition, the house officer is the primary physician for any infants on the hospital service. Daily rounds are made with one of three neonatologists who are also readily available throughout the day for consultation. Residents receive a core of lectures and are expected to attend all high-risk deliveries.
During the month's rotation at Greenspring in the first half of their internship, residents gain their initial experience in the daily activity of an outpatient pediatric office. In addition to seeing both acute care and health maintenance visits, the residents work with the front office staff to learn office management skills. Two afternoons are spent with nursing to develop skills in such office procedures as immunizations and vision and hearing screens.
Our NICU is a 22-bed Level III facility with the ability to handle a variety of neonatal problems. Sinai Hospital has more than 2,500 deliveries each year, allowing residents ample opportunity to acquire neonatal resuscitation skills. In addition, admissions are received from many outside institutions.
The residents' learning experience includes attending all high-risk deliveries, daily morning attending rounds with the staff neonatologists, weekly core neonatology conferences and resident presentations germane to the month. Also a weekly perinatal conference is held with the Department of OB/GYN regarding management and follow- up of patients. Residents are expected to take every fourth night call with an on-call neonatologist as backup for any problems.
Outpatient Subspecialties/Outpatient with Call
The outpatient month provides pediatric residents with opportunities to spend time in specialties outside the core curriculum and their chosen electives. There is a wide array of clinics available including pediatric ophthalmology and pediatric surgery. During this month, second- and third-year residents are expected to spend some time in the Greenspring outpatient clinic (on Sinai's campus) where their duties include precepting and teaching junior residents and medical students, including structured student tutorial sessions.
For third-year house officers, the rotation includes taking night phone calls for the clinic approximately every fourth night (and two weekends during the month). After a night on call, residents make phone calls to patients they are concerned about, thus providing valuable feedback and enhancing their phone triage skills. Many residents feel "home call" is one of the most valuable experiences of the residency.
Each month the inpatient team consists of two interns and two senior residents. During the month, residents care for a variety of common diseases in General Pediatrics, Oncology, Gastroenterology, Endocrinology, other subspecialties and many zebras as well. Other subspecialties include our newest addition of the Rubin Institute of Advanced Orthopedics, which provides pediatric housestaff with an opportunity to post-operatively manage children with limb deformities. Residents gain invaluable experience in post-operative management of complex pediatric orthopedic patients, including pain management. In addition, pediatric housestaff follow all surgical admissions to ensure these patients receive appropriate care. Private pediatricians and our inpatient director, Dr. Joanne Lanzo, provide supervision. The management of all patients is discussed daily during Family Centered Rounds, which take place each morning. The interdisciplinary team of caregivers share information, at the patient's bedside, so they can work effectively as a team. Call is taken every fourth night during which a resident from an outpatient rotation will cover along with one member of the team.
Formal teaching sessions include family centered rounds, attending rounds three times a week, and on an individual basis with patients' attending physicians. Residents are also responsible for the instruction of approximately four medical students per month from the University of Maryland and Johns Hopkins medical schools.
Pediatric Intensive Care
The curriculum provides two months of intensive care experience in our state-of-the-art 7-bed Intensive Care Unit. During these months, residents are exposed to a variety of critically ill children, including patients with respiratory failure, metabolic and hematologic derangements, traumatic injuries, and critically ill post-surgical patients. Residents become familiar with ventilator management, conscious sedation and a variety of remote procedures under direct supervision of one of three critical care attendings. Instruction is provided during morning work rounds, didactic teaching sessions and throughout the day. Call occurs every fourth night.
The Advocacy rotation provides residents the opportunity to spend a month at one of the following institutions - Baltimore City Health Department, Advocates for Children and Youth, Howard County Health Department, or the AAP Government Affairs Office, located in Washington DC. The focus of this rotation is on improving child health beyond the boundaries of the private office, pediatric outpatient department, NICU, PICU, ward, ER, subspeciality office, etc.
As part of the PL-1 year, every resident rotates with the Department of Pediatric Hematology/Oncology. The rotation, a mixture of both inpatient and outpatient medicine, includes daily rounding on all hematology/oncology inpatients and new consultations as well as daily outpatient clinic sessions of both complex hematology and oncology patients. Expectations include attending daily interdisciplinary team meetings on all patients, pathology slide review with the faculty, and presentations on a hematology /oncology topic of your choice to the attending physicians each week.
The specific content of the rotation includes daily attendance at the Pediatric Cardiology Clinic at the Johns Hopkins Out-Patient Center. The service experience includes fetal cardiac diagnosis, pediatric echocardiography, clinical history taking and auscultation, and formulating a diagnosis and plan. Patient discussions are held concurrent with the care provided. The resident may choose to attend cardiac catherization procedures, round on the in-patient services with the service team, in addition to the opportunity in the Out-Patient Center. In addition, residents may opt to join the clinical faculty at one of several off-campus offices where a large number of our patients are seen.
As part of the PL-2 year, every resident rotates with the Department of Pediatric Gastroenterology. During the rotation residents will assist in the evaluation and treatment of patients with complaints such as unexplained abdominal pain, persistent vomiting or diarrhea, swallowing or feeding difficulties, difficulties with defecation, failure to thrive, unexplained intestinal bleeding and unexplained jaundice.