Residency Training Program in General Pediatrics

In a three-year program, we aim to provide every resident with a broad and deep foundation in and understanding of general pediatrics, thereby preparing the resident for primary care practice or entry into any pediatric subspecialty. The residency training program at the SUNY Downstate is structured so that residents acquire greater degrees of responsibility as their competence, knowledge and ability in pediatrics increases. Our goal is for all residents to become fully competent pediatricians and develop a very solid and broad foundation in pediatrics so that as life long learners they are prepared with the information, understanding, clinical experience and skills for careers in pediatric practice, subspecialties or academics. The basis for the educational experience is the extensive clinical interaction with diverse patient populations, direct patient care and management of many common and not so common disease states encountered at our facilities under the aegis of dedicated faculty. Residents see, diagnose and directly manage a tremendous breadth of pathologic conditions. Clinical learning occurs at the bedside and during rounds with attending faculty, consultants and other care providers. It is supplemented with a structured educational program including a series of didactic conferences as well as both formal and informal consultations with readily available experts in the many areas of pediatric care. Attention is given to the humanistic, social and ethical aspects of pediatric care, as well as to the acquisition of academic knowledge, the intellectual challenges of pediatrics and to an understanding of the medico-legal and practical aspects of medical practice. Residents are given a progressively increasing level of responsibility for managing their patients and supervising more junior staff on the various inpatient, outpatient, newborn and intensive care services. The increase in responsibility is commensurate with their increase in knowledge and demonstrated performance. We strongly encourage intellectual curiosity, inquiry, and research for those interested and motivated. The academic year consists of twelve one month rotations. Elective extramural, research and overseas experiences can be arranged. Residents receive four weeks annual vacation leave.

The PL-1 Year

• 1 month of ambulatory pediatrics - OPD or ER
• 1-2 months of neonatal ICU
• 6 months junior resident - pediatrics inpatient (incl. 1 month night coverage)
• 1 month of behavioral/developmental pediatrics or subspecialty elective
• 1-2 months term baby nursery
• 1 month vacation

During the first year of the residency (PL1), a basic foundation of knowledge in pediatrics is acquired. Under supervision by senior residents, chief residents and faculty, house staff have direct and primary responsibility for the care of patients, including the initial history and physical, progress notes, all procedures, diagnostic information, all orders and communication with parents. Residents learn the characteristics of normal growth, development, nutrition, health maintenance, preventative care, anticipatory guidance as well as variations of normal. With a broad experience in inpatient and outpatient pediatrics and neonatology, house staff learn the characteristics and management of the more common illnesses encountered in neonates, infants, children and adolescents. In addition, first year residents directly supervise third year medical students assigned to them. During this year's experiences residents will realize many of the joys and challenges of contemporary pediatrics.

The PL-2 Year

• 1 month of ambulatory or community pediatrics
• 1-2 months of pediatric emergency care
• 1-2 months junior resident in pediatric ICU
• 1-2 months senior resident in neonatal ICU
• 2-3 months supervising senior resident inpatient units (including up to 1 month as night senior)
• 2-3 months of selective subspecialties or electives
• 1 month at Memorial Sloan-Kettering Cancer Institute
• 1 month vacation

During the second year of training (PL2), residents have greater exposure to pediatric subspecialties. They learn the pathophysiology and management of the more complex conditions encountered in pediatrics. In addition, residents learn to understand and manage multiple system disease and more serious, life-threatening conditions. PL2 residents rotate for one month at Memorial Sloan-Kettering Cancer Center. With this advancement in knowledge and demonstrated clinical competence, residents are given greater supervisory responsibilities as seniors over first year residents, care for the most critically ill patients, and rotate as a supervising night resident.

The PL-3 year

• 1 month of ambulatory or community pediatrics
• 2-3 months supervising senior resident on inpatient units (including 1 as night senior)
• 2-3 months pediatric emergency care
• 1 month of adolescent medicine
• 0-1 month senior resident in pediatric ICU
• 0-1 month of neonatal ICU
• 4-5 months of selective subspecialties or elective (research, extramural, self-defined)
• 1 month vacation

The third year of training (PL3) is one in which the pediatric experience is rounded out. Third year residents rotate with additional subspecialty services and expound on subjects briefly considered before. During this year residents improve and refine their clinical skills and judgment. Third year residents assume a still greater supervisory role. With their greater fund of knowledge they are expected to be educators of other residents, medical students, and ancillary personnel. Having formed a very solid foundation in general pediatrics, residents can now pursue their postgraduate plans with the assistance and advice of the chairman, program director and faculty mentors who help with guidance and postgraduate placement. A small group of the best senior residents are competitively selected and invited to remain with the program for a fourth year as Chief Residents.

The PL-4 Year (Chief Residency)

(4 Chief Residents at the Downstate campus + 1 at Staten Island and 1 at Lenox Hill full time)

• 3 months KCHC Inpatient
• 3 months UHB Inpatient and Outpatient
• 3 months KCHC Critical Care (and ER)
• 3 months Residency Administration
• 1 month vacation

Fourth year positions as chief resident are offered to select members of the senior house staff who have demonstrated the greatest clinical competence, teaching skills, knowledge, and leadership potential. Residents who are offered this opportunity and elect to stay the additional year assume the role of supervisors, liaisons, administrators and especially educators for all the house staff and medical students.

Evaluation of residents is multifaceted. The attending staff and chief residents are expected to give prompt oral formative feedback to the residents. In addition, midway through each rotation, the resident is expected to receive an informal oral appraisal of his/her performance from the supervising attending.

The formal evaluation process consists of a written summative evaluation form completed by the supervising attending at the conclusion of every monthly rotation. These evaluations are discussed with the resident by the attending. The program director reviews the evaluations and discusses them with the residents semiannually. In addition, residents are expected to review all evaluations in their record and acknowledge their review by initialing the evaluations.

Monthly meetings of the House Staff Affairs Committee are used to review resident performance in a forum consisting of attending faculty, chief residents, the program director and/or chairman.

Mandatory monthly web-based examinations are administered to all residents assessing knowledge in core topics in pediatrics presented at conferences and assigned readings during the preceding month. Residents receive immediate feedback with explanations for their responses, but they are expected to maintaining passing grades on these exams. Also, residents are required to take an annual in-training examination in pediatrics. The exam is distributed and administered by the ABP. The in-training exam is a resident self-assessment tool to assess progress over the course of the program.

Supervising physicians perform evaluation of procedural skills. The supervising physician (attending or senior resident of subspecialty fellow who has previously been privileged in the procedure) only complete the privileging form if the procedure is performed successfully and satisfactorily. The assessment includes discussing risks and benefits, record documentation and manual skills.

Informal evaluations occur spontaneously as needed. Formal written evaluations and House Staff Affairs Committee meetings occur monthly. The in-training exam is given annually in early July. Evaluations and in-training exam results are reviewed with residents by the program director, associate program director, or vice-chairman semiannually in the Fall and in the Spring of each year. The Pediatrics Residency program will be transitioning to the New Innovations web-based residency management and evaluation system this fall. The evaluations are competency based and allow the evaluator to identify the methods used for evaluating each of the six core competencies. Automated email reminders will notify faculty of delinquent evaluations. Misdirected evaluations will be easily redirected to appropriate evaluators. Faculty will complete the evaluations and residents will be able to review evaluations on-line via the web. Residents will be asked to anonymously evaluate the faculty, the rotations, the program and their peers using this system as well.

The training program is evaluated at faculty meetings, CEPI meetings, through the CQI process and written evaluation by resident staff. The anonymous written evaluation forms assess the rotation experience, location and supervising attending faculty. There are quarterly meetings held separately for first year residents and for second and third year residents with selected faculty to discuss issues regarding resident's experiences and concerns. A written report of these meetings is distributed to the chairman, program director and directors of service for action. In addition, an Annual Residency Program Review is conducted each Spring to assess performance of the program in satisfying its goals, satisfying the residents and faculty, and effectively training pediatricians. The review is conducted by a committee including program administration, select faculty and peer elected representatives of each resident training year.

Residents are organized with 3-4 representatives from each training year forming a Resident's Action Group. The purpose of this group is to make the program the best for residents that it can be. The Group identifies problems in a timely manner and recommends solutions to the Program Director in order to optimize the educational training environment and enhance resident-faculty-administration communication. Also, during the residents' semiannual evaluation meetings, residents are asked to provide an oral evaluation of the program, its training effectiveness and how well the trainee is meeting his/her personal learning objectives. A resident mentoring program exists. It is expected that residents will feel comfortable with their mentors and give honest feedback to them about the training program and the faculty.

Teaching effectiveness of the staff is evaluated by senior faculty and by residents' anonymous written evaluations. Discussions with chief residents, who act as the liaisons for the resident staff, also provide feedback on faculty performance. The annual in-training examination and board certification examination reports provide a summary of subject areas and resident performance in those disciplines and is used to assess faculty teaching effectiveness.

Finally, departmental faculty retreats are held every few years. These retreats serve to focus attention on the department's role and methods in advancing education, research and clinical practice. Periodically, the department holds pediatric resident's retreat. The purpose of this retreat is for the residents to independently assess the program with regard to education, training, socialization, development, administration, etc.. The residents identify their own issues and recommend necessary solutions.

All residents on all rotations are assigned on-call responsibilities. The on-call schedule for all residents conforms to the New York State Health Code - Section 405 hours limitation regulations. At KCHC and UHB residents on inpatient services have short calls, approximately every 4th day, only until 9:00 p.m. and then sign-out to a night shift resident who covers the unit until the morning. The night shift system functions from Sunday through Thursday night. On Fridays and Saturdays, there is no float coverage and calls are overnight. Each PLI and PLIII resident spends one month each year as a night shift resident, and PLII residents generally serve no more than 2 weeks as night shift. Depending on the NICU assigned to, residents in NICU are assigned either 12 hr day or night shifts (totaling 65 hrs/wk) or 24 hour overnight calls approximately every 3rd to 4th day. The junior resident in PICU has 24 hr calls every third night. The senior resident has night shift coverage as described previously. Residents on pediatric emergency department rotations are generally assigned 15 to17 12 hour shifts per month (occassionally shifts are 10 hours) with a minimum of 12 hours off separating each shift. Approximately 7 to 8 shifts are overnight with the rest being daytime or afternoon to evening. Residents assigned to Urgent Care coverage are on call until only 8 or 10 p.m. On most elective rotations, resident call schedules are often very light with very short calls in Urgent Care or only a few PICU calls or inpatient calls. At Long Island College Hospital, junior residents cover the inpatient unit 24 hrs overnight every 4th while senior residents cross-cover the inpatient unit overnight approximately once a week.

When residents are assigned rotations on night shift they are not a night float. The residents' experiences during night shift are meant to remain identical to those experienced by day time residents. Night shift residents are supervised in the same manner as residents on inpatient units during daytime. Attending faculty provide general supervision - they are immediately available by phone and in person within 20-30 minutes. Pediatricians (in the ER) and neonatologists (in NICU) are available in the hospital as needed 24 hours a day 7 days a week. In addition, a PL4 chief resident is always available either in hospital, immediately by phone or in-person within 15-20 minutes. A PL3 resident is always present as a senior supervising resident in hospital. Residents on night shift rotations participate in daily work rounds, scheduled conferences (Resident Education Conference, Grand Rounds, Patient Management Conference, Radiology Conference, Morbidity and Mortality Conference, Journal Club), daily morning report, and daily attending rounds (for 1 hour). Night shift residents are asked to reschedule their continuity clinic patients.

Residents must be provided with protected time off without clinical responsibilities (minimum 10 hours between shifts and a minimum of one 24 hour block per week). As a result, all residents receive at least one day (24 hours), usually a weekend day, off duty every week. On occasion, usually at the request of the resident or in order to comply with 405 requirements, a weekday may be substituted for a weekend day off if it will not interfere with educational and continuity clinic activities. Most residents have 1 or 2 weekends off per month.

Quarterly departmental surveys of resident's hours serve to monitor compliance with hours limitations, supervision and time off requirements. In addition, New York State conducts legislatively mandated yearly unannounced site visits to assure compliance.