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Pediatric Residency Training

 

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"We're it for this side of the earth."

James W. Bass, Col (R)

Pediatric residency training began at Tripler Army Medical Center 40 years ago with COL Ogden Bruton as the program director.  More than 150 pediatricians have been trained and find themselves as leaders in military and civilian pediatrics today.  The opportunity to evaluate and care for children with unusual tropical diseases and a close affiliation with an excellent children's hospital provide for a challenging, comprehensive pediatric training program.

Program Philosophy
The philosophy of the pediatric training program can be summarized simply:

"Person first, peers daily, patient always."

The resident in pediatrics must first attend to him or herself before he can be an effective pediatrician.  This includes a continuation of the adult process of development during which time it is essential that successful, maturing adults know that they believe, live like they believe it, match their priorities with their principles and address their own physical, emotional, intellectual and spiritual needs.  This involves careful attention to marriage and family commitments and responsibilities.  While residency is the time for developing progressively greater professional competence in the knowledge and practice of pediatrics, it is also essential to hone more basic areas such as reading in other disciplines, critical thinking, knowledge synthesis and communication skills.

The residents must see themselves as part of the Tripler Pediatric Team and as such they owe a measure of loyalty and commitment to their colleagues and to the successful functioning of that team.  This involves consideration for the concerns and needs of peers, participation in the program's educational process and regular critical evaluation of the team's function and educational activities.  

Finally, the measure of all of our efforts is to train pediatricians  who have the ability to deliver excellent, efficient, cost-effective care to children.  The care of our patients is the ultimate goal of all of our efforts.  In the past, simply "producing" excellent pediatricians was enough.  In recent years, it has become clear that we must also produce clinicians who are excellent "care managers."  Instead of merely recognizing and treating disease, the pediatrician must be the champion of the health of children individually and as a group.  Therefore, the training must include expertise in quality improvement, population medicine, utilization analysis and outcome measurement.  Thus, clinical excellence includes not only the ability to care for individual patients but the ability to provide anticipatory guidance and promote health to prevent injury and illness on an individual and population basis.

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Program Goals and Objectives

  1. To meet and exceed the requirements of the ACGME and the RRC for accredited pediatric training programs.
  2. To enable the trainee to become an expert pediatrician and primary care manager for pediatric patients.
  3. To have all residency trainees meet the general requirements for certification by the American Board of Pediatrics and to become board certified.
  4. To enable the trainee to practice pediatrics and military medicine in the unique environment of the United States Military.

Residents Responsibilities

  1. Develop a personal program of self study and professional growth with guidance from the teaching staff
  2. Participate in safe, effective, and compassionate patient care under supervision, commensurate with their level of advancement and responsibility.
  3. Participate fully in the educational activities of their program and, as required, assume responsibility for teaching and supervising other residents of the institution
  4. Participate in institutional programs and activities involving the medical staff and adhere to established practices, procedures and policies of the institution
  5. Participate in institutional committees and councils, especially those that relate to patient care review activities
  6. Apply cost containment measures in the provision of patient care

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Supervision
All trainees will have staff supervision of their professional activities and performance at all times.

Pediatric Workload and Staffing

  • 1,037 Pediatric Ward Admissions (2001)
  • 263 PICU Admissions (2001)
  • 276 NICU Admissions (2001)
  • 2627 Live Births (2001)
  • >1,000 Pediatric Surgical Admission per year
  • 56,844 Outpatient Visits (Pediatrics, Subspecialties, Adolescent) (2001)
  • 20 Pediatric Housestaff
  • 25 Staff Pediatricians Representing Expertise in all Pediatric Subspecialties
  • >100 Nursing and Support Personnel
    • Occupational Therapy
    • Physical Therapy
    • Speech and Language Therapy
    • Medical-Social Work
    • Pediatric Clinical Pharmacist
    • Child Psychologist
  • Tripler also has:
    • Pediatric General Surgery
    • Pediatric Urology
    • Pediatric Otolaryngology
    • Pediatric Orthopedics
    • Pediatric Radiology
    • Pediatric Ophthamology
    • Pediatric Dentistry
    • Child Psychiatry

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Specific Strengths of the Department

  • Close working relationship between staff and housestaff
  • High degree of housestaff responsibility
  • High quality housestaff and teaching staff
  • Diverse medical problems
    • Tropical Medicine patients from Samoa and Micronesia
  • Opportunity for contact with medical students throughout the academic year
    • Uniformed Services University of the Health Sciences
    • University of Hawaii
    • Health Professions Scholarship Program Participants
  • Diverse Patient Population
    • Dependants of all military services in Hawaii
    • Referrals from throughout the Pacific Basin (50% of the Earth's Surface)

Educational Plan

  • Daily Morning Report for all housestaff and teaching staff (0730-0800)
  • Daily teaching conference (0800-0900)
    • Visiting professors from around the globe
  • Daily staff attending teaching rounds: Ward, NICU, PICU
  • Weekly Chief's Rounds run by Teaching Chief Resident
  • Subspecialty elective rotations each year of training
  • Opportunities for study outside of Tripler (civilian and military)
  • Opportunities to participate in Humanitarian Missions

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Internship

  • Program Accepts 6 New Interns Annually
  • Academic endeavors to include: publications, research, departmental presentations are encouraged
    • Interns are required to give a one hour presentation to the entire department
  • Interns Average Call Every 4th Night
  • Interns Are Expected To Attend Morning Report and Morning Lecture
  • Interns Are Expected To Attend Weekly Chief's Rounds
  • Interns do 13 rotations during the PGY-1 Year
    • 3 Months of General Pediatric Clinic
    • 3 Months of General Pediatric Ward
    • 2 Months of Neonatal Intensive Care Unit
    • 2 Months of Newborn Medicine Service
    • 1 Month of Developmental Pediatrics
    • 1 Month of Tripler Emergency Department
    • 1 Month of Sub-specialty elective

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Resident PGY-2

  • There Are Generally 6 Second Year Residents
  • Residents Average Call Every 5th Night
  • Residents Are Expected To Pick-Up and Follow 100 Continuity Patients
  • Residents Are Expected To continue with academic pursuits
    • PGY-2 residents give 2 one hour presentations to the department
  • Second Year Residents Have 12 Rotations
    • 2 Months of Electives
    • 1 Month of Surgery Clinic
    • 2 Months of General Pediatrics Clinic
    • 1 Month of General Adolescent Clinic
    • 2 Months of WARD RESIDENT
    • 1 Month of PICU RESIDENT
    • 1 Month of NICU RESIDENT
    • 1 Month of Developmental Pediatrics Clinic
    • 1 Month of NIGHT FLOAT

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Resident PGY-3

  • There Are Generally 6 Third Year Residents
  • Residents Average Call Every 5th Night
  • Residents Are Expected To Pick-Up and Follow 100 Continuity Patients
  • Residents Are Expected to continue with academic pursuits
    • PGY-3 residents give 3 one hour presentations to the department
  • Third Year Residents Have 12 Rotations
    • 2 Months of Electives
    • 2 Months of General Pediatrics Clinic
    • 2 Months of CHIEF RESIDENT
    • 1 Month of Developmental Pediatrics Clinic
    • 1 Month of PICU RESIDENT
    • 1 Month of Community Nursery
    • 1 Month of Pediatric Emergency Department
    • 1 Month of NIGHT FLOAT
    • 1 Month of Community Pediatrics

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Curriculum Information

Intern

1.      Pediatric Ward: Intern is assigned his/her own patients.  He/she performs histories, physical examination, diagnostic and therapeutic procedures, keeps medical records and writes orders on those patients for whom he/she is given responsibility.  Interns make daily rounds with staff and supervising residents.  One inpatient month is at Kapiolani Medical Center for Women and Children where Interns are supervised by civilian Board-Certified Pediatricians.

2.      Newborn Medicine Service:  Intern is responsible for the admission and disposition of newborn infants.  He/she writes histories, performs physical examinations, does procedures, and responds to requests for assistance from the obstetrical staff in the delivery room or the operating room.  He/she participates in resuscitation of the newborn, the care of premature infants, and in the management of other problems of the neonates, and is supervised by senior residents, neonatal fellows, and staff neonatologists.

3.      General Pediatric Outpatient Clinic:  Interns evaluate and manage children with routine and acute appointments as well as continuity patients.  He/she is under direct supervision of a Staff Pediatrician who countersigns all charts.

4.      Emergency Medicine: Under the supervision of board-certified emergency medicine physicians, the intern spends four weeks (twenty 12- hour shifts) in the Emergency Room. During this time, the intern learns about triage and the care of the patient presenting with an emergent problem. The emphasis during this time is on caring for those emergent problems, and determining which patients can be treated on an outpatient basis and which patients require admission. The intern is responsible for providing emergency medicine care to those patients assigned to him/her. He/She receives bedside teaching by the emergency medicine staff.

5.      Combat Casualty Care Course:  Early in the year, the intern will spend ten days in San Antonio, Texas in the Combat Casualty Care Course (C4), which consist of training in Advanced Trauma Life Support (ATLS) and training in triage and care of the soldier on the modern day battlefield.

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Resident (PGY-2)

1.      Ward Resident:  Responsible for the diagnosis and treatment of infants and children hospitalized with acute and chronic medical diseases.  Participates in the management of pediatric surgical patients.  He/she supervises PL-1 and FP-1 interns working as part of the ward team.

2.      NICU Resident:  Responsible for admitting, managing, and discharging sick term and premature newborn infants.  He/she is responsible for all procedures and answers calls for a pediatrician in the delivery room or operating room.  He/she instructs and counsels new mothers.  Has supervisory role of PL-1, FP-1, and OB interns.  Is supervised directly by neonatal fellows and staff neonatologists.

3.      General Pediatric Outpatient Clinic: He/she sees patients with appointments, performs routine physical examinations, and manages pediatric emergencies.  He/she assists with precepting 3rd and 4th year medical students, supervision of interns, and is supervised by staff pediatricians.

4.      General Adolescent Outpatient Clinic:  The resident is assigned clinic appointments as well as ambulatory emergencies.  Primary care responsibilities will include consults, inpatient or outpatient, as assigned by the supervisory staff.  Supervision is provided by a staff Adolescent Medicine Specialist.

5.      Developmental Pediatric Clinic:  The resident actively participates in all developmental clinics where he/she will learn to assess developmental and learning problems.  He/she is directly supervised by the staff developmental pediatrician.

6.      PICU Resident:  He/she is responsible for the diagnosis and treatment of infants and children with acute medical diseases requiring intensive care, including post-operative surgical patients.  He/she is supervised by staff PICU physician

7.      Subspecialty Rotations:  During elective rotations through subspecialty clinics, he/she will provide care under the supervision of staff subspecialists

1.                              Endocrinology

2.                              Allergy and Immunology

3.                              Rheumatology

4.                              Gastroenterology

5.                              Nephrology

6.                              Child Psychology

7.                              Pediatric Radiology

8.                              Pediatric Orthopedics

 

 

9.                              Neurology

10.                          Pulmonology

11.                          Cardiology

12.                          Hematology/Oncology

13.                          Dermatology

14.                          Child Psychiatry

15.                          Pediatric Surgery

16.                          Pediatric Urology

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Resident (PGY-3)

1.      Chief Resident:  As chief resident, Department of Pediatrics, he/she attends staff meetings and participates in planning and administration.  He/she is required to keep in touch with all operations of the Department of Pediatrics at all times.  He/she serves as consultant for the Department of Pediatrics on patients not located on pediatric wards or in the Pediatric Outpatient Clinic.  He/she conducts conferences and rounds and generally supervises in the absence of a staff physician.  He/she prepares all of the duty rosters for the pediatric house staff, and manages special medical/administrative problems assigned to him/her by the Chief, Pediatric Clinic.  

2.      General Pediatric Outpatient Clinic Senior Resident:  He/she sees outpatient consultation  cases as well as the more routine pediatric problems.  He/she supervises other housestaff and medical students assigned to the clinics and is responsible to the Chief, Pediatric Clinic.

3.      PICU Resident:  He/she is responsible for the diagnosis and treatment of infants and children with acute medical diseases requiring intensive care, including post-operative surgical patients.  He/she is supervised by staff PICU physician. (In the future, this rotation may be accompolished in the 14 bed PICU at Kapiolani Medical Center for Women and Children).

4.      Subspecialty Rotations:  During elective rotations through subspecialty clinics, he/she will provide care under the supervision of staff subspecialists (see list above).

5.      Developmental Pediatric Clinic:  The resident actively participates in all developmental clinics where he/she will learn to assess developmental and learning problems.  He/she is directly supervised by the staff developmental pediatrician.

6.      Emergency Room Pediatric Resident:  He/she assesses, manages, and treats  all pediatric cases coming through the emergency department.  He/she helps supervise interns and medical students rotating through the emergency department.  He/she is directly supervised by a staff emergency medicine physician.

7.      Community Medicine Rotation: He/she will spend 4 weeks at a civilian or military, non-hospital-based Pediatric Outpatient Clinic where he/she will be responsible for the care of pediatric patients, and will be introduced into the aspects of the pediatrician's role in the military community.  Direct supervision provided by staff pediatricians.  

Night Float Resident (PGY-2 and PGY-3)

  • Each PGY-2 and PGY-3 will have a one month rotation per year serving as night float resident, covering the ward, NICU and PICU patients, and answering ER consults.  The night float will provide NICU coverage Monday, Tuesday, and Friday nights.  The night float will cover the ward and PICU on Saturday nights.  He/she is expected to be present at for morning report and morning teaching conferences.  

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Student Rotations
Students are invited at all times of the year to rotate on any one of the varying clinical services.  A description of these services follows as does contact information to set up future rotations.

Pediatric Ward

·         4th year students assist in the direct management of their own patients along with the ward team

·         Students are given the opportunity and resources to learn about their patients' disease processes

·         Students have significant input in developing and implementing patient care plans

·         Easy accessibility to all staff members allows students to appreciate the insights of different subspecialties

·         Students are encouraged to present their patients at departmental conferences

·         4th year students are included in departmental education by lecturing on a chosen topic

·         Internet medline searches available immediately on the ward

·         Access to fully automated digital radiology system and computerized patient database

·         Frequent didactic and interactive sessions with staff and housestaff provide a well-rounded pediatric experience

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Pediatric Clinic

·         3rd and 4th year students enjoy the opportunity to be the first line caregiver to clinic patients

·         Each patient is individually presented to a staff member to enhance the learning experience

·         A large and diverse group of patients help provide a well rounded general pediatric experience

·         Accessibility to staff allows for in depth discussion of patient problems at a subspecialist level

·         Daily noon lectures help build a general pediatric knowledge base immediately applied in the clinic setting

·         Separate well baby, general, and adolescent clinics allow for focused studies of different patient populations

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NICU and Newborn Nursery

·         Students will become familiar with healthy newborn exams and commonly seen problems

·         16 bed NICU and large nursery allow for management of multiple patients with various disease processes

·         Students learn the basics of newborn care, including the management of frequently seen disease processes

·         Staff neonatologists and housestaff readily available for teaching and discussion of patient problems

·         4th year students are assigned their own caseload of interesting patients under supervision of the housestaff and staff physicians

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Subspecialty Rotations

  • Students are invited to rotate with the various subspecialists. (see list above)

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Medical Student Rotations

  • Rotations range from four to six weeks.
    • Time can be spent on anyone of the subspecialties, the Ward, NICU, or General Clinic.
  • Call averages one per week with no weekend call.
  • Sponsor is provided to assist with transportation and lodging arrangements.
  • Contact the Pediatric Medical Student Coordinator at one of the following.
    • Phone: 1-808-433-6407.
    • Fax: 1-808-433-4837.
    • Address: MAJ Sean T. Carroll, MD (Student Coordinator) ATTN: MCHK-PE, Tripler Army Medical Center, 1 Jarrett White Road, Tripler AMC, HI 96859-5000.
  • Students are encouraged to contact Dr Carroll at:
  • Contact Mrs. Gladys Nakamura, Medical Student Coordinator, Tripler Medical Education Office for administrative assistance. She can be reached at one of the following.
    • Phone: 1-808-433-6992.
    • Fax: 1-808-433-1559.
    • Address: Department of the Army, ATTN: MCHK-ME (Medical Student Coordinator), Tripler Army Medical Center, 1 Jarrett White Road, Tripler AMC, HI 96859-5000.


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R.Ridout,MD 7/99