Newton-Wellesley Hospital
Goals and Objectives
The pediatric resident rotation at Newton-Wellesley Hospital consists of two PL2 and one PL1 resident. One of the PL2s has the primary responsibility of covering the inpatient pediatric service. He or she is responsible for working up all new medical and ENT admissions to the pediatric unit, leading work rounds each morning, following pediatric surgical patients up to the age of 21, supervising medical students on the inpatient unit and participating in the evaluation of pediatric patients in the emergency room when requested. The other PL2 functions as the “Teaching Resident” who is responsible for precepting medical students in the Newborn Nursery and preparing a weekly medical student conference. Both the rotating PL2s as well as a third PL2 on elective or ambulatory rotation take night and weekend call at NWH that involves working up all new pediatric medical/ENT admissions and covering the inpatient unit. The PL1 takes call along with the cross covering PL2 so that there is continuity in patient care. The objectives of this rotation are designed to further the residents’ development of competency in the following six areas:
I. Patient Care
II. Medical Knowledge
III. Practice-Based Learning and Improvement
IV. Interpersonal and Communication Skills
V. Professionalism
VI. Systems-Based Practice
I. Patient Care
- The residents are exposed to a wide range of patient presentations in terms of age range, socioeconomic status, and diagnoses. The patients are seen in different hospital settings (the ER, nursery, outpatient subspecialty clinics or the inpatient unit). All components of history taking and physical exam are taught during their rotation.
- The PL1 will learn community pediatrics in the inpatient setting by routinely working up and managing a variety of illnesson the inpatient unit. The PL1 will also have the opportunity to learn about primary versus specialty care in the community hospital setting by attending the primary care clinic or subspecialty clinic as time allows.
- The PL2s will focus on examining a wide range of pediatric patients on the unit and in the ER with an emphasis on learning to distinguish signs of deterioration versus a stable child’s response to therapy. The inpatient teaching attendings round DAILY with the house staff on all the patients on the pediatric unit including medical and surgical. The attendings directly observe the residents conducting a physical examination and point out significant and/or interesting physical findings. If there is an error in the physical examination skill, the attendings educate the house officer.
- Residents order all radiologic diagnostic studies and therefore will learn what studies are needed for specific situations. They will be able to learn from the pediatric radiologists who are available daily in the radiology department and during the pediatric radiology conference.
- Residents prescribe all medication and intravenous fluid orders. Medications include all oral and intravenous meds (i.e. antibiotics), all nebulized medications for respiratory treatment and all medications and treatments in a code situation.
- As medically indicated, residents will perform appropriate diagnostic and therapeutic procedures after obtaining informed consent from the patient and/or family. Residents will document procedures in the chart and in their personal logbooks. On this rotation, these may include:
- arterial puncture
- bladder catheterization / suprapubic aspiration
- delivery of nebulized medications
- intravenous catheter placement
- lumbar puncture
- nasogastric tube placement
- pediatric/neonatal resuscitation
- venipuncture
- x-ray interpretation
II. Medical Knowledge
- Aside from daily rounds with the pediatric inpatient attendings the residents attend weekly pediatric grand rounds, a weekly pediatric radiology conference, routine teaching conferences given by pediatric subspecialists and teaching rounds given by community pediatricians serving as the “visit attending” for the month.
- Televideoconferencing equipment allows them to participate in the weekly didactic sessions at MGH Hospital for Children as well as MGH grand rounds, morning report and Chief of Service conference.
- The residents attend didactic sessions 1 to 2 times per week with the inpatient pediatric attendings and weekly with the neonatology attendings.
- The unique role of the teaching resident affords the PL-2 the opportunity to further substantiate their own knowledge by preparing teaching sessions weekly medical students, and contributing daily to teaching during rounds.
- During this rotation, it is expected that residents will manage patients diagnosed with, but not limited to:
- Asthma
- Acute appendicitis
- Bronchiolitis
- Enteritis
- Fever
- Hyperbilirubinemia
- Hypovolemia
- Pneumonia
- Urinary tract infection/Pyelonephritis
III. Practice-Based Learning and Improvement
- The residents are expected to read about their patients. This is assessed during morning rounds by the rounding inpatient attending.
- The teaching resident will conduct a didactic for the medical students on fluid and electrolyte management as well as other topics that come up in patient care.
- The new PALS algorithms are given to each house officer at the beginning of their rotation and a hospital wide mock pediatric code is usually conducted once during the month in which the ward PL2 is required to be the team leader.
- The Department of Pediatrics conducts a monthly Quality Improvement meeting and a monthly Peer Review meeting. The teaching resident is asked to join in the QI meeting. Rotating residents that were directly involved with issues raised in these meetings regarding patient care or the hospital system are contacted by the Inpatient Director. The director and the resident discuss the case, the committees concerns and the actions taken for improvement.
IV. Interpersonal and Communication Skills
- The residents are observed by an inpatient attending daily on morning rounds during their interaction with families and patients. How best to approach certain difficult interactions is discussed by the team prior to entering the patient’s room. If there is concern or an opportunity to improve a communication skill, the attending discusses it privately with the resident after rounds.
- The teaching resident works on teaching skills during the medical student conferencesand both residents develop teachign skills during daily team rounds and supervision of medical students. Daily noets in the chart clearly documenting patients' progress, diagnostic results and ongoing plan will be completed in order to maintain accurate medical records and share information among team members.
- Informal case discussions with individual pediatric attendings revolving around inpatients afford the resident exposure to different styles of practice and the collective experience of a large community faculty.
- Residents will provide feedback to their co-residents, students and attendings on an ongoing basis throughout the rotation, completing written evaluations at the completion of the rotation. Similarly, they will receive regular verbal feedback and a final written evaluation from the service attending that will be placed in their permanent record. Residents will use constructive feedback to guide their efforts in ongoing learning and self-improvement.
V. Professionalism
- Ethical principles are innate in the discussion of patients. The Pediatric unit often admits patients with chronic issues for whom treatment or withholding treatment are addressed. Residents also learn the role of confidentiality in adolescents with psychiatric diagnoses.
- The patient population ranges from upper middle class residents of Newton and Wellesley to shelter residents from Waltham. House Officers encounter Spanish and Russian speaking patients as well as East Asian and mixed populations.
- Occasionally, patients are on a self selected or family selected diet or taking alternative medications for their health problems. Some families are very demanding in what they feel should or should not be done for their child. The house staff learns how to approach these families and deal with their personal feelings in response to different situations.
- Maintenance of patient confidentiality will be of highest priority.
- Residents will obtain informed consent for procedures or transfer when indicated.
VI. Systems-Based Practice
- The inpatient attendings as well as the primary care pediatricians teach cost-effective care. Residents cannot call consultations without discussing their reasons with the PCPs. What labs to order and why are discussed on morning rounds with the inpatient attendings.
- Residents advocate for their patients by helping to set up outpatient follow-up appointments with their pediatricians and helping to set up outpatient studies or subspecialty appointments. They are required to call and speak to consulting physicians themselves to ensure accurate transmittal of information.
