MGH Inpatient Wards
Goals and Objectives
The goal of the MGH pediatric inpatient rotation is to develop the ability of residents to evaluate and manage patients with a broad range of medical problems and make decisions about need for hospitalization, changes in status necessitating intensive care, and readiness for discharge. The rotation is based on a general pediatric ward in a tertiary care setting with patients aged birth to 21, and exposes residents to complex, referral-based medical problems. Learning will occur in a multidisciplinary team-based system. First year residents will be the primary caregivers for their patients, under the close supervision of third year residents, who will serve as team leaders. Residents will benefit from guidance by admitting pediatric and subspecialty attendings, as well as the service attending who will round with the team on a regular basis. 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
Residents will have primary responsibility for the management of medical patients from the time of admission until discharge or transfer. Residents are also responsible for consultations as requested by pediatric surgical specialists.
At the time of admission, both first year and third year residents will perform complete histories and physicals appropriate for the patient’s complaint. After evaluating the patient, they will formulate a differential diagnosis and plan appropriate diagnostic and therapeutic interventions, in coordination with the admitting and consult service attendings.
Through thoughtful review of diagnostic results and frequent reassessment of the patient, residents will reconsider the differential on a continuing basis, making changes to management plans as appropriate. Clinical decisions to transfer patients to and from the PICU will be made by the residents.
At all times, it is the residents’ responsibility to educate and work with the patient and family, maintaining a strong therapeutic alliance.
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
- intravenous catheter placement
- lumbar puncture
- nasogastric tube placement
- venipuncture
Residents will focus on anticipatory guidance and counseling when interacting with families. They will order appropriate vaccinations, hearing screenings, car seat tests and state metabolic screening aimed at preventing health problems.
II. Medical Knowledge
Residents will draw from the wide range of patient diagnoses requiring admission to this tertiary care referral hospital, to broaden their exposure to a wide range of complex disease processes. In developing a differential diagnosis, the resident will demonstrate his ability to apply analytical thinking to the clinical situation.
Application of basic and clinical research to patient care will to management plans will be stressed during this rotation. Residents will be exposed to a wide-range of cutting edge research being done at MGH and around the world that is applicable to the care of their patients.
The patient population at this city-based referral center includes patients admitted for general pediatric problems, as well as those admitted for complex, rare, or multi-organ system disease. Residents will care for patients with multiple diagnoses who may present with common pediatric problems in the setting of significant underlying medical complexity. During this rotation, it is expected that residents will manage patients diagnosed with, but not limited to:- cancer (including leukemia, solid tumors, fever and neutropenia)
- congenital heart disease
- cystic fibrosis
- dehydration/electrolyte disturbances
- eating disorders
- epilepsy/seizures
- hyperbilirubinemia
- inflammatory bowel disease
- renal disease (including pyelonephritis, ESRD, HUS, nephrotic syndrome)
- respiratory distress (including bronchiolitis, pneumonia, asthma)
III. Practice-Based Learning and Improvement
In caring for patients, residents will utilize a broad range of published medical information available through web-based resources, as well as print textbooks and the hospital library. It is expected that decisions about patient care will be informed by review, synthesis and application of studies available in the literature. Daily work rounds will include discussion of information gathered from the literature by residents and other team members.
Daily attendance at morning report will serve as another opportunity to discuss evidence-based patient management and current therapies as a team, with the input from senior faculty. The teaching senior resident will facilitate scholarly discussion of the literature as it applies to current patients being cared for on the inpatient service. Residents will use this opportunity to explore the application of basic scientific research to the care of their patients.
Residents will take part regularly in radiology rounds, reviewing radiologic imaging of their patients with pediatric radiology attendings.
Once per week, residents will attend a multidisciplinary teaching conference based on a patient recently admitted to the service. The first year resident involved will present the case.
All third year residents will prepare a case with in-depth discussion that they will present at pediatric grand rounds during their senior year.
All residents will take an active role teaching third and fourth year Harvard and visiting medical students rotating on the pediatric service. This will include guiding students through history taking and physical exams, reviewing written notes and assessments, supervising students’ care for patients, and teaching procedures as is appropriate. Residents will also work with nursing and pharmacy students when they rotate as part of the team, facilitating their learning as well.
IV. Interpersonal and Communication Skills
Residents will take part in daily collaborative interdisciplinary team rounds, led by the senior residents, that will include attendings, medical students, nurses, case managers and pharmacy staff. In addition, all residents will work closely with team members from social work, chaplaincy, child life, nutrition, interpreter services and other support staff.
Residents will regularly meet throughout the day with the patient and family to listen to their concerns and maintain a dialogue about the patient’s care.
Residents will coordinate consult services and facilitate discussion among clinician members of the team and the patient and family. Residents will arrange regular team meetings to discuss the management of complex patients, in which the families will also be involved.
Daily notes in the chart clearly documenting patients’ progress, diagnostic results and ongoing plan will be completed in order to maintain an accurate medical record and share information among team members. Upon discharge or transfer, the resident is responsible for the timely completion of a succinct discharge summary. When leaving the rotation, an off-service summary will be prepared and made part of the medical record.
Regular meetings between nursing and resident staff occur throughout the year, offering the opportunity for discussion aim at quality improvement in areas of communication, team dynamics and logistics of daily care of patients.
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
Residents will interact with an extremely ethnically and socio-economically varied patient population who come to this referral hospital with diverse cultural backgrounds and beliefs. Patients will include those living in local communities, as well as those referred from a distance (including international patients) for highly specialized medical care. Residents will care for patients independent of their ability to pay for services.
Residents will continue to develop compassionate, empathic and culturally sensitive communication with patients and their parents. They will demonstrate sensitivity and responsiveness at all times to patients’ culture, gender, sexual orientation and disabilities. Care will be given in a developmentally and age appropriate manner.
Maintenance of patient confidentiality will be of highest priority.
Residents will at all times demonstrate ethical and professional behavior. During this rotation, in particular, residents will deal with issues of end of life care, long-term disabilities, chronic illness, child protection and family discord. Residents will take part in discussions between attending physicians and patients/families about end of life care decisions.
When appropriate, residents will utilize the MGH Ethics Consultation Service to facilitate team meetings to discuss difficult issues.
Residents will ensure that patients and families give informed consent for all aspects of care.
VI. Systems-Based Practice
Residents are expected to provide high quality, but cost-effective health care. They will collaborate with case managers and other team players to implement timely discharge plans. Home care plans, transfer to rehabilitation facilities and follow-up outpatient care will be facilitated by the residents. Decisions to involve consultation services will be made by the resident in conjunction with the healthcare team.
Residents will communicate regularly with primary care physicians in order to deliver informed, coordinated care for hospitalized patients, and ease transition back to home. This communication will include written and verbal notifications upon admission and discharge, with frequent updates during the hospitalization.
At all times, residents will act in accordance with the legal mandate in the Commonwealth of Massachusetts to report any suspicions of child abuse or neglect, being familiar with the process by which such suspicions are reported. The MGH Child Protection Consultation Team will be a unique resource for residents working in the complex referral atmosphere of this rotation
