Gain a unique perspective during your pediatric residency rotational experiences

Children’s Hospital of Richmond’s downtown campus has a total of 41 pediatric beds plus seven step-down beds in the Acute Care Pediatrics unit. The step-down beds are for patients with medical and surgical problems that require close monitoring above the level of care provided on the wards, but that do not require PICU admission. Continuous telemetry monitoring is available for these patients. All patients with primarily non-surgical problems are covered by house staff teams under the supervision of the attending for either general pediatrics or the appropriate subspecialty.

Two house staff teams provide coverage for pediatric inpatients of all ages on the wards and in the step-down beds. These teams care for general patients as well as subspecialty patients. Subspecialties include: neurology, cardiology, infectious diseases, pulmonology, gastroenterology, allergy-immunology, rheumatology, nephrology, and endocrinology. Hematology-oncology patients are admitted to their own team. Residents are supervised by academic faculty members and fellows who are dedicated to educating residents and students in evidence-based patient care.

Each team consists of one PGY-3 or Med-Peds PGY-4, one PGY-2 or Med-Peds PGY-3, two to four PGY-1 residents, and 0-5 medical students. The PGY-3 serves as the senior house officer and provides direct oversight and education for interns. The PGY-3 conducts daily work rounds, facilitates attending rounds, coordinates all non-ICU inpatient admissions, responds to rapid response calls and code blues, and performs general pediatrics consults. The PGY-2 serves as the junior house officer and shares duties with the PGY-3. He/she also is the designated teaching resident, with responsibility for leading teaching sessions for medical students and performing literature searches on clinical questions that arise during rounds. Each PGY-1 acts as the primary physician for a subset of patients on the team from admission to discharge. Housestaff are primary caregivers for patients regardless of their designation as general or subspecialty admissions. At all levels, they provide education and mentorship to M-3 and M-4 students.

All inpatient hematology-oncology patients are cared for by the inpatient heme-onc team. The team consists of a pediatric heme-onc nurse practitioner, PGY-2s, and occasionally an intern or fellow. The team works closely with the attendings. There is no overnight call on this service and the average census ranges from eight to 20 patients.

Our 21-bed PICU includes state-of-the-art equipment and large private rooms for the families providing intensive care to critically ill patients. Children’s Hospital of Richmond’s PICU is the only Level 1 PICU in Central Virginia.

The PICU provides care for children with conditions such as acute respiratory failure, status asthmaticus, circulatory shock, major trauma, head injury, intracranial hypertension, status epilepticus, diabetic ketoacidosis, renal failure, and chemical intoxication.

The PICU also provides postoperative care for a broad range of surgical subspecialties such as neurosurgery, cardiac surgery, general surgery, transplant surgery, orthopedics, plastics, and ear-nose-and-throat surgery. The PICU not only receives admissions from the emergency room, pediatric floors, and operating rooms, but is a referral site for hospitals in the Richmond area and regions beyond.

The three or four senior residents and nurse practitioners who staff the PICU are the primary caregivers to all patients admitted. Supervision is by a PICU attending and often a fellow as well. PGY-3s cover the PICU night shift for a two-week block. Residents have direct hands-on experience with issues such as ventilator management, sepsis, respiratory failure, trauma and multisystem dysfunction. Interdisciplinary rounds include nurses, dieticians, social workers, child-life specialists and pharmacists.

The NICU is a 40-bed capacity unit with ECMO capabilities and an operating room in the unit. PGY-1 residents are responsible for both intermediate and intensive patients. PGY-2 residents are also responsible for coverage of the unit during night shifts alongside a neonatal nurse practitioner, fellow, or attending. The residents are responsible for calls to the delivery room throughout the day, as well as supervisions and teaching of the PGY-1 residents.

The newborn nursery is staffed by one to two PGY-1s, who work alongside pediatric nurse practitioners. All residents provide primary and direct care to term infants born at VCU Medical Center under the direction of general pediatrics faculty. The average daily census is 15 to 30 infants. There is no overnight call as the PGY-2 resident on night shift provides nursery coverage for acute issues.

The pediatric ED is the only Level 1 emergency department in Central Virginia. Residents from the departments of Pediatrics (including medicine-pediatrics), Family Medicine, and Emergency Medicine provide direct patient care in 10-hour shifts. There is 24-hour coverage of the pediatric ED. An active transport unit, including MedFlight helicopter, is maintained by the ED attendings. In addition, the ED houses an active child protection program staffed by attendings and nurse practitioners who are experts in child protection and who serve as teachers for pediatric residents. All interns rotate through the Child Protection Team.

The pediatric group practice (PGP), located in the Children’s Pavilion, serves as the resident continuity clinic. Residents have continuity clinic only during non-inpatient blocks and provide preventive and urgent care. Residents are assigned to one of 7 continuity care teams in their intern year and will stay on the same team throughout residency. Each team has a designated animal name, and patients are assigned to an animal team to provide better continuity of care in PGP. Each animal team consists of 8-10 residents of all years. Residents are often able to maintain individual continuity at most visits. However, when the individual resident is not scheduled to be in clinic at the time of a patient's needed follow-up visit, another member of their animal team will be available to see the patient.

Each continuity care team also has a resident leader who communicates resident feedback to clinic administrators and who directs the team's performance-based improvement project. Each team has its own message pool in the electronic medical record so that patient questions, requests for medication refills, information exchange between providers, and referral information can be followed by the appropriate residents. The clinic schedule with team templates is published several months in advance to ensure scheduling continuity at each visit. This system not only assists with continuity, but also distributes clinical responsibility among a specific group of residents. Therefore, when one resident is on vacation or an ICU rotation, they are not solely responsible for following-up on outpatient demands. The continuity care teams are also intentionally composed of residents of different levels of training, so clinical or administrative questions that arise can be easily escalated if needed.

Faculty-to-resident ratio is 1:3 to 1:5. Residents see a gradually increasing number of patients per session based on academic advancement. On average, PGY-1 residents see four patients per half-day session; PGY-2 residents see six patients per half-day session; and PGY-3 residents see eight patients per half-day session.

During the three-year residency, residents have several elective outpatient rotations. While on these rotations, residents are exposed to the evaluation of pediatric patients in the outpatient setting. Residents rotate on outpatient surgical subspecialties, outpatient pediatric subspecialties, behavioral and developmental pediatrics, adolescent medicine, genetics, child abuse, and HIV clinics.

PGY-2 and PGY-3 that choose the primary care longitudinal tract have the option to spend one-half day per week in a community clinic during non-inpatient blocks. Here, they can experience outpatient pediatrics in various settings, develop an understanding of the differences between academic and community practice, and see a diversity of disease processes. Often the residents have used these experiences to develop ties to the community and ultimately generate employment opportunities.

The pediatric research curriculum gives PGY-2 and PGY-3 pediatric residents the opportunity to gain research experience. This experience includes any work that could be defined as a scholarly project and ranges from bench-top studies to clinical studies to literature review. Research time is available as one half-day per week during outpatient rotations. Residents also have the option to do research electives to enhance the research experience.

Residents are involved extensively in the educational program. Senior residents present new admissions and important follow-up of patients at the twice-weekly morning report conferences. Residents are directly responsible for the day-to-day teaching of medical students on the various services. A curriculum of general and subspecialty topics has been developed to expose residents to a variety of topics during their tenure. Each rotation has written goals, objectives, and resources that are published on the residency curriculum website.

There are computers in all areas where housestaff work as well as free access to UpToDate. The Tompkins-McCaw Library for the Health Sciences is located one block from the hospital and houses a vast array of journals, books, and other educational resources. Most journals are available online through the VCU Libraries website.

The department has developed several ways to assist residents pass the American Board of Pediatrics exam. Residents take the annual American Board of Pediatrics In-training Exam. Residents discuss the results with their assigned faculty mentor to develop study techniques and learning activities to improve their future performance. The Department of Pediatrics also pays for each resident’s membership in the Med-Challenger board preparation program. This is a computer-based program with nearly 5,000 board-style questions to help residents prepare for the boards. Users of Med-Challenger PEDS report a 98% pass-rate on the boards.