THE JOURNAL OF


ROBERT WOOD JOHNSON MEDICAL SCHOOL
UMDNJ, New Jersey's University of the Health Sciences

PEDIATRIC RESIDENCY

ABSTRACT

In common with all excellent pediatric training programs, we share the commitment to provide quality education in all aspects of pediatrics. We undertook this study to evaluate the education of the pediatrician in the Pediatric Department of the UMDNJ/Robert Wood Johnson Medical School and to examine the unique features of this program. Our findings show that the broad and comprehensive training in the health care needs of infants, children and adolescents prepares the graduates of the program for careers in both primary care and subspecialty pediatrics. Especially noteworthy features of this program include faculty availability, excellent teaching, compassionate approach to the health and care of children, a congenial atmosphere, a wide variety of patients, and a pleasant place to live.

INTRODUCTION

Robert Wood Johnson Medical School began in 1966 as Rutgers Medical School. In 1970 the State of New Jersey created the University of Medicine and Dentistry of New Jersey (UMDNJ) to consolidate medical education in New Jersey. Rutgers Medical School became one of the schools within this university. In 1977 Middlesex General Hospital (now the Robert Wood Johnson University Hospital -- RWJUH) signed an affiliation agreement with the University, transforming this hospital into the primary teaching hospital of the medical school. As such, it is the primary referral center for central New Jersey and is a Level I trauma center. In 1986 the name Rutgers Medical School was changed to Robert Wood Johnson Medical School.

The development of the pediatric residency program at Robert Wood Johnson Medical School parallels the dramatic growth of the medical school's clinical and research programs. The Department of Pediatrics, including faculty and resident rotations, is primarily based at Bristol-Myers Squibb Children's Hospital. The pediatric faculty, with over 90 members, and residents provide a full range of clinical services. There are 12 pediatric residents in each class (36 total) and two PL-4 chief residents. Fellowships are offered in neonatology, the only accredited neonatal fellowship in New Jersey. A pediatric critical care fellowship has been approved.

This study was undertaken to evaluate the education that this training program provides future pediatricians.

METHODS

SUBJECTS:

A non-random, stratified sample of residents, fellows, and faculty members from the Robert Wood Johnson Department of Pediatrics participated in this research. The voluntary faculty (n = 110) were not surveyed. The demographic characteristics, including socioeconomic status (SES) and gender, of the sample are listed in Table 1.

Table 1. Demographic Characteristics

PROCEDURE:

Letters were sent from the Department Chairperson to all pediatric residents, fellows and faculty of Robert Wood Johnson Medical School. The subjects were asked to voluntarily complete a questionnaire and return it within two (2) weeks. The compliance rate of 100% was higher than the expected 40%. In retrospect, this may have been due to the rumor that salary and/or promotion was contingent upon completion of the questionnaire.

MEASURES:

The Pediatric Complete Training Inventory (PCTI) was developed by Taft, Osgood and Tannenbaum (1986) in order to tap the five basic domains of Pediatric training and experience:

1. Hands-On Experience
2. Educational Resources
3. Research
4. Non-Academic Activities
5. Resident Contentment

Each domain of the PCTI was measured by five items which were rated on a seven (7) point scale from great to abysmal. Split half reliability of the PCTI was excellent (r = .90), and one month test-retest reliability for a sub-sample of 10 subjects in each group was moderate (r = .65).

RESULTS

1. HANDS-ON EXPERIENCE

1. Clinical Services
   
   Residents reported that they spend the majority of their time at the
   Bristol-Myers Squibb Children's Hospital (Table 2).
   
   Table 2. Number of Beds
   
   

   Pediatrics Unit	24
   Adolescent Unit	14
   PICU/Step down	14
   Hematology/Oncology Unit	10
   NICU	40
   Level II Nursery	15
   Cardiac Care Unit	6

   
   
   

   All of the residents commented that this hospital provided a variety of experiences. Robert Wood Johnson University Hospital is the main teaching hospital of the medical school. A pediatric unit, adolescent unit, hematology/oncology unit and pediatric intensive care unit are located in the new Bristol-Myers Squibb Children’s Hospital at RWJUH (fig. 1). In addition the Clinical Academic Building (CAB) houses a full range of subspecialty clinics. The Eric B. Chandler Health Center and Plainfield Health Center, community-based primary care health centers, serve as sites for our busy primary care clinics.

   
   

   Figure 1. The Bristol-Myers Squibb Children Hospital at Robert Wood Johnson University Hospital.

   

   Figure 2: Note the concerned yet confused look.

1. Resident Rotations:
   
   The Pediatric Residency Program is a non-pyramidal three year program. It is carefully structured to provide graduated responsibility and independence. See Curriculum for details of rotations.
   
   PL-1
   

   The PL-1 year forms a core of training in inpatient and ambulatory pediatrics. The PL-1 has primary responsibility for the care of acute and chronically ill patients from birth through young adulthood. During this time, the resident develops basic skills in evaluation and treatment of both common and unusual pediatric problems. The first year is spent in the inpatient pediatric units at RWJUH or in various outpatient settings. PL-1s also have two developmental rotations and one subspecialty surgical rotation.

   The child development/developmental disabilities rotation emphasizes normal neurological and behavioral development as well as developmental disabilities. The resident sees children with a wide variety of conditions, including behavior problems, intellectually gifted children, developmental delay, learning disorders, speech and language problems, and children with spina bifida. Children are seen through the Pediatric Behavior Clinic, the Laurie Neurodevelopmental Institute, The Institute for the Study of Child Development, and a Cerebral Palsy Center. On the normal development rotation, residents visit to a daycare center, the hospitals’ child life department, a local school, learn how to perform Denver developmental screenings and get one-on-one supervision by the department’s child psychologist.

   While first year residents are given significant responsibility for patient evaluation and management, there is always a senior resident (PL-2 or PL-3) to supervise and teach them (fig. 3). Beginning in 2003, in accordance with ACGME guidelines, a night float system was instituted in order to decrease overall resident work hours and improve efficiency of learning. PL-1s have 6/8 weeks of night float and 1call free month (not including vacation).

   

   Figure 3: The mural outside of the Children’s Hospital clearly depicts a PL-3 providing leadership to the junior housestaff.

   PL-2

   The PL-2 year builds on and broadens the foundation developed during the first year. On the inpatient units and during night float, PL-2s function in a supervisory capacity. In the intensive care unit they gain experience in the care of critically ill children and adolescents. Resident education in the care of non-hospitalized patients is expanded by rotations through the outpatient clinic, psychiatry/adolescent medicine, an elective and emergency medicine rotation. During the emergency medicine rotation, residents work one-on-one with a member of the pediatric ED faculty. The elective block in the second year is used by many of the residents to help make decisions about career plans. On-call responsibilities include 8-10 weeks of night float and 1 call free month (not including vacation).

   PL-3

   The PL-3 resident is a supervisor and teacher on the pediatric inpatient units. The transport rotation, which involves transporting acutely ill children from an outlying facility, gives residents experience assessing and stabilizing critically-ill children as well as coordinating pre-transfer care at outlying hospitals. Five elective rotations give PL-3s ample opportunity to focus on subspecialty patients and their specific needs. In addition, residents rotate in a private practice, and do a community pediatric rotation in order to round out their education. All PL-3s have a research selective rotation during which they initiate or work on ongoing research. They complete a case report or literature review for publication. At the end of the rotation, residents present their project at the departmental weekly conference. Each PL-3 also organizes and presents two case conferences during the year. On call responsibilites include 7-8 weeks of night float with 1 call free months (not including vacation). The residents reported that following their own patients and families over time helped them feel like a real family pediatrician (fig. 5).

   Continuity Clinic

   Each resident has continuity clinic one half day per week for all three years. Continuity clinic has priority over all rotations, and residents are relieved of other responsibilities during their clinic time. Patients are added to the continuity clinic through the emergency room, newborn nursery, inpatient units, subspecialty clinics, and by community referrals.

   

   Figure 4: A resident providing care to an infant on the inpatient unit.



Neonatology

The neonatology program is centered at BMSCH-RWJUH, the site of the regional perinatal center. Because of the excellent clinical training and ongoing research, Robert Wood Johnson Medical School has the only accredited Neonatology Fellowship program in New Jersey. A fellow and attending supervise the team (fig 6)





Figure 5: A neonatology fellow. Is he awake?

2. EDUCATIONAL RESOURCES

1. Faculty
   
   

   The pediatric faculty includes general pediatricians and a full complement of pediatric subspecialists (figure 7 and Electives). In addition, the following pediatric surgical aubspecialists are actively involved in teaching and patient care: orthopedics, ophthalmology, ENT, urology, surgery and neurosurgery. Residents interact frequently with community pediatricians, some of whom participate in daily morning report on the inpatient ward. These physicians provide valued perspective on the practice of pediatrics.

   

   Figure 6: Supportive attendings can always be found laughing with (or at) the residents.

   All of the residents commented favorably on the high quality of the teaching program and the accessibility of the faculty. The faculty are readily available for formal and informal consultation on all patients. It was noted that the faculty was dedicated to maintaining a superb educational program in a supportive environment.
   

2. Chief Residents
   
   The two PL-4 chief residents are chosen for their extensive pediatric knowledge, teaching ability, supervisory skills, and ability to take comments/criticism/complaints from all directions with equanimity. Creativity (especially in finding last minute coverage for a sick resident) is also considered a prerequisite for the job. The chief residents play a valuable role in didactic and bedside teaching of residents and students, as first line resources for advice and help for the residents, and as members of hospital and departmental clinical/administrative committees.
3. Conferences
   
   A variety of conferences are scheduled at BMSCH (or outside them; fig. 7). Table 3 lists the regularly scheduled departmental conferences. Residents at all levels (particularly PL-1s) felt that over 80% of the time, the food made it worth attending conferences. (See quality of refreshments, same Table). Noon conference is held daily at RWJ-BMSCH. The noon conference schedule is arranged to coincide with the goals of the curriculum to ensure residents’ success on the pediatric boards. Grand rounds and weekly clinical case conferences are attended by residents, faculty, community pediatricians, and medical students. Case conference is an interactive teaching conference and is reported to be particularly stimulating and informative. The Institute for the Study of Child Development runs a monthly colloquium series as well as an annual conference with invited speakers in developmental psychology, psychiatry and epidemiology. Attending rounds are held three (3) times per week at RWJ-BMSCH.
   
   
   

   Figure 8:

   Textbook example of resident conferences

4. Fellowships
   
   Fellowships are offered in neonatology, and approved for critical care.

5. Support Services

   LIBRARY

   The majority (99.9%) of residents surveyed felt that the medical library had an excellent selection of journals and books. Independent sources indicated that the library has direct ties to the highly regarded Library of Science and Medicine on the medical school campus in Piscataway. This library contains over 2,000,000 bound volumes and over 1,000,000 government documents, pamphlets, maps, and other materials. Periodical holdings are strong in older as well as current issues. An excellent reference collection includes most of the indexing and abstracting titles important to the sciences. National network computer searches (including Ovid, Medline, etc.) and material exchanges are readily available. The reference librarians are especially helpful. The library is also equipped with the most up-to-date computer technology and resources available, which are freely accessible to the housestaff.

   PSYCHOSOCIAL SERVICES

   A child psychiatrist provides consultations, conducts weekly patient psychosocial rounds on the inpatient units, and gives some noon conferences. Pediatric social workers are readily available to help with family support, evaluation, discharge planning, etc. Professional Child Life staff help attend to the child's need for fun, play and understanding of medical procedures and illnesses. Children and adolescents eagerly attend the Child Life rooms or await the child life worker coming to their bedside.

   PEDIATRIC NUTRITION

   The Department of Pediatrics has inpatient and outpatient pediatric nutritionists who consult on patients and provide teaching to patients, family, and staff regarding special nutritional needs. The pediatric nutritionist always smiles, even at 11:59 AM with two interns asking advice for the noon peripheral alimentation orders.

   PHARMACY

   The pediatric pharmacist as well as the Doctoral students are a valued members of the various in-patient and intensive care teams. They regularly attend ward rounds and teaching conferences, and are always available for consultation on the ever expanding world of pharmaceutical therapy.

3. RESEARCH

In addition to teaching and clinical activities, faculty, fellows and residents are involved in basic clinical research . Examples of some of the many projects in the department include: pediatric HIV disease, rapid viral diagnostic tests, cerebral blood flow in the neonate, developmental follow-up of premature infants, control of neonatal respiration, necrotizing enterocolitis, transdermal drug administration, autism, Tourette’s syndrome, effects of anticonvulsants on cognitive skills, learning and motivation in the infant, sexual abuse in children, new treatments of childhood cancer, respiratory mechanics in children with lung disease, gastroesophageal reflux, molecular genetics, emergency room utilization, and screening for language delay. It was concluded that this academic atmosphere has been crucial in keeping residents aware of and involved in the constantly evolving knowledge base of pediatrics.

Resident participation in research is actively encouraged. Research opportunities exist in all three years of training, but is a required third year rotation. Residents from RWJ have won competitive awards for the excellence of their projects and have presented their projects at various national meetings.

4. NON-ACADEMIC AFFAIRS

The New Brunswick area (see map) provides an interesting blend of urban, suburban and semi-rural areas. Because of its many attractive features, the New Brunswick-Princeton corridor is one of the most prominent corporate and residential growth areas in the country. The city of New Brunswick itself has undergone a dramatic rebirth and redevelopment. Residents have been caught paging their colleagues out of rounds to plan social activities.

One hundred percent (100%) of the residents reported participating in various activities outside of the hospital. Ninety-five percent (95%) of the sample reported doing so while awake.

Table 4. Highlights of Central New Jersey

1. Proximity to New York and Philadelphia-- but not too close.
2. Numerous parks and recreational areas.
3. Sailing, trout fishing, hunting, canoeing, hiking, skiing, white water rafting.
4. The Jersey Shore.
5. Many cultural centers with performances by nationally known professionals in music and
   dance.
6. Professional theaters, including McCarter Theatre in Princeton and the Crossroads and
   George Street Theaters in New Brunswick.
7. Wide variety of employment opportunities available for spouses -- especially in the high tech
   and pharmaceutical industries.
8. Good schools.
9. High quality day care centers.
10. Attractive, safe residential areas with lots of affordable housing.
11. Many historical sites.
12. Convenient shopping malls (one on every corner).
13. Excellent variety of restaurants.
14. Easy accessibility to transportation: close proximity to Newark International Airport, Amtrak
    and NJ Transit and interstate bus lines.
15. Excellent local museum and art galleries.
16. Atlantic City.
17. Sports: Phillies, Mets, Yankees, Eagles, Giants, Jets, Flyers, Islanders, Devils, 76ers, Knicks, Nets, and numerous college teams.

5. RESIDENT CONTENTMENT

1. Overview

   All of the residents were enthusiastic about the program (fig. 10). They emphasized the variety and number of patients they care for, excellent teaching, interested and accessible faculty, and high resident morale as the best features of the program (fig. 11).

   

   Figure 7. The residents smile with the mere mention of the program.

   

   Figure 8: Having a great time… wish you were here!

2. Resident Support

   Members of the faculty were found to take an active and ongoing interest in resident well-being. Table 5 lists mechanisms used to help support the residents. In addition, residents are members of several important departmental committees that help shape policy for the department.

   ---

   Table 5.

   ---

   1. Individual faculty advisor.
   2. Resident advisor for incoming PL-1s.
   3. Regular meetings with the director of the residency program.
   4. Monthly resident meetings that are chief resident-run.
   5. Resident retreats -- twice/year for PL-1s and PL-2s; once/year for PL-3s.
   6. Open door policy of the Chairman and faculty.
   7. Annual year-end residents' day off.
   8. End of the year dinner for residents, fellows and faculty.
   9. Back-up residents for sick call.
   10. Parental leave policy.
       
3. Professional

   After completion of their training at Robert Wood Johnson, the residents all felt well prepared for their professional activities. Approximately fifty percent of the residents chose work in a variety of pediatric practice settings, while the remaining 50% pursued subspecialty training. Residents were selected for competitive fellowships throughout the country. Graduating PL-3s felt relatively calm about their upcoming general pediatrics board exam because program graduates have traditionally done well.

DISCUSSION

Overall and overwhelmingly, the pediatric residency program at
UMDNJ-Robert Wood Johnson Medical School was found to provide excellent training for the prospective pediatrician regardless of future career goals. All of those polled agreed that, during the three years of residency here, physicians develop expertise in the care of children from birth through the first two decades of life. Caring for children in a variety of health care settings was judged to be important in developing a broad pediatric perspective.

Other findings of note included the excellent resources within the department in developmental psychology, developmental disabilities, and neonatology. Graduates of the program have been very successful in obtaining competitive fellowship training or pediatric practice opportunities and in passing their pediatric boards.

CONCLUSIONS

We conclude that this program is highly recommended for all students interested in becoming pediatricians (Table 6). The program is large enough to accommodate all aspects of pediatrics and to provide residents with exposure to primary care pediatrics, tertiary care pediatrics, and pediatric surgical subspecialties. At the same time, the program is small enough to maintain its close interaction between residents and faculty, to be responsive to residents' needs, and to be flexible to accommodate family and other personal needs of the residents. Without a doubt, this is one of the most outstanding medium size residency programs in the United States.

Table 6.
Reasons for Choosing Robert Wood Johnson Pediatric Residency Program

1. An integrated program utilizing a university hospital and an academically oriented
   community hospital.
2. Busy clinical services with a large variety of patients.
3. All pediatric subspecialties represented on the full-time faculty.
4. Graduated responsibility and independence.
5. Wide diversity of outpatient experience, including primary and subspecialty care.
6. Excellent ancillary staff.
7. Strong neonatal service.
8. Many recently renovated units and outpatient sites.
9. Faculty dedicated to giving their patients state of the art and compassionate medical care,
   and to instill these qualities in students and residents.
10. Supportive environment with open relationships between residents and faculty.
11. New Children’s Hospital.
12. Availability of pediatric nutritionist, pharmacist, and social workers for teaching and
    consultation.
Stimulating case conferences.
14. Nationally renowned Institute for the Study of Child Development.
15. Research opportunities and support.
16. Professional, dedicated nursing staff who work collaboratively with pediatricians.
17. High likelihood of obtaining a competitive fellowship or practice position upon graduation.
18. Caring senior and chief residents.
19. Bagels and coffee at Grand Rounds and Case Conference.
20. An honest and creative Residency Program Brochure.

David Mandelbaum, M.D., Ph.D.
Revised 8/2005: Stephanie Crewe, MD & Jessica Stevens, M.D.