Rotation, Calls & Electives

Improving Resident Wellness and Continuity of Care: the X+Y System

Traditionally, pediatric residencies are structured so that residents would rotate on weeks-long inpatient rotations with a half-day of afternoon clinic each week.  At Rainbow, we were proud to be one of the first pediatric residency programs to embrace the “X+Y” scheduling model to improve our resident wellness and continuity of care.  We follow a “6+2” model, in which residents spend six weeks on inpatient, elective, or individualized curricular rotations followed by 2 weeks of ambulatory experiences:

The “6”:  Inpatient, Individualized Curricula

During your non-ambulatory blocks, you will rotate on two- or four-week inpatient blocks, participate in structured electives of your choosing, and/or participate in individualized curriculum tailored to your specific interests as a clinician, educator, or researcher.

The “2”:  Ambulatory Rotations and Longitudinal Curricula

All residents are scheduled for two consecutive weeks of ambulatory rotations.  Your ambulatory experience will include clinics at our multi-disciplinary medical home where we provide primary care to a medically underserved patient population.  Additionally, Rainbow’s Adolescent Medicine and Developmental/Behavioral Pediatrics departments integrate our residents into their clinical work during ambulatory rotations, and a longitudinal outpatient-based advocacy curriculum allows you to identify a passion project in improving the lives of Cleveland’s children.

Why X+Y?

The transition to X+Y has been embraced by our residents since the change was made more than five years ago.  The advantages of this model include:

• Ensuring that residents are on ambulatory 2 weeks out of every 8, helping to break up long stretches of inpatient work
• More frequent “golden” (two-day) weekends, as residents do not routinely have scheduled clinical duties on ambulatory rotations
• Less frequent resident sign-outs, as residents no longer leave their inpatient rotations to do a half-day of clinic.  This has the added benefit of more equitable distribution of work on busy inpatient services.
• Creation of - cohorts – called “flights” – of residents spanning all years of training who will always be in clinic and ambulatory didactics together.
• Opportunities for patient continuity, as residents will know the dates of their ambulatory blocks and can encourage families to see them for both short-term follow-up in the next few days or long-term follow-up in the next six weeks.

Curriculum

OVERALL YEAR

Each year is divided into 13 four-week blocks:

Vacation

• Each year, all residents have one two-week block of vacation and two one-week blocks of vacation totaling four weeks.
• An additional full week is typically scheduled over the winter holidays, but can easily be tailored to your preferred days of celebration.
• First year residents have an additional one-week vacation at the end of their internship year.

Sample Block Schedule (1 Block = 4 Weeks)

REQUIRED ROTATIONS

Inpatient Ward Teams

University Hospitals Rainbow Babies & Children’s Hospital’s inpatient wards are covered by six resident teams. The six teams (Red, Orange, Yellow, Green, Purple, and Silver) are generally staffed by one junior or senior resident supervisor, 2-3 interns, one acting intern (depending on the time of year), and one or two third-year medical students. Attending physicians and fellows (where applicable) participate in daily multidisciplinary rounds with their team. Each color team comprises the following services:

• Orange Team: Pulmonology (asthma, cystic fibrosis, interstitial lung disease, trach/vent management), and Endocrinology (Type 1 diabetes, thyrotoxicosis, pan-hypopituitarism)
• Purple Team: Cardiology, with the opportunity to provide care to patients on the cardiac stepdown unit, participate in fellow education and conferences, and observe cardiac catheterizations and open-heart surgeries
• • Green Team: Gastroenterology (Crohn’s disease, ulcerative colitis, autoimmune hepatitis, bowel obstruction) and Nephrology (acute kidney injury, nephrotic syndrome, glomerulonephritides, transplant care)
• Red Team: Hematology (sickle cell anemia, hemophilia, thalassemia) and Oncology (leukemia, lymphoma, solid organ tumors, brain tumors, and BMT)
• Yellow and Silver Team: General pediatrics, ranging from common pediatric complaints (bronchiolitis, dehydration, failure to thrive) to the complex (patients with technology dependence) to the diagnostically challenging (fever of unknown origin, new-onset neurologic or rheumatologic illnesses).
  • Yellow team also houses our inpatient metabolism service where residents care for sick patients with underlying metabolic pathology
  • Junior Hospitalist (Silver Team): This four-week rotation provides junior residents with a unique opportunity to develop their independent patient management skills under the mentorship of a member of the Division of Pediatric Hospital Medicine. The team consists exclusively of five junior residents who work in close collaboration with the pediatric hospitalist on service.

Day/Night Coverage

The inpatient ward teams utilize a day team/night team system. Over the course of the year, interns typically work a total of 14 weeks on day teams and six weeks on night teams, allowing for maximum continuity and education.

NICU

UH Rainbow Babies & Children’s Hospital’s Neonatal Intensive Care Unit has long been a leader in the field of neonatology. The unit comprises two hybrid resident/NP teams, each with a neonatology fellow and attending. The Junior and Senior residents follow a day/night system, whereas the interns only do days. Residents care for everything from meconium aspiration to congenital diaphragmatic hernia requiring maximal support with ECMO. The NICU has its own didactic curriculum, with neonatology lectures given by our esteemed attendings and fellows.

PICU

The 20-bed Pediatric Intensive Care Unit is staffed by five residents from pediatrics in addition to critical care fellows and attending physicians. Residents have the opportunity to care for critically ill children with the benefits of a large support infrastructure and all modern medical technologies, including ECMO and oscillatory ventilation. Clinical conditions seen include respiratory failure, ingestions, heart failure, liver failure, major trauma, and life-threatening infections. Residents in the PICU also participate in critical-care noon didactics given by our fellows and attendings.

Emergency Department

The emergency department at UH Rainbow Babies & Children’s Hospital is the only emergency center dedicated to pediatric care and level 1 pediatric trauma care in Cleveland. We receive patients of all acuity levels from local emergency medical services, community hospitals, the hospital’s Critical Care Transport & MedEvac Services, as well as by private vehicle. Residents learn how to assess, evaluate and treat pediatric patients with acute medical and surgical conditions. Residents are directly supervised by board-certified pediatric emergency medicine physicians 24 hours a day. During their ED rotation, residents also attend interactive weekly didactic sessions that are led by our emergency medicine faculty and fellows.

Newborn Nursery

Residents rotate in the Newborn Nursery for three weeks their intern year (days), one week during their junior year (nights), and three weeks during their senior year (two weeks of days and one week of nights). The team covers the newborn nursery at University Hospitals MacDonald Women’s Hospital, which is connected to UH Rainbow Babies & Children’s Hospital. Rounds are supervised and led by a general pediatrician. Deliveries are attended by the residents in the Newborn Nursery. A Code Pink resuscitation team as well as a neonatology attending or in-house neonatology fellow responds alongside the residents to all deliveries where a pediatrician is needed.

Advocacy

This rotation provides first-year residents with an introduction to core principles of Community Health/Child Health Advocacy. During the Community Health/Child Health Advocacy rotation, residents will have the opportunity to spend time working with various agencies that support the well-being of children and families in the Cleveland area. In addition, residents will develop a better understanding of core concepts related to social determinants of health, injury prevention, child health policy, and legislative advocacy. Rotation components include experiential learning within the hospital and local community, small group didactic sessions with faculty and other local experts, as well as the completion of individual advocacy projects.

Developmental-Behavioral Pediatrics

This rotation is split between the first and third years of residency. The intern experience is an introduction to developmental pediatrics including clinics in general developmental, fetal alcohol syndrome, ADHD, and autism. This is supplemented with didactic teaching sessions designed to educate the resident on a wide variety of topics in developmental and behavioral pediatrics. In the third year, the residents take on additional responsibilities, now with a much deeper appreciation of the system-based practices needed to care for patients with developmental and behavioral problems.

Adolescent Medicine

This rotation is split between the first and third years of residency. Taking place at our new UH Rainbow Center for Women & Children, residents learn about the unique medical and social needs of adolescents during this rotation. The rotation is led by our adolescent medicine specialists and psychologists. This rotation also includes a variety of off-site visits to our community partners who specialize in providing medical, social, and psychiatric care to adolescents.

OBRE (Outpatient Based Residency Experience)

This block is completed in your PL-2 year. This popular rotation provides an immersion experience in primary care pediatrics in a community setting. Residents work with one of our providers in the Rainbow Care Network to learn about topics such as ambulatory pediatric care, billing and coding, telephone triage, practice management, and the basics of health insurance. Residents are able to compare their experiences in the community with those in their own continuity clinic and see how medicine is practiced in different settings and with different patient populations. PL-3 residents can also elect to have their longitudinal continuity clinic experience to be in an OBRE clinic in combination with the continuity clinic at Rainbow’s main campus.

Subspecialty Rotations (Electives and Individualized Curriculum)

During each of the three years, residents have several blocks to explore pediatric subspecialties of their choosing. A list of available electives at UH Rainbow Babies & Children’s Hospital is below; however, residents may also design their own electives, with the help of a faculty mentor and program directors.

• Allergy-Immunology
• Anesthesia
• Breastfeeding
• Business of Medicine
• Cardiology
• Child Protection & Advocacy
• Comprehensive Care (Children with Complex Medical Needs)
• Community Hospitalist
• Dermatology
• Medical Education
• Endocrinology
• Ethics
• Gastroenterology
• Genetics
• Hematology and Oncology
• Infectious Disease
• International Health
• Metabolism
• Nephrology
• Neurology
• Nutrition
• OBRE (Outpatient Private Practice Pediatrics)
• Ophthalmology
• Orthopedic Surgery
• Otolaryngology (ENT)
• Pain Medicine
• Palliative Care
• PICU Pre-fellow
• Psychiatry
• Pulmonology
• Radiology
• Research
• Respiratory Therapy
• Rheumatology
• Sedation Unit
• Sports Medicine
• Subspecialty Pre-fellow
• Teaching Skills
• Transport