PEDU-4005 - Acting Internship in Pediatrics-Neonatology

PEDU-4005 - Acting Internship in Pediatrics-Neonatology

Elective Title: Acting Internship in Pediatrics-Neonatology
Course Number: PEDU-4005
Elective Type: clinical Duration/Weeks: 4 Max Enrollment: 4
Prerequisites: Successful completion of Year 2
Additional Requirements: Successful completion of Pediatric and Ob/Gyn clerkships.
Responsible Faculty Director: Monica Huff, MD Periods Offered: 1-7, 9-13 excluding holiday period 8 
Coordinator: Tiffany Swain Other Faculty: UTMB Neonatology Faculty
Location to Report on First Day:
Senior resident in NICU or Newborn Nursery

The student will assume the responsibility of the acting intern for 2 weeks in the Normal Newborn Nursery and 2 weeks in the Neonatal Intensive Care Unit. The acting intern will thus learn to care for the normal newborn and for critically ill term and preterm infants in the intensive care unit.

NEWBORN NURSERY: At the completion this elective, the student should be able to: 1. Obtain an adequate, detailed neonatal history. This includes obtaining and evaluating relevant details regarding maternal history and events occurring prenatally and during the course of labor and delivery. 2. Understand the pathophysiology of fetal and neonatal asphyxia and be able to initiate emergency resuscitation of the newborn. 3. Perform a complete physical examination of the newborn including: a. Transitional examination, b. Estimation of gestational age, c. Evaluation of intrauterine growth, d. Screening for congenital anomalies and other potential problems. 4. Detect and differentiate the following neonates and be aware of the common problems encountered by each group: Small for gestational age infant, b. Pre-term infant, c. Large for gestational age infant, d. Post-mature infant. 5. Be familiar with the general care of a normal newborn infant and be capable of counseling the family about routine care, particularly infant feeding and nutrition. 6. Be aware of common newborn problems and be able to detect and institute initial appropriate management of the following: a. Hyperbilirubinemia, b. Hypothermia, c. Hypoglycemia, d. Hypocalcemia, e. Infection, f. Respiratory distress, g. Cyanosis, h. Gastrointestinal disorders, i. Congenital malformations, j. Asphyxia. NICU: The student will be able to perform a physical examination on a premature or low birth weight infant and accurately assess gestational age. 2. The student will be able to identify the pregnancy at high risk for neonatal disease and to obtain appropriate, detailed prenatal, labor and delivery history. 3. The student will understand the pathophysiology of asphyxia and participate in resuscitation of the newborn. 4. The student will be familiar with the general care of a low birth weight infant including temperature support, glucose homeostasis, oxygenation, fluids and electrolytes administration, and nutrition. 5. The student will be aware of common problems of the low birth weight infant and will be familiar with diagnosis and long-term management.

Description of course activities
1. During the NBN portion of this AI, students will spend one week on day shift and one week on night shifts. The night shift hours are from 5:00pm to 6:00am The student functions as an intern in the nursery and is supervised by the Pediatric house officer at nights and the Nurse practitioners during the day. He/she takes patients in rotation with the other interns and is responsible for their evaluation, examination, nursery care, and discharge. Along with this goes the responsibility for reading in-depth about the patients and their problems, for checking on lab work, for seeing them each day, and for adequate documentation of their medical record. 2. During the NICU portion of this rotation, the student is responsible for all attending high risk deliveries with the NICU team. The student participates in daily rounds and presents a panel of his or her assigned patients. The student is expected to have learned about common NICU diagnoses and be able to discuss during rounds. The student is also responsible for talking with the families of babies assigned to him/her and participating in parent education regarding their newborn.

Type of students who would benefit from the course
Students interested in Pediatrics, Family Medicine, OB-Gyn or Anesthesiology

Weekly Schedule
  Clinical Activities (estimated schedule)  
Day of Week   AM   PM
Monday 6:00 5:00
Tuesday 6:00 5:00
Wednesday 6:00 5:00
Thursday 6:00 5:00
Friday 6:00 5:00
Saturday 6:00 5:00
Sunday 6:00 5:00

 Average number of patients seen per week: 50
 Call Schedule: Students will receive an email prior to the course with the details of their particular schedule including nights/days off.

Research Activities (estimated schedule)
Activity Hours per Week
Faculty Contact-Time
Self-Directed Study

Method of Student Evaluation
1.  Clinical Observation
  A. Where are students observed on this elective?
    Inpatient Service   Ambulatory   Surgery   Standardized patients
Patients simulators   Other
  B. Frequency - How often are students observed clinically?
  C. Format - What method(s) are used to document the student's clinical performance?
    Daily oral feedback   End of period oral feedback   Written feedback

2.  Oral Presentation
  A. Audience - To whom does the student present?
    residents and faculty
  B. Frequency / Duration of Presentation(s)?
    daily on rounds
  C. Format - What guidelines are set for the student's presentation?
    Review history, physical, problems, and plans for the day.
  D. Assessment - Who assesses the student's presentation performance?
    Self-assessment   Peer assessment   Faculty assessment
  E. Method of content selection
    Current cases  Student-selected topic   Assigned topic

3.  Written Assignment (H&P's, notes, papers, abstracts, etc.)
  A. Frequency of written assignment(s)?
    Daily notes on patients being followed.
  B. Format - What guidelines are set for the student's written work?
    Standard format for written history & physicals and program notes.
  C. Length of written assignment(s)?
    Abstract   Annotated bibliography   1 - 2 page paper   3+ page paper
  D. Are recent references required?   No    If yes, how are they selected?
  E. Method of content selection - e.g. student-selected, relate to cases, etc.?
  F. Audience - Who assesses the student's written performance?
    Peer Assessment     Faculty Assessment     Other

4.  Examination
    Oral   Written multiple choice   Written essay / short answer   OSCE

5.  Extra Course Activities
  What expectations do you have for the student to demonstrate participation in the elective (e.g. small group activities, seminars, thoughtful questions, providing resources, journal club, resident lecture attendance)?
    Participation in patient care and rounds. Completion of six online modules Required reading: NICU Housestaff Mini Manual. Suggested reading: NICU Housestaff Manual, Nelson Textbook of Pediatrics

6.  Additional Costs
  Please list any additional costs and/or purchases (books, materials, movies to watch, etc.) that are required for this course. Include an estimated total cost. If there are no additional costs, please enter "None".

7.  Other Modes of Evaluation
  Please explain below.
    Students are evaluated by the attending faculty and supervisory house officers based on the following criteria: attitude, willingness to work and seek knowledge, responsibility, working relationship with personnel, patients and other physicians, thoroughness, concern for patient welfare, organization, and ability to obtain necessary data, state problems clearly, and implement appropriate action.

8.  If this course is an Acting Internship, please complete the following:
  A. Objectives for the AI should relate directly to the Entrustable Professional Activities (EPAs). Each AI should describe how the four key Year-4 EPAs that our school has identified as being Year-4 skills are assessed. The Year-4 objectives are:
1. Entering and discussing orders/prescriptions.
2. Give or receive patient handover to transition care responsibility.
3. Recognizing a patient requiring urgent or emergent care and initiating management.
4. Obtaining informed consent for tests and procedures.
Specify how the student will be given formative feedback on their clinical skills.
    Students receive feedback on their clinical skills on patient rounds and in interactions with the faculty attending and the residents.

Year-4 students should demonstrate mastery of EPAs they developed in the clerkship year, including recommending and interpreting common diagnostic and screening tests, and performing general procedures of a physician. They should be able to demonstrate masterfully and independently skills they mastered in Years 2-3, including efficiently performing comprehensive admission-notes and succinct daily progress notes and perform accurate, concise, and hypothesis-driven clinical presentations, form clinical questions and retrieve evidence to advance patient care. They should be able to demonstrate basic understanding of and beginning mastery of collaborate as a member of the interprofessional team and identify system failures and contribute to a culture of safety improvement.

List advanced clinical skills that a student will be assured an opportunity to practice.
    Complete physical examination of babies with assessment of gestational age and Apgar scoring in the delivery room.

How specifically will this AI build on developing skills from the clerkship year to prepare students for internship?
    Interpretation of neonatal X-rays, ultrasounds, and MRI scans.

What opportunities will typically be available to all students who take this AI (procedures, required presentations, etc.)? What opportunities may be available based on patient load/presentation or student initiative (ie. Writing a case report)?
    The AI responsibilities are very similar to the PGY1, although they may require a bit more supervision. They will have patients assigned to them just as the PGY1 residents. The AI is responsible for seeing each patient, talking to the family, writing a progress note, presenting the patient on rounds, and following up on lab and procedure results. Generally, the AI is not required to write TPN orders on their patient without the help and supervision of an upper-level resident.

An AI should have expectation of a minimum of 32 hours per week of clinical responsibilities. Duty hours should be capped at ACGME limits for an intern, thus up to 24 hours followed by 4 hours of activities related to patient safety, education, and handoff. Students cannot work more than 80 hours per week averaged over 4 weeks. They can only have 1 day off in a 7-day work week with 8 hours off between shifts.

Clinical responsibilities will vary depending on specialty, but how is the student functioning with work commensurate to a PGY1 with an appropriate level of training?
    Exposure to normal newborns and complex NICU patients and gaining an appreciation of the common diagnoses presented in this population.

How is the student demonstrating drawing clinical conclusions and/or developing a management plan and documentation as an intern would do?
    The student will meet with the faculty attending at midpoint in the rotation to provide feedback and discuss areas of strength and areas which need improvement. For any deficiencies noted, a remediation plan with clear, measurable goals to be accomplished during the remainder of the rotation will be developed.

How and by whom will midpoint feedback be provided to the student? How will you remediate deficiencies identified at midpoint?
    Generally, the student will work with 2-3 different faculty for at least a week each. They will receive very close supervision and opportunities to interact with each of the faculty with whom they work.

Acting Internship students often seek letters of recommendation following their experience. How many different Faculty will work directly with the student and have knowledge of the student's abilities to detail in a written evaluation? Describe the degree of supervision and interaction with faculty vs. residents or other providers and how feedback will be obtained if more direct work is with residents or other providers.
    our AIs typically work with 2-3 neonatologists during their time in the NICU. They are directly supervised by these faculty members and are part of a resident team which include 2-3 other residents and ~40-50 patients. Rounding, patient presentations and clinical cases learning topics are made directly with the faculty member each day. The AIs also have the opportunity to attend low and high-risk deliveries of neonates with the attending faculty. We ask that the AIs ask only one neonatologist for a letter of recommendation and comments from other faculty are added to that individuals letter.