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Rotations

Internship is 15 rotations spread out over the first 16 months of residency. Intern rotations provide the basic skills in medical knowledge, procedures, organization, and management that provide the foundation for practicing medicine. We ensure all residents rotate through any service as an intern that they will have to manage as a senior in the future. Senior rotations provide increasing opportunities for autonomy and working in a supervisory role with interns and medical students. Review our rotation schedule here. 

Continuity Clinic

Ambulatory training occurs both in the Ambulatory Care Clinics, located on site at MMC, and in community-based practice sites. The combined Internal Medicine-Pediatric Resident Continuity Clinic is conveniently located in the hospital across from the Pediatric Clinic and one floor above the Internal Medicine Clinic. Radiology, laboratory and other support services are also close by. In addition to learning from their clinical experience, residents build primary care knowledge through our established outpatient curriculum with teaching sessions prior to clinic sessions. Many of the resident QI projects during residency focus on areas related to their own patient panels and they are given time during ambulatory rotations to move their PDSAs forward. Our clinic faculty, APP, nurses, social work, dietician, case managers and administrative staff are phenomenal and the clinic is a home base for the residents even when they are not scheduled for continuity clinic.

The MMC continuity clinic patients include an ethnically diverse group of patients who have immigrated to Portland and many others whose families hail from Maine for many decades. Residents receive standardized patient/interpreter training to develop their communication skills working with interpreters in-person, by phone, and telemedicine given that English is not the primary language for many of our patients.

We have now switched to a 4+2 model for our continuity clinic to better match our Internal Medicine colleagues. Pediatrics will be moving to this model starting in 2022-2023. Residents cross-cover inboxes during vacations, night teams and for urgent clinic questions.

Community Med-Peds & Rural Rotation

One of our unique components of ambulatory training here at MMC includes 2 outpatient rotations located in more rural settings outside of Portland. Residents are matched with Med-Peds physicians to give them an opportunity for immersion into what it is like to practice in a community away from the specialty environment of Maine Medical Center and experience different practices with Med-Peds physicians. Sites include Windham (all residents do 1 month there with 4 Med-Peds faculty), Norway, Damariscotta, Brunswick and Ft. Kent (housing is provided if not within reasonable daily driving distance). We also have a hospitalist elective in Bar Harbor (Acadia National Park) to provide inpatient experience in a rural community. Residents enjoy the opportunity to take advantage of some other parts of Maine’s beautiful outdoor activities in the more remote settings.

Personal Learning Block (PLB)

Up to 16 weeks of individualized elective time spaced out over 4 years of residency. PLBs occur during transitions between categorical programs in 2 week blocks (i.e. Medicine to Pediatrics or Pediatrics to Medicine). Residents have an opportunity to create a specialized curriculum that suits their particular interests/education requirements.

Examples the elective time include:

  • Patient Quality and Safety week (required for interns)
  • Ultrasound elective (scheduled for interns)
  • Step 3 prep and exam time
  • M&M week (capstone to Patient Safety education – required for PGY4)
  • Scholarly activity block: writing a case for publication, completing a poster, continued work on quality improvement projects
  • Practice of procedural/technical skills
  • Continuity clinic
  • Extension of International Health electives

International Health Elective

Residents have ample exposure to a diverse population in Portland due to a large refugee/immigrant population but for those who are interested in expanding global health education outside of the country there is opportunity for elective rotations. Residents have completed rotations in Haiti, Belize, Dominican Republic, Guatemala, El Salvador, Zambia, Uganda, Malawi, Lesotho, and Cambodia.

Faculty have been working to establish a mechanism (and funding) to support any resident or fellow who wishes to do an international rotation. Faculty in multiple departments (including Dr. Diamond-Falk for Med-Peds) have been going to a teaching hospital in Rwanda for several years and have begun taking trainees and do some teaching virtually. For those residents looking for other opportunities, faculty are available to help find established sites to participate in global health experiences.

 

Pediatric Inpatient Unit

More than 2,000 patients per year are cared for on the inpatient unit of the Barbara Bush Children's Hospital (BBCH). Pediatric diagnoses range from common respiratory and gastrointestinal disorders to congenital heart disease, metabolic disorders, and end-stage renal disease. The attending faculty at the BBCH includes a Pediatric Hospitalist group and a full range of sub-specialists involved in medical and surgical specialties. In addition, community pediatricians admit their private patients to the inpatient unit and follow these patients with residents and medical students.

Pediatric Intensive Care

Med-Peds residents rotate for one block in our 10-bed PICU during their second year before doing their first Pediatric Supervisory block. Here, residents are the primary caretakers for critically ill children under the direction of our PICU staff and Pediatric sub-specialists. The patient population in the PICU is varied, so residents care for children with a myriad of diagnoses including, but not limited to, status epilepticus, respiratory failure, diabetic ketoacidosis, and sepsis. Unique to this program is the opportunity to care for children with both non-surgical and surgical cardiac disease in both the pre- and post-operative periods. Residents are also members of the Pediatric Critical Care Transport Program. This is a ground-based system that transports critically ill children from Maine and New Hampshire hospitals to the Barbara Bush Children's Hospital.

Neonatal Intensive Care Unit

The neonatal intensive care unit experience occurs in our Women and Infants - Coulombe Family Tower, a state-of-the-art 50-bed NICU and Step Down unit as well as a new Labor and Delivery suite that opened in September 2008. The Barbara Bush Children's Hospital sees 2,500 deliveries per year. The NICU has an average of 700 admissions per year, of which 150 are transports from outlying hospitals. Residents are supervised by board certified neonatologists with a wealth of experience caring for premature infants as well as educating residents. Residents gain valuable delivery room experience, manage premature infants with complex needs, and learn assessment skills to quickly triage those infants requiring intensive care from the delivery room. A team of experienced neonatal nurse practitioners complement the neonatology service and are involved in many aspects of the hands-on training in the NICU.

Medicine Inpatient Rotations

The Department of Medicine has an average daily census of more than 280 patients. Patient care at Maine Medical Center ranges from primary care to a full spectrum of tertiary care issues, ensuring a superb patient population for residency training. Tertiary care is provided through programs such as invasive cardiology, ERCP, advanced critical care, neurosurgery, infectious disease consultation, renal, and cardiovascular surgery. The department is staffed by over 150 board-certified internists, two-thirds of whom have subspecialty certifications. The attending faculty includes an Adult Hospitalist group, subspecialists as well as community internists. Residents complete inpatient rotations in general medicine, cardiology (including cardiac ICU), renal transplant and hematology/oncology. In addition many residents choose elective on the inpatient subspecialty consult services.

Medical Intensive Care Unit

Residents spend 2-3 blocks in the 45-bed intensive care unit. The ICU is staffed by board-certified combined pulmonologists/intensivists (including a Med-Peds trained attending) with approximately 2,000 admissions per year. A thriving pulmonary and critical care fellowship program fosters a vibrant learning and research environment. Med-Peds residents find that they are exposed to a challenging mix of patients, providing both ample procedural and medical experience with critically ill adult patients. In addition to the time in the Medical ICU, residents are exposed to the Cardiac Intensive Care Unit during their subspecialty cardiology rotations.

Ambulatory

As mentioned in the Med-Peds Continuity Clinic and Community Med-Peds & Rural Rotation, ambulatory experiences take place in many locations. For the Pediatric ambulatory care rotations, the Pediatric Ambulatory Clinic is based here at MMC. During the Pediatric Ambulatory Care blocks, residents rotate onto the Newborn Nursery Teaching Service under the supervision of the dedicated Newborn nursery faculty. These experiences allow residents to learn first-hand about general pediatric practice. Residents will also work in the Teen, Dermatology and International Clinic while on pediatric ambulatory rotations. In the setting of COVID-19, residents are spending time at the Respiratory Assessment Center where any patients with symptoms concerning for COVID-19 are seen at a separate clinic a brief distance from the hospital with all providers in PPE (PAPR/N95+face shield) to ensure trainees continue to get exposure to patients with acute respiratory illness.

Internal Medicine ambulatory care rotations allow residents to participate in a variety of specialty clinics such as dermatology, international/travel clinic, homeless health, Preble Street Learning Collaborative, STD clinic, sports medicine, and women's health. Residents complete an IM subspecialty rotation at the VA which includes time with GI, Rheumatology, Pulmonology, Nephrology and Cardiology.

Emergency Department

Three blocks are spent in the ED. Residents care for children and adults who present to the ED including those with major or minor trauma, orthopedic injuries, poisonings, ingestions, and lacerations. Interns are expected to see both Pediatric and Adult patients during their first block in the ED. The MMC ED serves approximately 80,000 patients per year. This level one trauma site provides residents the opportunity to manage adult and pediatric patients that present with critical medical and surgical problems.

The second and third blocks are Pediatric ED supervisory blocks in the Pediatric Emergency Department. The pediatric emergency department was opened in summer 2009 with 10 beds dedicated to pediatric patients. It is geographically distinct from the rest of the department and is open 13 hours a day. This experience is supervised by board-certified emergency medicine physicians. Residents have the opportunity to supervise the learning of pediatric and emergency medicine interns in the care of pediatric patients in the ED. Residents also spend time at the Northern New England Poison Control Center during this time and gain valuable knowledge about toxicology during this month.

Adolescent Medicine

Adolescent medicine training includes a block in the second year where residents work side by side with faculty in school-based health clinics, eating disorders clinic, adolescent psychiatry clinic, sports medicine clinic, STD clinic, and other venues where care is directed toward teens. This experience also includes the weekly Teen Clinic which takes place at the MMC Pediatric Clinic during afternoon-evening hours

Developmental and Behavioral Pediatrics

This is an intern year rotation where residents work with board-certified developmental pediatricians (one of whom is Med-Peds trained) and a neuropsychologist caring for children with behavior issues, autistic spectrum disorders, ADHD, and learning disabilities. The bulk of this rotation occurs in the outpatient developmental-behavioral pediatric clinic. Time is also spent in pediatric neurology clinic, spina bifida clinic, child abuse clinic, and developmental team clinic. The rotation involves interactions with a diversity of experts in child development, learning disabilities, neurology, and child psychiatry.

Geriatrics

During this rotation, residents are able to get a flavor of both the inpatient and outpatient care of geriatric patients. Residents will work in the ACE unit (Acute Care for the Elderly) and with HELP (Hospital Elder Life Program) during the days they are in the hospital. In addition, they do geriatric and palliative care consults on inpatients. For their outpatient experience, residents work with Hospice of Southern Maine and also go to the Geriatric Center. Scheduled educational sessions include a weekly morning conference and a talk by a geriatric fellow. Geriatric Grand Rounds and Journal Club occur once a month.

Electives

Five blocks of Internal Medicine and six blocks of Pediatric subspecialty/electives are set-aside over the four years of training. All of the major subspecialty areas are represented in our program. 4 blocks of “required” subspecialty rotations are required on both IM and Pediatrics. Residents have additional electives in both programs that may come from the list below or may be a more individualized experience.

Electives may be chosen from the following areas in Pediatrics: Advocacy, Allergy/Immunology, Anesthesiology, Cardiology, Child Abuse, Child Psychiatry, Endocrinology, Gastroenterology, Genetics, Global Health, Hematology/Oncology, Hospitalist Medicine, Infectious Diseases, Nephrology, Neurology, Ophthalmology, Orthopedics, Parenting, Pulmonology, Research Experience, Rheumatology and Sports Medicine.

Medicine Electives include: Addiction Medicine, Cardiology Consults, Endocrinology, Gastroenterology, Global Health, Hospitalist Medicine, Infectious Disease, Neurology, Pharmacology, Psychiatry Consults, Pulmonology, Rehabilitation Medicine, Research Elective, Rheumatology and Sports Medicine.

A Day in the Life

We asked some of our interns to describe in detail what a 'Day in the Life' was like as a resident.

Pediatric Senior Resident

4:45: My alarm goes off; I convince myself to only snooze once and make my way to the kitchen to start coffee. I drink my coffee and eat breakfast while looking over charts from home.

5:50: I hop on my bike, take a quick detour to enjoy the sunrise at the top of the Eastern Prom, then make my way to the hospital. I live in Munjoy Hill, a neighborhood at the end of the peninsula about 2 miles from the hospital. I love being able to bike to work - I get some exercise and fresh air, and never have to worry about parking!

6:30: Time for signout from the night team! We have two IPU teams, team 1 which carries all the hematology/oncology patients as well as some hospitalist/other subspecialty patients, and team 2 (that's me!) which carries all the GI patients as well as some hospitalist/other subspecialty patients. Each team is composed of 1 senior and 2-3 interns as well as a 4th year med student on their Acting Internship/Sub-Internship and one-two 3rd year medical students. We roll deep! The night team is 1 senior and 1 intern. After getting signout, I huddle with the rest of team 2 to come up with a game plan for the morning. One of the interns and I head off to see a patient who sounds less stable - they end up getting transferred to our PICU for increased oxygen support before rounds even start.

7:45: Morning report! Morning report happens 4 mornings a week via zoom, and is generally a case or topic presented by our Chief Resident or a resident on an elective rotation. I like that it's only 30 minutes long, which makes it easier to attend even if the IPU is busy.

8:30: After morning report, each team gets ready to round. Because we carry patients admitted under a number of subspecialty attendings on any given day (neurology, nephrology, pulmonology, etc), I pay close attention to which patients are covered by which attending, and come up with a rounding schedule based on acuity, discharges, and scheduled procedures happening that day. On team 2, we generally round with our GI attending first. We try to round at the bedside when possible, or at least with parents in the doorway. Something I love about peds is that we also always include the nurses in rounds - this really ensures that everyone is on the same page regarding the plan for the day, and makes us truly feel like a healthcare team. My goal is to always finish rounds by 10:30.

11:30: Radiology rounds! Seniors from both teams submit interesting radiographs to our pediatric radiologists, who go over them with us twice a week.

13:00: I'm carrying the admission pager today, and it goes off with a call from an outside hospital requesting transfer to our IPU for a 14 month old with multiple congenital abnormalities and new increased work of breathing. I discuss the case with the outside provider, and deem that it is very reasonable for this child to be transferred directly to our IPU. I check with our hospitalist and our charge nurse; they agree that this is a reasonable transfer, and confirm that we have nursing and bed availability. I call the outside hospital back, and confirm that we can accept this child. They will bring her down via ambulance. When she arrives, an intern and I go through her history, place orders, consult our cardiology and pulmonary colleagues, and get her tucked in for the night. The admission pager is the initial point of contact with a pediatric provider at MMC. Anyone looking to talk with a pediatric provider regarding an admission, management advice, or transfer talks with the senior resident carrying the admission pager first. It's a little intimidating but we have a lot of support here between the hospitalists, subspecialists, and PICU team, so you're never alone if you need help. Things can get crazy when the pager won't stop going off, but it's such a cool opportunity to triage pediatric cases from all over Maine - something we don't get to do on the medicine side.

15:00: We spend the rest of the afternoon discharging a few patients, admitting one from the Emergency Department, and doing some teaching on fluid management.

17:00: I'm not sure where the day went, but the night team is back, meaning it's time to signout for the day. Each team signs out their patients, and I let the night team know about a patient getting some imaging in the ED who I'm worried may have to be admitted. I try to gather with team 2 once more after signout to go over discharges for the next day and see what we could have done better today. I hand over the admission pager, turn my personal pager off, and hop back on my bike to ride home!

18:15: I'm generally home between 18-19:00, with plenty of time to go for a run, make a nice dinner, or meet up with a few other residents at one of Portland's many breweries with outdoor seating - all before my strict 2130 bedtime!


Pediatric Intern

5:00AM: My alarm goes off. I eat breakfast, take my pups for a walk, and am out the door by 6:00AM. My wife and I decided to buy a house when I matched here, so my commute is about a 12 minute drive. Most residents live within walking or biking distance of the hospital.

6:15AM: I arrive at the parking garage and hop on the shuttle for the short ride to the hospital. During the warmer months, the garage is a nice short walk to the hospital. I grab a coffee on my way through the lobby and head up to the pediatric inpatient unit.

6:30AM: Sign out. The day teams (usually comprising a senior resident, two interns, one M4, and one or two M3s) meet the night team in the conference room to run the list and learn about new admissions. After sign out, I touch base with the 3rd year medical students and find out which patients they are interested in seeing for the day and try to arrange a time to practice their presentations before rounds. I try to speak with the overnight nurses before they sign out at 7:00AM. The nurses are fabulous, easily accessible, and great at sharing information from overnight. If kids are sleeping, we let them sleep and examine them on rounds. Otherwise, I examine my patients and talk to parents before rounds. I update the treatment board with who the medical team is for the day so the patient’s family knows who to expect on morning rounds.

7:45AM: Morning report! Most days the topic is an interesting case from the floor, but resident or attending presentations from various specialists are often in the mix as well. On Thursdays we attend a Grand Rounds at 9:00AM and two didactic sessions from 10 to 12 instead of morning report - all via Zoom, although the inpatient team is able to watch together in a hospital classroom. During this time, attendings hold our pagers so we can be fully focused on didactics. On Thursdays rounds will be quicker to ensure everyone has a plan prior to Grand Rounds. Journal club on pertinent Peds articles occurs monthly after didactics.

8:30-11:00: Rounds with the attendings, trainee team, nurses, and one of our incredible pediatric pharmacists! There are two teams on the floor each month. One team has hospitalist and pulmonology patients while the other team has hospitalist and hematology/oncology patients. Additionally, both teams share low-census subspecialist patients (cardiology, neurology, gastroenterology, endocrinology, nephrology, etc.). After rounding with the hospitalist and oncologist (or pulmonologist), we contact any additional subspecialists whose patients we may be caring for. Rounds is a great time for learning. We primarily do bedside rounds, but occasionally do table rounds (Thursdays). As an intern we carry anywhere from 2-10 patients depending on the census. Pediatric volumes can be variable by season and often even day-to-day!

11:30AM: On Wednesday and Friday we have Zoom radiology rounds, where any new images on our patients are pulled up on the screen for discussion with a pediatric radiologist. This is a great opportunity for sharpening our image reading skills and asking questions to advance patient care!

1:00PM: I finish up remaining notes, call consults, work on discharging patients, and take admissions from the emergency department, clinic, and outside hospitals. Sometimes we have a lecture from an attending and/or senior resident in the afternoon. I also take this time to touch base with our wonderful social workers, nutritionists, physical and occupational therapists and other ancillary staff on certain patients. Sometimes in the afternoon we will attend family meetings on our complex patients. Nearly all of our patients are on our 30 bed inpatient pediatric unit or are intermediate level care in the PICU, but on our service if they do not require PICU management (occasionally an older adolescent or young adult on pediatric team will be in another unit). This makes it easy to catch the interdisciplinary providers on the unit and connect with nurses and attendings in-person throughout the day.

5:00PM: Time to sign out to the night team. The overnight intern works one week of night float (Sunday through Friday night) at a time during their inpatient pediatrics block with an overseeing senior resident.