Clinical Rotations

Welcome from our General Pediatrics Faculty

A major focus of the program is care of the child and adolescent in the outpatient setting. The Ambulatory Care rotations operate out of the Robert B. Green facility, our 6-story state-of-the-art clinic building providing the resident with an opportunity to experience general and subspecialty outpatient pediatric care with on-site, readily available, full-time faculty for consultation/teaching. The resident’s Continuity Clinic, also at the Robert B. Green facility, provides the core of this education. Each resident has the opportunity to follow patients that he/she has recruited from the nursery, other rotations, and the walk-in clinic to provide ongoing well-child care, care for children with chronic illness or recurring problems, and care for children with acute illness. The resident attends his/her Continuity Clinic in this one facility, one-half to a full day a week throughout the three-year residency, allowing the opportunity to observe each child through a two- or three-year period of growth and development.

• Longitudinal Continuity Clinic experience across 3 years
• Ambulatory, ER, and Urgent Care – 28 weeks

Ambulatory Care Rotations

Three-four interns, 1 PGY 2, and 1 PGY 3 (usually with medical students) per month rotate through this service, which occurs exclusively in the Robert B. Green Outpatient Clinic. Patients are seen in the Acute Care Clinic with a common pediatric medical problem requiring a focused history and physical examination. There are typically 2 General Pediatrics faculty supervising the clinic and providing support to seniors and initially more direct supervision of interns. Regular teaching sessions for Morning Report and noon lectures/board review occur on this rotation. This is a rotation that establishes the foundation of a well-rounded General Pediatrician.

Emergency Medicine

Interns rotate through the Pediatric Emergency Room at University Hospital. During the ER month, the resident works approximately 13 twelve-hour work shifts as well as their regular clinic and 4 half day sessions in the Urgent Care Clinic downtown with at least one full day off per week. Training goals of the ER service include managing a broad range of pediatric urgencies/emergencies, developing an understanding of criteria for admission versus outpatient management of non-emergent medical conditions, learning the judicious use of laboratory and radiologic studies in the initial assessment of patients, the application of principles of PALS, as well as common procedures in pediatrics like sutures, fracture and dislocation assessments, and stabilization.

University Hospital anchors our inpatient services for general and subspecialty patients. We have a robust and engaged Academic Hospitalist Division that staffs the General Wards, Newborn Nursery, and a procedural sedation service. Our PICU is staffed by educationally oriented faculty and fellows in highly collaborative interprofessional models. Our goal is to expose you to the full range of practice and pathology. The Hematology/Oncology service is a comprehensive interdisciplinary service supervised by faculty and fellows. On all of these rotations the emphasis on assessment, critical decision making, and management and treatment plan development is fostered through supported autonomy, a growth mindset, and regular feedback. Our culture of family centered care and interprofessional collaboration creates an environment where clinical learning and advocacy for evidence based, patient safety-oriented care are the shared mission.

• General Pediatrics Inpatient – all General, Pulmonology, Neurology, Complex Care, Rheumatology, Infectious Disease, and co-management of surgical, other specialty patients. Also carry intermediate care unit level patients with some degree of medical complexity.
• Inpatient Admitting Ward Senior/Night Float
• Hematology/Oncology Inpatient/Consult and AYA
• Subspecialty Inpatient Care – Gastroenterology, Nephrology, transplant patients
• Newborn/Couplet Care

General Pediatric Inpatient Service (UH)

Two-three interns and 1 PGY 2 supervisory resident (usually with medical students, outside rotators from Family Medicine, military pediatrics program, and Anesthesia interns) supervised by an attending hospitalist physician. This team cares for general pediatric patients admitted from the Emergency Department and clinics as well as direct admissions and downgrades from the ICU. They also co-manage with Pediatric Trauma and subspecialty surgical services to ensure comprehensive, patient centered care is maintained. The team cares for both acute care unit and intermediate care unit patients. At 5PM handover, the night float team assumes responsibility. The night float team is comprised of 2 interns and a supervising PGY 3 – Ward Senior. Night Float is Monday–Friday and every intern level trainee on the primary service does 3 weeks of days and 1 week of Night Float. The training goals for interns on the general ward services include developing a robust and efficient approach to the diagnosis and management of common medical disorders, refining clinical reasoning skills, maintaining a respectful communication style with the interdisciplinary team, and developing and refining caring, humanistic patient relationships. Finally, interns make the transition from student to teacher in their interactions with the medical students under their supervision.

Inpatient Services Admitting Ward Senior/Night Float (UH3)

Two PGY 3 residents alternate day and Night Float coverage (2 weeks/each). This supervisory senior is the overall resource for the inpatient services teams (Ward, Hematology/Oncology, Subspecialty, Nephrology) and performs daytime admissions and consults as well as patients downgraded from PICU. They can help cross cover teams when needed. On Night Float assignment, they manage and supervise 2 interns covering all the inpatient (non ICU) services. Taking admissions, assessing patients with changes in clinical condition, and assessing any patient care situations. They teach and facilitate active learning for their teams. A wonderful culmination of autonomy in clinical decision making, this service is supported by phone supervision by Pediatric Hospitalists on Call as well as in house Critical Care faculty available for any urgent (<30 minutes delay) bedside assessments and all rapid response or code situations.

Hematology/Oncology and AYA Inpatient Service

The Hematology/Oncology and AYA service is an inpatient and consult rotation with 1 intern, 1 supervising PGY 2, medical students, at times a fellow, and a faculty physician. Interns on this service take no call and PGY 2s take 2 weekend ward calls during the block. Training goals for the service include learning the diagnostic, staging techniques and treatment options for common pediatric malignancies and hematologic disorders, mastering the fundamentals of chemotherapy administration (including the prevention and/or management of common side effects), treatment of neutropenic fever, and management of other oncologic and hematologic emergencies. Our unique exposure as the South Texas Sickle Cell and Hemophilia Treatment Centers afford our trainees exposure to the common complications of these disorders. Opportunities for diagnostic procedures such as lumbar punctures and bone marrow aspiration abound. Additionally, we have the only adolescent and young adult combined full service unit in the city allowing residents to understand the unique and seamless transition of care of childhood diseases into young adulthood.

Subspecialty Gastroenterology/Transplant Service

One Intern and a PGY 3 supervisory resident take care of a dedicated service of inpatient gastroenterology and liver transplant patients and consultations throughout the hospital (NICU/PICU). They round with the multidisciplinary transplant teams and learn to manage these complex patients with unique risk profiles. A dedicated gastroenterology faculty member staffs this service and provides extensive focuses teaching in addition to clinically oriented teaching rounds. This is a call free service.

Newborn/Couplet Care Nursery

One-two interns, 1 PGY 2 supervisory resident, Family Medicine and Obstetrician intern rotators (students) along with dedicated Pediatric Hospitalist faculty provide care to late preterm and term newborns born at 35 weeks of gestation. They attend deliveries and provide neonatal assessment and resuscitation where indicated, evaluate every infant born within the first 12 hours of life, and daily during their hospital stay. Residents learn to manage the very common issues of feeding, breastfeeding establishment, hyperbilirubinemia, assessing risk of infectious or respiratory complications, and assessment of individual risks associated with pregnancy factors. Residents become proficient in performing circumcisions and in the education and counselling of new parents as they transition home. Infants born at risk for Neonatal Abstinence Syndrome are also managed by this team in a collaborative standardized bundle of care to optimize outcomes.

Neonatal Intensive Care Unit

Separate rotations on the Neonatal Intensive Care and Term Nursery services allows the attention of the resident to be focused on the problems of the acutely ill neonate at one time and on the more common problems of the normal newborn at another. The pathophysiologic basis for the management of neonatal problems is the focus of faculty attending Neonatologists and resuscitation of the newborn is particularly emphasized. In addition to daily rounds and faculty lectures, there is a weekly discharge planning conference and a Perinatal Mortality Conference is held monthly.

Two interns, 1 PGY 2 supervisory resident, outside rotators from military pediatrics and family medicine along with NICU fellows, pharmacists, NNPs, and fellows form the team.

Pediatric Critical Care Unit

One PGY 2 and one PGY 3 (often with a fourth-year “extern” and rotators from Emergency Medicine program) comprise the critical care team along with (occasionally) fellows, NNPs, and faculty. Residents on service take a call average of every 5th night during this rotation (the most call intensive in the program). Those calls include robust opportunities for procedural and critical management skills to be developed. During in-house PICU call, the resident is always supervised by in-house faculty. Supervision and teaching is provided in daily rounds and bedside AM/PM handovers. Training goals for the critical care service include management of complicated patients requiring interventions such as mechanical ventilation and vasoactive medications, in addition to procedures such as endotracheal intubation and central venous catheter placement. Common disease processes encountered include sepsis, respiratory failure, status epilepticus, DKA, TBI, multisystem trauma, burns, multisystem organ failure, and post surgical care. The unit provides ECMO care. The ethical issues commonly arising during ICU care (i.e., end-of-life care) are an integral part of the resident’s training.

Required subspecialty rotations over the three years (beginning in year 1) include Gastroenterology, Pulmonology, Cardiology, Endocrinology, Nephrology, and Neurology, each preparing the resident to individually manage common subspecialty problems and prepare him or her to participate as a member of a multidisciplinary team in the care of complex subspecialty patients. Subspecialty rotations cover both inpatient admissions and outpatient patient visits and procedural experience.

Subspecialty Outpatient Required Rotations

To allow exposure to the full scope of practice of the subspecialist, this rotation is anchored in outpatient clinic setting but includes participation in interesting inpatient consultations and procedural opportunities. For most of these services, the resident is working directly with faculty and fellows with medical students and the occasional outside rotator.

• Pulmonary Service – outpatient/consults – RBG and UHS
• Endocrinology – outpatient/consuls – TDI and UHS
• Adolescent Medicine – SAMMC
• Neurology Service – outpatient/consult – UHS
• Cardiology – outpatient/inpatient/consult – Children’s Heart Network and UHS
• Nephrology – outpatient/inpatient/consults – UHS
• Child Behavior/Development – SAMMC and community sites

Children’s Association for Maximum Potential (CAMP)

Children’s Association for Maximum Potential (CAMP) provides a wide range of recreational, respite, rehabilitative, and training services for children with disabilities and their families in a camp-like setting. Medical support is central to the program, ensuring all children regardless of their medical needs can participate in all programs and activities. Residents rotating on the Child Behavior/Development service during June, July, and August participate in Camp CAMP. CAMP residents are members of an interdisciplinary team with 20-25 campers with disabilities assigned to each resident within the context of that team. The residents provide ongoing chronic medical care and treat acute illnesses or the injuries associated with participation in a recreational program.

Center for Miracles

A collaborative clinic that serves the needs of neglected and abused or at-risk children in our community. It houses the UT Health San Antonio Pediatric Department Child Abuse Pediatrics faculty and a fellowship in Child Abuse Pediatrics.

Migrant and International Child Health Pathway

Designed for selected pediatric residents who are interested in improving their understanding of care for underserved children here at home and abroad. The overall goal is to train pediatricians who understand the consequences of socioeconomic conditions on migrant children and families, who recognize the impacts of such life experiences on their health, and who can take an active role in advocating for their health and well being.

Individualized Resident Tracks

There are over 24 weeks of elective time across 3 years that are part of the resident’s Individualized Resident Track and are based upon the resident’s interest in general outpatient, hospitalist, or subspecialty practice and include opportunities for off-campus or individually crafted electives as well as core options to prepare residents for their next career step. Residents can take up to 1 academic (board review/research) elective per PGY 2 and PGY 3 year.