At UC San Diego, we have developed a four-year curriculum that not only meets the guidelines set forth by the ACGME to ensure comprehensive combined medicine-pediatrics training, but we have also built in flexibility in the third- and fourth-year schedules to allow more elective time to pursue career-oriented interests. The academic year is divided into thirteen four-week blocks. While one block is reserved for vacation, the remaining 12 blocks are evenly split between internal medicine and pediatrics. Switching between internal medicine and pediatrics occurs every three months.
The standard internship lasts 12 months. An additional one month is reserved for "resitern" experience at Rady Children’s Hospital ward that aids the transition between internship and team leadership as a supervisory resident. Typically, these months are spent in a capacity where patient loads are limited as those for interns are, but independent decision-making responsibilities mimic those of senior residents. There is also one additional month in second year in the MICU working at an advanced “intern-level” to solidify MICU knowledge and skills before becoming a supervisory MICU resident in the third year.
Internal medicine inpatient ward and ICU rotations occur at UC San Diego Medical Center in Hillcrest and the VA San Diego Healthcare System Medical Center. At both hospitals, the ward team is led by the supervisory upper-level resident (PGY-2 or higher) along with two interns, often a sub-intern and two to three medical students. Each team has a dedicated full-time hospitalist faculty for both general and subspecialty medicine cases. When the service is not busy, resident teams are invited — but not required — to participate in the care of patients traveling nationally and internationally to receive specialized procedures, such as pulmonary thromboendarterectomy and fiberoptic bronchoscopic laser surgery. This system enhances exposure to world-famous sub-specialists working at UC San Diego. Occasionally, a sub-specialist or general internal medicine faculty will attend on one of the ward teams at each of the hospitals, which has been favorably received by housestaff as this provides a different perspective in management than from hospitalist-only faculty.
At UC San Diego Medical Center in Hillcrest, there are four traditional teaching teams, one "flex" team comprised of two independently functioning senior residents and an attending, and one non-teach team. Teaching teams are capped at 16 patients to optimize learning. There are short, medium and long teams assigned each day to alternate admissions on a shift day-time basis. At 5:30 p.m., a night team consisting of one resident and one intern take over admissions with a cap of eight patients, and share admissions with the nocturnist on call. A separate night float intern cross-covers on the established patients in the hospital. These new night-time admissions are then distributed to the day teams in the morning in a thorough, safe hand-off process.
The VA Medical Center functions similarly to Hillcrest wards but has four teaching teams that also alternate admissions on a shift day-time basis. In the evening, two night-float residents will alternate evenings admitting overnight admissions that are passed off to the day teams in the morning. At both inpatient ward locations, there is always an in-house hospitalist attending and ER attending for immediate supervision and back-up.
At UC San Diego Medical Center in Hillcrest, the MICU service is well staffed with four residents and three interns. Twenty-four hour call is every fourth night for upper level residents only. The VA ICU functions as a combined MICU/CCU also consisting of four residents and three interns. Again, 24-hour call is every fourth night for upper level residents only. Interns cover either day or evening shifts and the schedule allows the nighttime intern to round with the morning team for educational purposes. Owing to the nature of intensive care, the ICU team admits 24 hours a day with 24/7 dedicated fellow and attending back up.
Sulpizio Cardiovascular Center at UC San Diego Health, located in La Jolla near the VA Medical Center, contains impressive state-of–the art technology, facilities and world-renowned faculty. Opened in August 2011, the Sulpizio Cardiovascular Center is San Diego County's first dedicated cardiovascular center. The facility unites leaders in cardiovascular medicine, cardiothoracic surgery, pulmonary vascular medicine, vascular surgery, cardiovascular imaging and cardiovascular research to battle heart disease and stroke.
Sulpizio Cardiovascular Center offers a unique cardiology inpatient experience for house officers. The house officer team consists of primarily cardiology patients who are inpatient ward level of care (usually on telemetry) with a limit of two to four additional patients in the critical care unit (i.e., acute STEMI). This offers an enriched experience in cardiology, seeing patients in different stages of acuity. In addition, there are electives available in both inpatient and outpatient congestive heart failure and cardiomyopathy led by world-renowned specialists at Sulpizio Cardiovascular Center, which offer additional depth of training in cardiology. Even though the majority of patients are ward patients, the structure of Sulpizio Cardiovascular Center follows that of the other ICUs being staffed with four residents and three interns with similar call/shift schedules as described above.
Rady Children's Hospital San Diego (RCHSD) provides premier care for all pediatric patients within the greater San Diego area. At Rady Children's Hospital, there are four teaching teams. Three of the teams have a traditional structure with a senior (R3 or R4) resident, two to three interns, and two to three medical students. The fourth team is the “resitern” team, comprised of two categorical internal medicine or medicine-pediatrics R2 residents and a hospitalist attending. The R2 residents function independently with no junior residents or medical students, with the purpose of improving their pediatric skills and developing independent thinking and management. Interns and R2 residents carry a maximum of 10 patients each on wards. Approximately two-thirds of patients are cared for by the resident teams in conjunction with dedicated general pediatric hospitalists who are assigned to a specific team for rounds and teaching. Each team also has a sub-specialty theme with 25 per cent of the patients being cared for along with sub-specialty attending physicians from that division.
The four teams each cover a certain subspecialty(ies) in addition to the general pediatric patients. We designate each team with a certain color. Red team covers neurology and endocrinology patients; yellow covers nephrology patients; green covers gastroenterology patients and blue covers pulmonary patients. General admissions during the day are triaged via a long-medium-short call cycle, with long call admitting until 6 p.m., medium call admitting until 4 p.m, and short call admitting until noon. There is a separate night rotation which is covered by one R3 or R4 resident, one mid-level resident (R2) and two interns. The night team transfers patients to the various teams in the morning, with the night team members remaining to present these patients on rounds, which enhances the overall educational experience. A senior resident, endearingly nicknamed the “mole,” does cross-coverage at night on established patients and is available to provide back-up support to the night admitting team. The “mole” rotation is not a standard rotation for medicine-pediatrics as it is for categorical internal medicine residents, but senior medicine-pediatrics residents will participate in about four “mole” shifts throughout the PGY 3/PGY 4 years.
During the four years of training, chief residents ensure that residents are assigned to all four colored teams at least once so that residents have exposure to all the inpatient subspecialties.
One month of the intern year is dedicated to an outpatient primary care rotation at North Park Family Health Centers, a federally-qualified health center. During this rotation, residents have the opportunity to work with an underserved patient population, including a large refugee population.
NICU training is centered at UC San Diego Medical Center in Hillcrest in the Level III nursery, giving comprehensive training in complex neonatal care. PICU training is done at Rady Children's Hospital, which is a Level I Trauma Center for all pediatric cases within San Diego. This 30-bed PICU also has one pod dedicated to postoperative care of congenital heart disorders. At the UC San Diego Medical Center NICU and RCHSD PICU, a fellow is in house 24/7 with the resident. In the NICU, the residents rotate on a day/night shift system with three weeks on day-shift and one week on night shift during a four-week rotation. The PICU is done as a PGY 3: residents take four to five 24-hour calls during their month of service.
The practice of medicine has changed dramatically over the last 20 years such that increasingly complex medical problems are being managed in the outpatient arena. Moreover, approximately 75% of all medicine-pediatrics graduates nationally enter primary care, making exposure to ambulatory care critically important in our residency. UC San Diego is remarkable among academic programs for its recognition and fulfillment of this need by stressing the importance of continuity clinic experiences and by providing ample opportunities for ambulatory and elective experience in both internal medicine and pediatrics. With an extensive choice of electives, graduates are assured a well-rounded education with enough exposure to subspecialists to comfortably apply these skills once they are practicing in the community or to decide whether to pursue a subspecialty fellowship. Below is a list of many of the ambulatory and subspecialty rotations offered at UC San Diego:
- Infectious Disease
- Musculoskeletal/Orthopedics clinics
- Women's Health
- HIV Clinic
- Infectious Disease
- Sports Medicine/Orthopedics
- Adolescent Medicine
In addition to the standard experiences, residents are encouraged to create their own electives to further tailor their education.
International Health and Research Opportunities
International Health and Research Electives
Global Medicine Elective Rotation in Mozambique
UC San Diego medicine-pediatrics residents can take part in the global medicine elective offered by the Department of Medicine. Residents travel during a four-week block to Mozambique, where they work alongside local internal medicine residents at the major teaching hospital in the capital of Mozambique, Maputo. If interested, residents also have the opportunity to extend this elective to an eight-week rotation in which they are asked to participate in an ongoing research project. Housing, visa and vaccinations are all paid for by the Department of Medicine. For more details, please click on this link to the elective web page.
UC San Diego Global Health Rotation
Another elective opportunity for UC San Diego medicine-pediatrics residents is to explore global health topics on a local level. The Global Health in Local Populations rotation through the internal medicine department exposes residents to concepts in global health not traditionally incorporated into graduate medical training. In addition to an overview of global health, the two-week rotation explores the connection between international health, human rights, epidemiological trends and health disparities at local and global levels. Residents build skills in culturally competent care of local asylee and refugee populations in San Diego County. The rotation is offered as an elective during the internal medicine months of the medicine-pediatrics residency.
The Department of Pediatrics also offers a global health elective, which includes attending several clinics in Tijuana, Baja California, Mexico, as well as a visit to the hospital in Tijuana.
Other Away (Including International) or Research Electives
Residents are allowed one month of either research or clinical away electives while on both medicine and pediatrics (total of two months over four years). These research or elective months should have specific goals and objectives which are individually approved by the program director and faculty mentor. Most residents take advantage of these opportunities in their third and fourth year of residency. UC San Diego encourages residents to use these opportunities to explore different career interests. The new Global Medicine elective rotation described above is one way to achieve this, but interested residents may still arrange their own rotations elsewhere. Several residents have created international health rotations to places such as Africa, Asia, New Zealand, Costa Rica, Chile and Honduras.
Research opportunities are abundant at UC San Diego, whether clinical, translational or basic science research. Many faculty are eager to be research mentors to our residents.