Rotations

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.

Typical Inpatient Gen Med Day

Most interns/residents will arrive at the hospital between 6-6:30 AM to pre-chart, and will receive sign-out from the night team between 6:30-7:00. Following sign-out you will chart and pre-round on your patients before formal rounds with the attending, which usually begin around 9:00 AM. In the afternoon you will follow-up with consultants, finish notes, perform procedures, and staff new admissions. During the afternoon attendings and senior residents will make an effort to provide more structured didactics. Sign-out for all teams begins at 5:30 PM. General medicine teams are made up of one intern, a senior, and one attending.

Typical Inpatient Pediatric Day

Sign-out is at 6:30 AM during the week and 7:00 AM on the weekends. Residents will usually get to the hospital at 6:00 to pre-chart on patients, and will get sign-out from the night team. Family centered rounds with attendings and nursing staff will begin at 8:30 and finish by 11:30 AM. Residents/interns will carry both hospitalist and specialist patients on their teams. On Wednesday and Friday there are radiology rounds midday to review interesting imaging from the week. Attendings will provide formal didactic teaching in the afternoon for interns and medical students. After interns have finished their work they will help the senior resident in the afternoon with admissions. Sign-out will takes place at 5:00 PM.