Caring for Children Across The City in the Boston Combined Residency Program

Each hospital in Boston is known to have its own “personality.” While Boston Medical Center is known for providing exceptional care without exception and focusing on social determinants of health, Boston Children’s Hospital is recognized for its breadth and depth of pediatric specialties and subspecialties. These complementary strengths and missions provide a wide range of pediatric care throughout the city of Boston, and each year a new group of residents has the chance to learn from both through the Boston Combined Residency Program.

“When the program started in 1996, many hospitals around the country were merging for economic reasons,” says Catherine Michelson, MD, MMSc BMC program director of the Boston Combined Residency Program. “But when the two Pediatrics chairs decided to merge the two residency programs they did it for purely educational reasons, creating a unique educational program that allows residents to get a taste of everything pediatrics offers, from sub-sub-specialties to community health.”

The residency program has approximately 150 residents, making it one of the largest pediatric residency programs in the United States. Most of those residents are categorical residents, which means they are officially employed by Children’s Hospital and spend 60-70 percent of their time there. Approximately 20 percent of residents, who are employed by BMC, are in the Urban Health and Advocacy Track (UHAT), which provides them with extra opportunities for advocacy and public health outside of the clinical space. Both tracks go through the same clinical rotations—at both hospitals—and educational programs.

“The great thing about UHAT is that we all have similar visions for our career, but different endpoints,” says Tyler Rainer, MD, a second-year pediatric resident in the combined program. “For example, one of us might end up as a pediatric oncologist, while another might end up in general pediatrics, but we all combine our subspecialty interests with an interest in advocacy and service. It’s a very unique part of the program.”

Clinical Practice

Clinical practice for all residents includes not just the typical general and specialty rotations, such as oncology or emergency medicine, but also learning how to be a top community physician. To this end, the program leverages the wide network of community health centers and private practices affiliated with both hospitals to ensure residents have a variety of experience. In addition, residents go through an advocacy rotation, to help ensure that they develop into doctors who are knowledgeable about the communities they serve.

“Approximately 85-90 percent of children covered by MassHealth in Boston get care at either Boston Medical Center or Children’s Hospital,” says Michelson. “Thus, the impact that residents can have by working at both hospitals is pretty amazing.”

One of Rainer’s experiences highlights this unique aspect of the program. On a BMC inpatient ward rotation, she cared for a 13-year-old girl who had been in and out of the Emergency Department with shoulder and back pain. She had been admitted this time, and stayed at BMC for two weeks for testing; many specialties were involved, from pediatric hematology-oncology to pediatric rheumatology. Eventually, the patient was given a new cancer diagnosis.

The patient was living with her grandmother and the family had many financial hardships. But doctors at both hospitals advocated for her transfer to Children’s Hospital for chemotherapy, to get the best specialized care possible. The pediatric residents who cared for the patient at BMC can now care for her at Children’s on oncology rotations and at BMC when she comes back to the ED.

Education In and Out of the Classroom

Another goal of the program is to deliver time for residents to pursue their individualized academic interests. A three-month block of self-directed academic development time is built into the third year of residency, where residents are expected to take advantage of the minimal clinical time for academic pursuits.

The program also provides support for scholarly development through four academies designed to help residents explore different aspects of academic leadership (medical education, clinical investigation, basic science investigation, innovation). Formal development as a teacher and supervisor are also stressed in a Resident-as-Teachers rotation, where residents are paired with a coach to learn how to effectively teach and supervise others.

UHAT provides additional educational opportunities for residents in that track, including “work-in-progress” meetings, where residents brainstorm legislative, advocacy, and research initiatives they’re interested in, then bring in BMC leaders in those areas to learn more. The program also stresses informal and formal vertical mentorships across UHAT classes.

In addition, working at two different hospitals, with different systems, electronic health records, protocols, and structures, provides residents with a unique view that will help them as they finish residency and move to other hospitals.

“You learn a lot this way,” says Rainer. “It’s difficult to master two different systems at first, but when you get the hang of it, you feel like a superhero.”

According to Michelson, the curriculum has significantly changed since the beginning of the program, and will keep evolving as health care needs change. For example, program leadership is currently considering the best way to equip pediatricians to care for mental and behavioral health issues, potentially in the form of a new rotation. The program is also committed to involving residents in activities related to accountable care organizations by pairing interested students with leaders in the space and building in elective time for them to learn more.

“We’re always thinking about the next horizon in health care, and our residents make sure we are continuously evolving,” says Michelson.