Overview

Residency at Children's Hospital of Philadelphia delivers in-depth experience in both inpatient and outpatient areas while progressively increasing responsibility and opportunities for individual and elective study. In light of their important role as teachers, all residents are offered faculty appointments in the School of Medicine as instructors.

X+Y scheduling model

“X+Y” is a popular way of scheduling in Internal Medicine programs that is receiving growing interest from Pediatric programs. We are excited to be one of the first large pediatric residency programs to embrace this model of scheduling.

Among other factors, X+Y has been shown to improve balance between inpatient and outpatient experiences, allowing residents to be more present in each clinical setting. Evaluations have also noted improved longitudinal relationships and learner continuity between residents and faculty. Implementation of this model has allowed us to continue to deliver the highest quality educational experiences while also continuing to espouse our holistic approach to professional development of future pediatrics leaders, which includes complementary non-clinical experiences and a structural approach to fostering well-being.

“Now that I am in an X+Y program, I cannot imagine being in a program that does not have X+Y. It is so much easier to get through an intense 6-week block of inpatient knowing that there is a 2 week outpatient block waiting where I can devote my time to my clinic patients while working on research and exploring elective time.”

Why did we switch?

The “traditional” model of scheduling (i.e., leaving an inpatient setting to go to clinic for a certain number of half days per year) has many drawbacks, including:

• Providing care in multiple venues is challenging. Attention is divided: residents may be thinking ahead to afternoon clinic responsibilities while inpatient and can still end up dealing with floor issues from clinic
• There can be limited rounding with consult attendings and afternoon follow up on patients, resulting in lost educational opportunities. As residents leave for clinic, remaining members of the team can feel “abandoned”
• The opportunity to develop an understanding and passion for primary care can be compromised  
  • Clinic may be viewed as intrusiveThere is often more limited time at clinic
  • There can be a lack of continuity that is frustrating

The X+Y model allows for reimagining of what clinical training looks like, including:

• Increasing the ability to be mentally present for the role one is in
• Improves team collaboration, while fostering more meaningful relationships with patients and faculty in both the inpatient and outpatient settings
• Development of innovative curricula and longitudinal experiences
• Spacing “diastole” rotations to prevent burnout and improve well-being
• Provides time to engage in career exploration and pursuit of scholarly activities and projects
• Emphasizing the importance of primary care and continuity clinic education
   

What is the structure?

X blocks consists of required and elective clinical experiences including inpatient floors, ICU rotations, and the Emergency Department, as well as required ambulatory experiences, including Developmental Behavioral Pediatrics, subspecialty ambulatory experiences, and the Mental Health experience. Rotations during X block can vary in length, from 2-4 weeks in duration.

Two- and four-week Individualized Educational Units (IEUs) are included in the X blocks. 

The Y blocks are two-week experiences in which a variety of clinical experiences and opportunities for career and professional development are embedded. Experiences include primary care continuity clinic, a longitudinal elective, advocacy and community-based experiences, and additional ambulatory experiences. Additionally, three Academic Half Days (AHDs) focused on clinical learning and professional development specific for each year of training occur during each Y block.

What do our residents think of this model?

More feedback from our residents on the X+Y scheduling model:

• "[What’s great about Y block is] having something different to look forward to each day! It's a good variety of experiences to provide some fresh inspiration, new perspectives, and still some time to see some friends!"
• "[One of the best parts of Y block is] the guaranteed golden weekends, so you can plan quality time with friends and co-residents!"
• "It is incredibly helpful to know that there are scheduled, regular times where you can get a lighter schedule to refresh and rejuvenate in whatever way you need. I also love having clinic in set aside chunks of time rather than having to rush from inpatient life in the morning to clinic in the afternoon. The scheduled time for teaching and debriefing has also been wonderful and given me educational opportunities I have not had before."
• "I love having a full day in clinic and getting to work with more of the amazing preceptors that we have."
• "Y block is a restorative time to focus on primary care clinic and engage in advocacy and other areas of interest, but it also provides our program with a greater sense of community. The opportunity to work with the same cohort each Y block allows us to build close relationships with our colleagues, providing us with a smaller community within a large program."

Example of a PL1 Schedule

 *Interncation is a 10-day period (June 21-30) during which all interns are off prior to starting the PL2 year

Example of a Y Schedule

Year-by-Year Preview

FirstYear (PL1)

The PL1 year focuses on learning about the typical child, variations of normal and recognition of the sick patient. The PL1 is the primary clinician and takes primary call from the floor. For the first seven blocks of the intern year, the intern is closely supervised by senior residents . The PL1 completes all orders, admission histories, physical exams and management decisions, but all are reviewed by supervisory senior residents. The supervisory resident is responsible for the triaging admissions to the floor.

In the second half of the PL1 year, there is graduated autonomy on the inpatient floors. The PL1 begins to take responsibility for the admission process, in addition to primary patient responsibility. The senior resident remains on the floor as a consulting physician for the team. The supervisory resident is aware of all patients on the floor, evaluates all admissions after discussion with the PL1 and is available for any questions or concerns.

Second year (PL2)

A core focus of the PL2 year is obtaining proficiency at assessing and managing critically ill children. PL2s have experience in oncology, cardiology, endocrine/metabolism, the Pediatric Intensive Care Unit (PICU), and the Newborn/Infant Intensive Care Unit (N/IICU) as the primary clinician.

On the inpatient floors, PL2s take on a leadership role equivalent to that of PL3s, which includes supervision and teaching of interns and medical students.

In the Emergency Department and the outpatient clinics, the PL2 has the opportunity for increased autonomy.

Third year (PL3)

The core focus of the PL3 year is integration of knowledge and further development of patient management, teaching and leadership skills.

Curriculum elements

• Educational Sessions
• Research
• Longitudinal Curricula: Residents-as-Teachers, Quality and Patient Safety
• Advanced Skills Program