1. EDUCATIONAL PROGRAM The pediatric surgical educational program at The Warren Alpert Medical School of Brown University and Hasbro Children's Hospital incorporates all of the facets of the discipline to mold disciplined, skillful and investigative Pediatric Surgeons. A combination of Divisional, Departmental and multidisciplinary conferences, teaching rounds and a demanding clinical schedule creates a well-rounded, structured and complete educational environment. All trainees who finish Residency will have a broad and full understanding of pediatric and neonatal physiology and disease with the technical expertise to provide the highest level of Pediatric Surgical care. A. Institutions and setting The Rhode Island Hospital complex consists of 27 buildings situated on 52 acres. Major patient care facilities include four adult inpatient care buildings, the Hasbro Children's Hospital, a 12-story ambulatory patient care center, a four-story medical office center, a co-operative care center and the new Andrew F. Anderson Emergency Center. Rhode Island Hospital/Hasbro Children's Hospital is an American College of Surgeons-verified Level One Trauma Center. It serves as a regional tertiary and quaternary center for the entire state, southeastern Massachusetts and eastern Connecticut. The opening of Hasbro Children's Hospital on February 14, 1994 greatly enhanced the Pediatric Surgical program. It is a state-of-the-art pediatric care center incorporating areas dedicated to pediatric emergency medicine, trauma, surgery, intensive care, pathology, and radiology. Two major changes in the physical plant of the Children's Hospital have occurred in the last few years. In 2006, a new Center for Pediatric Imaging vastly expanded the footprint of Hasbro Children's Hospital. It includes MRI, CT ultrasound and fluoroscopy suites. This new center also incorporates a pediatric sedation service, and space for expansion of procedures performed under conscious sedation. Women and Infants Hospital of Rhode Island is the other major component of the Pediatric Surgical program. It serves as southeastern New England's regional perinatal care center and maintains an active and prominent maternal-fetal medicine program with a 23-bed inpatient unit for the care of high-risk pregnancies. The 75-bed neonatal special care unit is a major component of the hospital with preeminence in the care of newborns. Women and Infants Hospital is physically connected to Hasbro Children's Hospital and is a major part of the Brown Medical School programs in Obstetrics and Gynecology, Neonatology, Anesthesia, Pediatrics, Perinatology, Radiology, and Pathology. Clinical and basic science efforts at Women and Infants have been achieved for an outstanding level of NIH extramural funding (including a COBRE grant in Perinatal Biology) that has greatly enhanced the level of our program. In 2007, construction began on a new building complex, which will house a new state-of-the-art neonatal intensive care unit with a capacity of 90 beds. B. General Structure     One Pediatric Surgical resident is selected by the members of the Division of Pediatric Surgery every two years through the National Residency Matching Program. The Resident then proceeds through a structured two-year program leading to eligibility for a Certificate of Pediatric Surgery from the American Board of Surgery. The educational program for Pediatric Surgery takes place within the larger context of medical education sponsored and supervised by The Warren Alpert Medical School of Brown University, Rhode Island Hospital and the Departments of Surgery and Pediatrics. The General Surgery Residency at Brown is structured as a five-year program, leading to Eligibility and Certification by the American Board of Surgery. General Surgery is currently accredited to finish five Chief Residents. The clinical pediatric surgery service is led by the Pediatric Surgery resident and is composed of two PGY-1 and one PGY-4 surgical residents. The Division of Pediatric Surgery enjoys regional academic recognition for senior pediatric surgical experience. Through an institutional agreement with Berkshire Medical Center two PGY-4 residents rotate on the service for two months each, to overlap the busy summer trauma season. Collaborative academic relationships have been developed by the Division of Pediatric Surgery to assist the Alpert Medical School and the Pediatric Residency program. The Department of Pediatrics has added Pediatric Surgery to its PL 2 rotation schedule based on the quality and structure of our educational program for inpatient and outpatient teaching. Two Pediatric residents per month rotate for in- and outpatient experience. The Pediatric Surgery resident leads this team of house officers for a service where the average daily patient census is 25 patients; weekly hospital evaluations average 60. The operative experience is extensive with close to 2000 general pediatric surgical cases per year available for the resident. Additional case volume in special areas of congenital cardiac, otolaryngology, head and neck, endocrine, transplant, and orthopedic surgery adds significantly to the richness of the exposure. Pediatric Urology provides a mandatory rotation with a yearly exposure of greater than 500 cases. The interface between pediatric surgery and the Medical School is well established. Specific clinical or basic science research projects and exposure to pediatric surgery are available to medical students and the Program in Liberal Medical Education, with established rotations on our service. Members of the Division of Pediatric Surgery actively participate in a course in multidisciplinary fetal medicine (BIOL 5720), an initiative that is unique to Brown. The Pediatric Surgical Resident and General Surgical Residents attend and take an active role in presentations at interdisciplinary conferences throughout the Academic Medical Center. The Division meets separately for our specific Morbidity and Mortality conference, as well as its clinical and basic science conferences. The Pediatric Radiology, Urology, Gastroenterology, and Pathology Divisions all have individual conferences with the Division of Pediatric Surgery. The General Surgery Trauma Conference meets every week to discuss weekly trauma cases at Rhode Island and Hasbro Children's Hospital. The Multidisciplinary Pediatric Trauma Patient Care Committee meets twice a month for quality improvement reviews. Pediatric Tumor Board with the residents and faculty of Pediatric Hematology/Oncology, Radiology, Radiation Oncology and Pathology meets twice a month. General Surgery Grand Rounds, Morbidity and Mortality conference, Basic Science, and Patient Management conferences are held weekly and are attended by the Pediatric Surgery Residents and faculty. Throughout the rotation, clinical or basic science presentations are required to be prepared by the PGY-1 and PGY-4 residents. These are then presented at the Pediatric Surgery conferences under the guidance of the faculty. The Department of Surgery has four major lectureships each year under the direction of the Chairman. The Pediatric Surgery Resident and faculty take the opportunity to present clinical and research presentations to invited leaders in American Surgery. Schedules are cleared to attend the lectures, rounds, and conferences. There is a funded Lectureship in Pediatric Surgery named for Frank Deluca MD. Past Lecturers have included Drs. Grosfeld, Altman, Touloukian, Donahoe, Krummel, Ziegler, Stolar, Caniano and Vacanti. The Division of Pediatric Surgery organizes a yearly conference on Pediatric Trauma, in conjunction with Lifespan, Kiwanis of Greater Providence and the Emergency Medical Services of the Rhode Island Department of Health. The pediatric surgical attending, the pediatric surgical fellow, and the residents have formal daily teaching rounds in Hasbro Children's Hospital, giving the residents an opportunity to participate educationally in diagnostic and perioperative care. Hasbro Children's Hospital's Emergency Room takes all pediatric trauma and burn cases. All trauma cases and burn patients are admitted to the Pediatric Surgery service. As was tragically confirmed with the Station Night Club fire in 2003, where all 50 patients admitted to this institution (with burns of up to 85% body surface) survived, Rhode Island Hospital and its burn service are a nationally recognized facility offering state-of-the art burn care and results that meet or exceed current standards. The majority of admissions to the Neonatal Special Care Unit originate from the hospital's own Labor and Delivery Unit which, with close to 10,000 births each year, is the largest in Rhode Island and the second largest in New England. In the NICU, the Resident and on call Attending are primarily responsible for pmreature and full-term neonates with surgical conditions, and co-manage neonates with multi-system problems. Full-term neonates with mothers to be discharged are transferred to the Surgical service in the PICU or the 4th floor at Hasbro. Since 1994, the Hasbro operating suite has grown from 4 to 6 operating rooms. There is a scheduled operating room for pediatric surgery every day of the week with an ample one-room extension to 2 rooms 3 days a week. C. Faculty changes and recent accomplishments Since obtaining Accreditation in 1997, several major changes have taken place within the Pediatric Surgery Residency Program. New initiatives in living related renal transplantation, pancreas transplantation, burn surgery, craniofacial and endocrine surgery have opened and will provide increased exposure to these expanding areas to our training program. A multidisciplinary ECMO program to support cardiac surgery and neonatal and pediatric respiratory failure has been funded with equipment and a full pediatric trauma transport team has been in place for several years. In 2000, the Warren Alpert Medical School of Brown University sanctioned the University-wide Program in Fetal Medicine. This initiative is the first such progam in the country and combines Pediatric Surgery, Maternal - Fetal Medicine and Neonatology and more than 15 Pediatric and Surgical subspecialties, representing 3 hospitals, for the teaching of medical students and training of residents and fellows. Its BIOL 5720 Introduction in Multidisciplinary Fetal Medicine is a preclinical elective seminar aimed at 1st and 2nd year medical students. The program is the academic counterpart of the clinically oriented Multidisciplinary Antenatal Diagnosis And Management ("MADAM") conference, held twice a month. It also provides an umbrella for novel basic and clinical science approaches to fetal treatment. This has given rise to the newly established Fetal Treatment Program, which initially incorporated services at the New England Medical Center in Boston. Through this program, the first cases of in utero surgery were performed at Hasbro Children's Hospital in 2000. Since then, more than 50 fetal operations have been performed, including laser ablation of placental vessels for twin-to-twin transfusion syndrome, cord ligation for acardiac twins, EXIT procedures and fetal tracheal occlusion for severe diaphragmatic hernia. fThe Fetal Treatment Program has become the designated regional fetal surgery center for other New England institutions, including Brigham & Women's Hospital in Boston and Yale Medical Center in New Haven. PAtient referral has been extended as far as Georgia, Minnesota and North Dakota. In 2005, Dr. Christopher Muratore joined the division, as Dr. Conrad Wesselhoeft retired from practice after a very long career in expert thoracic and general pediatric surgery. Dr. Muratore has special interest and expertise in the management of pulmonary hypoplasia and congenital diaphragmatic hernia, having been part of a premier basic science research lab focused on pulmonary hypoplasia, as well as the country's leading longitudinal CDH clinic, at Boston Children's Hospital. Further interests include laparoscopic and thoracoscopic procedures and fetal surgical interventions. There is a longstanding tradition of minimally invasive surgery at Rhode Island Hospital, where Dr. Joseph Amaral (who was the hospital's president from 2003 to 2007) was one of the developers of the harmonic scalpel. Since then, the institution has maintained a strong emphasis on laparoscopic and thoracoscopic procedures, not in the least through its ventures with industrial partners: Rhode Island Hospital is wired, through a collaboration with Ethicon Endosurgery, as a telemedicine center, and a more recent association with Storz Endoscopy has helped create the "operating room of the future" in the newly completed 'Bridge' operating suite. This tradition of excellence in minimally invasive surgery was further consolidated when Dr. Jeremy Aidlen joined the group in 2008, bringing the number of pediatric surgeons to five. Dr. Aidlen, who trained at Schneider Children's Hospital in Long Island, NY, has developed a particular expertise in advanced laparoscopic and thoracoscopic surgery, including minimally invasive approaches to bariatric surgery in adolescents. The Chairman of the Department of Surgery is Dr. William Cioffi. He is a national leader in Trauma, Critical Care and Burns. He is responsible for the formation and maintenance of our Level I Trauma Center. His expertise in burn surgery has allowed him to recruit Dr. David Harrington to provide an added dimension for treatment of those infants and children with burns that now exceed 40%. In addition we received funding and grant support to provide critical care nurses with the additional training to care for infants and children that previously required transfer to a formal burn unit program as provided by the Shriners Institute in Boston. Dr. Paul Morrisey has successfully maintained a living related renal transplant program. His is currently the busiest kidney transplant program in the region. The pediatric surgery resident participates in the pediatric transplant cases, which are cared for on the pediatric surgical service. The multidisciplinary Airway Management Program is a collaboration between two highly expert specialists, Dr. Sharon Gibson, pediatric otorhinolaryngologist and Dr. Tracy. This program is yet another example of how the modern approach to medicine transcends divisional boundaries. It provides expert, long-term care for patients with tracheal stenosis and other congenital or acquired conditions of the upper respiratory tract. Special initiatives of the Airway Management team include a VIP program for children with tracheostomies and the care of infants with life-threatening congenital high airway obstruction syndrome (CHAOS), salvaged at birth by EXIT procedures. Pediatric Endocrine Surgery has increased with greater referrals directly to the Division along with access to the residents from Dr. Jack Monchik of the Division of Endocrine Surgery. Dr Thomas Tracy has continued NIH funding in liver injury and repair to further enhance the academic activity of the Division. An FDA grant was obtained to study the effect of cholecystokinin on parenteral nutrition associated cholestasis in neonates. Dr Luks has been funded by the American Lung Association for his studies in pulmonary development. Several research initiatives have also been undertaken with the Division of Engineering at Brown. In addition to mentoring for study groups of Engineering and Economics students, members of the Division of Pediatric Surgery are collaborating with Engineering faculty members and industrial partners to develop novel systems of surgical imaging and non-invasive monitoring devices for fetal surgery. Most recently, Hasbro Children's Hospital and Brown received an Investigational Device Exemption from the FDA for the in utero treatment of severe congenital diaphragmatic hernia, using endoscopic fetal surgery and placement of a detachable tracheal balloon. This was the first such IDE granted for this device; since then, only one other institution (UCSF) received a similar approval; our institutions are the only two centers in the country where this procedure can be offered, and a joint research project is now under way.         2. BASIC SCIENCE The Pediatric Surgery has established the goal of pediatric surgery residency training to ensure development of future outstanding leaders in academic or community pediatric surgery. It is our intention that the pediatric surgical residents gain experience as well to the use of statistical analysis, methods in scientific writing, biomedical ethics, educational techniques, outcome analysis and preparation of grants for peer review. The didactic basic science curriculum is a core curriculum lecture series provided by basic science medical faculty, the Department of Pediatrics and Pediatric Surgery. This lecture series teaches the Resident principles that are the foundations of current clinical practice. Furthermore, this is the fund of knowledge necessary for the resident to begin to ask questions about the evidence for clinical and surgical decisions. From this point they can formulate hypotheses to investigative new directions in pediatric surgical science. The basic science program has been carefully defined to coincide with the curriculum outline accepted by the Association of Pediatric Surgery Program Directors. It is further structured to cover all components outlined by the American Board of Surgery. The lecture series presented by the medical faculty and residents is organized administratively by Dr. Kurkchubasche, the Associate Program Director, and the pediatric surgery resident. Each rotation, the residents, including the pediatric residents who rotate on our service are required to present at the lecture series. A significant emphasis on cellular and molecular development has been infused into the program through the Program in Fetal Medicine. This has drawn a national and international exposure to the basic science of all the multidisciplinary fields represented within the Program. 3. SUPERVISION                                             Our pediatric surgery residency curriculum fosters independent decision-making. This is accomplished by direct supervision and progressive responsibility. The surgical faculty directly supervises the pediatric surgical resident in both inpatient and outpatient surgery and in separate pre- and post- operative surgical office visits. Current supervision and teaching participation are completed within HCFA guidelines across the academic medical center. Direct supervision in the neonatal intensive care unit and in the pediatric intensive care unit is provided by the pediatric surgical attending staff augmented by appropriate consultation with critical care faculty in Neonatology and Pediatrics, respectively. The Pediatric Urology service directly supervises the Pediatric Surgical Resident during his/her rotation on these services. As mentioned previously burns, transplant, endocrine and ENT patients remain under the care of the pediatric surgery team directed by the responsible attending. The first-year resident operates with attending surgeons on all portions of each case. As a chief resident, he/she performs all index cases under the direct supervision of the attending surgeons; the role of the attending surgeon on these cases is modified, as the chief resident matures in confidence, judgment and ability. Gradually, the chief resident assumes complete responsibility for operative decisions. The goal of the program is to train confident, independent pediatric surgeons. This goal can only be met by direct supervision, constant instruction, and a nurturing academic environment. 4. CONTINUITY OF CARE   Continuity of care is assured by having direct pediatric surgical resident involvement in the initial assessment and decision-making process for both elective and emergency admissions. The pediatric surgery resident performs the history and physical examinations on inpatients, participates in that patient's operative procedure and post-operative follow-up. The importance of documenting an understanding of the patient's condition and indication for surgery is stressed to the resident, who is required to evaluate and to write a pre-operative note prior to participating in any given operation. The pediatric surgical resident subsequently dictates the operative findings and writes orders for post- operative treatment given by the pediatric surgical service. If the resident claims credit as the primary operating surgeon for that operation, it requires an operative note. At the time of discharge from the hospital, the resident formulates follow-up plans, including discharge instructions, and assessment of need for a visiting nurse or home therapy. A current understanding of home care and discharge planning is increasingly an element of our residency educational program. To that end we have a masters level, advanced practice nurse. The pediatric surgical office is on the 1st floor of the Medical Office Center. This building is physically connected to Hasbro Children's Hospital and Women and Infants Hospital. There is a well-appointed and well-equipped office that is used by the pediatric resident and faculty. Schedules for the operating room, clinics, and office visits are made by the Chief of the Division of Pediatric Surgery. The chief pediatric surgical resident and faculty oversee all scheduling. The pediatric surgical resident sees all scheduled patients consults and post operative visits hours, Friday 1:30-3:30 PM. All index cases as a Chief Resident are seen at that time with the supervision of the faculty as described. Pediatric Urology cases are followed with that service. The surgical faculty is always available for all clinic and outpatient activities. Decisions made regarding major surgery are discussed at length and reviewed in detail after the resident has fully formulated an original plan, which is analyzed and reviewed with the faculty. In addition a group preoperative conference is held after Morbidity and Mortality conference. 5. EMERGENCY DEPARTMENT The Pediatric Surgical Resident functions as the consultant for all pediatric surgical problems seen in the emergency room. Hasbro Children's Hospital emergency room evaluates 150-250 children per day, making it one of the busiest Pediatric Emergency Departments in the country. It is manned by board-certified pediatric emergency room physicians, fellows and pediatric residents. The pediatric surgical resident's interaction with the emergency room personnel in clinical and educational work is very extensive. The Pediatric Surgical Resident and the service manage all patients with multiple injuries and burns. Rhode Island Hospital and the Hasbro Children's Hospital are the Level I trauma center for the state of Rhode Island, with more than 450 trauma admissions as well as more than 60 burn admissions last year. The Resident and faculty work in conjunction with a nationally recognized trauma team on program development, quality assurance and research projects. Pediatric Surgery assumes the leadership role and full responsibility for each injured child who enters the Southeast New England Trauma System. All pediatric trauma cases are seen in Hasbro. The variety of cases with blunt and penetrating trauma is extensive due to the large inner city and rural geographic area the trauma service covers.   6. WORKING ENVIRONMENT       We adhere to the principle that a surgical resident must be treated with dignity and respect. It is our belief that learning, even under great stress, is accomplished best when there is an atmosphere of collegiality and benevolence. We also believe that time away from the hospital is therapeutic and in the resident's best interest, both professionally and personally. The "Ocean State" is in a wonderful cultural and geographic region in that regard. The call schedule for the pediatric surgical resident is labor-intensive, but not overwhelming. The Pediatric Surgical Resident is on second call every third night with an intern, rotating with PGY 4 residents. He/she is not required to directly supervise the senior general surgery resident on call. However, the pediatric surgery resident is expected to be available for index/neonatal cases and critical care continuity for surgery in the PICU when not on vacation (provided 28 days/year). During the one-month rotation in pediatric urology, the one-month rotation in Neonatology and the one-month rotation in the pediatric intensive care unit during the first year, the pediatric surgical resident is on call for general pediatric surgical evaluations after 6:00 PM. It is not mandatory that the pediatric surgical resident remain within the hospital when on-call, but it is stressed that the pediatric surgical resident must be within a ten-mile radius at all times. When the pediatric surgical resident is on vacation or when it is necessary for him/her to be out of town on other occasions, appropriate arrangements are made with the general surgical senior resident for coverage. The pediatric surgical resident spends 60 to 70 hours per week at the hospital, depending on the circumstances for a given week. The resident living quarters and dining facilities are all superlative at the Hasbro Children's Hospital. The moment the pediatric surgical resident begins training at Brown, the faculty becomes available for any type of professional, personal or emotional support needed at any time during the Residency. Professional psychiatric and social work help is available when it is perceived or indicated by the residents of faculty. Confidentiality is strictly maintained. Our investment in the resident is both professional and personal.   7. RESEARCH Access to research opportunities is excellent in the Division and Department. The Division of General Surgical Research is a vital aspect of our program, as the 7,782 square foot of laboratory space and the 1,555 square feet of space are held by Pediatric Surgery. The laboratories are well equipped with analytical tools and have technical personnel who are attuned to interactions with surgical resident-investigators. The last Research Fellow in pediatric surgery worked in this environment for 7 national clinical and basic science presentations. We have made it mandatory that our Pediatric Surgical Resident submit at least one article per year and submit an abstract to either APSA or the Academy of Pediatrics Surgical Section, each year. The Neonatology basic science laboratory facilities are also available to the Pediatric Surgical Resident, and direct support from NIH and the American Lung Association are available. In addition, the perinatal physiology laboratory has been the center for investigations by the pediatric surgical faculty. The active research of Dr. François Luks has generated much interest and work at the Brown University campus-based animal laboratory where the pediatric surgical resident participates in bench research surgery. A list of recent publications can be found on this web site. 8. EVALUATION The performance of the pediatric surgical resident is evaluated in a detailed and comprehensive manner. Pediatric Surgery uses an evaluation system which is similar to the one used for General Surgery, yet our evaluation involves other facets that are unique to our training program. Every six months all of the faculty complete a comprehensive evaluation. The Resident is then invited to formally meet with the Program Director and faculty to cover progress in the Program. Prior to discussing the evaluations, the resident is given ample time to fill out his own evaluation form. The resident then discusses and compares his evaluation with that given by the faculty. This format allows for unique dialogue to discuss the Resident's strengths and weaknesses. These meetings enable both the resident and the faculty to speak freely concerning the training program, the faculty, the pediatric surgery teaching curriculum, as well as the resident's performance. All evaluation, papers written and other pertinent data concerning the resident's performance are kept confidentially in a personal file.