Training Environment - Child Abuse Pediatrics Fellowship

The CAP Fellowship goals and objectives in years 1, 2, and 3 emphasize the development of fellows’ competence in recognizing and managing all forms of child maltreatment including physical abuse, sexual abuse, neglect, emotional and/or psychological abuse, factitious disorders (medical child abuse), and abuse by poisoning. Fellows gain the majority of their clinical training in recognizing and managing child maltreatment during their CARE/CARES rotations at the Children’s Regional Hospital at Cooper and the CARES Institute. The fellow will gain additional skills and knowledge during their subspecialty rotations and advocacy rotations. An approach of progressive responsibility is employed to provide the fellow with the optimal learning experience.

CAP/CARE/CARES Rotation

This is the core rotation in which fellows will participate in outpatient and inpatient consults and on-call coverage under the supervision of Child Abuse Pediatricians at CARES Institute and Cooper University Health Care. In addition, fellow will have exposure to clinical experiences in our CHEC program providing medical evaluation to children in the foster care system under the supervision of faculty general pediatricians, as well as exposure to mental health evaluations and therapeutic services under the supervision of CARES psychologists. The fellow will also have opportunity to observe initial evaluations as well as didactic sessions with the Postdoctoral fellows to learn about Trauma Focused Cognitive Behavioral Therapy (TF-CBT) and Combined Parent Child-Cognitive Behavioral Therapy (CPC-CBT.) Weekly Faculty-Fellow conferences will be held each Friday, including didactic sessions, journal club and case conferences.

During the CARE/CARES rotations, the fellow will gain experience evaluating and managing all forms of child maltreatment as part of a multi-disciplinary team in multiple settings:

The CARES Institute outpatient services is where fellows will participate in the medical evaluations. Each year, nearly 1,400 patients are evaluated at CARES Institute due to concerns of abuse. Teaching and feedback will be regularly provided to the fellow in CARES clinic. In the Comprehensive Health Evaluations for Children (CHEC) program, each year over 430 children who are placed into foster care and kinship placements receive a comprehensive medical and psychological evaluation.

The CARES Institute is the regional diagnostic and treatment center (RDTC) for seven counties in southern New Jersey. During the first year, the fellow will attend at least one MDT meeting for each county and will be assigned to regularly participate in a county MDT for the second and third year along with a faculty member. The fellow will also participate in southern regional Child Fatality Near Fatality Review Team Meetings. Locations are at the Rowan University-School of Osteopathic Medicine campus in Stratford, NJ, and CARES in Vineland, NJ.

The Inpatient Child at Risk Evaluation Team (CARE) Consult Service is where CAP fellows will evaluate and manage patients as part of a multi-disciplinary team, including an attending CAP and a full-time social worker. More than 60 medical consults are provided by the inpatient CARE consult service per year for concerns of child maltreatment. When on inpatient call, the CAP fellow will serve as the initial point of contact for consults and are placed in a role of team leader, when they have demonstrated the ability to assume that role. With guidance and direct supervision from Dr. Kathryn M. McCans and other CAP faculty, and assistance from the team social worker, the fellows will perform consultations throughout the hospital.

Emergency Department

The fellow will rotate in the Pediatric Emergency Department for one month in their first year to focus on pediatric injury to improve skills in differentiating accidental from abusive trauma, and the deciding initial workup of abuse and neglect.

Pediatric Sexual Assault Response Team (P-SART)

The fellow will be assigned clinical time to be on-call with the Pediatric SANE/SART team to learn the evaluation and management of acute sexual assault. As members of the SART team, the CAP fellow will perform acute sexual assault evaluations including forensic evidence collection and photo documentation and guide the medical management. Follow-up care will be coordinated by the fellow. The fellow will review all cases with the CAP faculty. In addition, the fellow will receive SART workshops early in the first year and booster sessions each year for the second and third year on the use of the colposcope and photo-documentation procedures; and performing evidence collection, given Subspecialty Elective Rotations.

Elective Subspecialty Rotations

The fellow will have the opportunity to choose elective rotations with particular relevance to CAPs to allow the fellow to expand differential diagnosis, thereby preventing the misdiagnosis of abuse or neglect, including but not limited to: ophthalmology, radiology and neuroradiology, orthopedics, genetics, neurology, adolescent medicine, toxicology and gynecology. Additional experiences are possible based on the fellow’s interests.

Advocacy/Policy

The fellow will have the opportunity to visit regional agencies and organizations which interact with and provide services to families affected by abuse or neglect to learn the system of care available to our patients, including Children Protective Services Agencies such as the NJ Division of Children Protection and Permanency, Criminal and Family Court, etc. The fellow will also set up visits with local and regional policy makers to learn how policy affects our ability to care for our patients and to learn their role in and ability to affect change. During this block, the fellow will continue to have clinical responsibilities in the inpatient and outpatient consultations.

On-going Feedback

Our belief is that through on-going informal and formal feedback, a fellow will be able to develop the capacity to self-evaluate as means of continuous improvement. The fellow’s competence will be evaluated through direct observation, daily clinical encounter evaluations, self-evaluations, monthly evaluation by faculty and global assessment, and semiannual in-person evaluations as outlined below. Global assessment and semi-annual evaluations will be available online through New Innovations at Cooper

Expert Opinion and Testimony

Fellows will develop expert reports and provide testimony for cases for which they provide the primary assessment with direct oversight by the program director or attending CAP. The first year fellow will observe testimony in family and criminal court proceedings and testify as an examining physician witness as requested. The second year fellow will begin to testify as an examining and/or expert physician witness. By the third year, the fellow will understand the New Jersey family and criminal investigative systems and how this knowledge will translate to other potential jurisdictions where the fellow may practice. By the third year, the fellow will be prepared to effectively and independently testify as an examining or expert physician for family and criminal court proceedings. Prior to testifying in court the fellow will have a court testimony preparation session with a faculty member to discuss the fellow’s planned testimony. Fellows will keep a log of the number and type of cases in which they have testified. Efforts will be made to observe each fellow testifying in court at least twice during his or her fellowship. Direct feedback and debriefing of the testimony points are provided by the faculty regarding successful performance and identified challenges. In addition, the fellows will solicit feedback on testimony performance from the attorney with whom they testified.

Call Responsibility

CARES provides on-call telephone consultative services for the southern region of NJ, and inpatient and telephone consults at Cooper University Health Care. Clinicians and fellows alike take call as scheduled on a rotation basis (shared with the seven CAPs) and follow the cases acquired during call through completion and conclusion of the case. There is no in-house overnight call. However, if a child presents with acute or severe injuries, the fellow may need to go in to the hospital during the night or weekend.