DEPARTMENT OF PEDIATRICS

The Albert Einstein College of Medicine
Montefiore Medical Center

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Administration

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MESSAGE FROM THE CHAIRMAN

All who care about children must care deeply about the education of those who provide their health services. [1]

Many of the important health needs of today's infants, children and adolescents are not being met as effectively and as fully as they should be. The Department of Pediatrics of the Albert Einstein College of Medicine/Montefiore Medical Center, with its affiliated hospital services, is dedicated to identifying and meeting these needs now, as well as to developing the various educational strategies necessary to prepare pediatricians to meet future needs.

The foundations upon which health promotion and disease prevention among children are based appear bounded by several limiting factors. These include the genetic potential of the fetus, as well as the physical, chemical, biological, psychological and social environments in which children are reared. The scientific exploration of all these limiting factors is a primary goal of the Department. It is this exploration that will, ultimately, lead to the proper preparation of pediatric clinicians and, so, to more effective health care for children. The residency program is, thus, incorporated into the full expanse of departmental activities and, as such, is central to all of our many missions.

Michael I. Cohen, M.D.
Professor & Chairman

1. The Future of Pediatric Education, a Report by the Task Force on Pediatric Education, 1978

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INTRODUCTION

Although its origin dates only to the mid 1950's, the Department of Pediatrics of the Albert Einstein College of Medicine/Montefiore Medical Center has a rich and impressive history. The founding faculty of the Department, a group of internationally-renowned pediatricians of diverse backgrounds, shared a common goal: to create a Department that would offer state-of-the-art care for the children of the Bronx, produce an outstanding educational experience for medical students and residents, and advance our understanding of the biological and social processes affecting the well-being of children. The early faculty included Dr. Henry Barnett, the Department's first Chairman and a founder of pediatric nephrology; Dr. Bela Schick, a pioneer in immunology who developed the test for immunity to diphtheria and in whose honor the Department was originally named; Dr. Harry Gordon, a founder of neonatology and a Dean of the Medical School; and Drs. Lewis Fraad and William Obrinsky, leaders nationally in general pediatric education. Among other prominent pediatricians who helped shape the Department were Drs. Laurence Finberg, Chester Edelmann, Abraham Rudolph, Lawrence Taft and Lawrence Gartner. The standards they set, with their dedication to excellence in teaching and patient care, as well as in science, continue to serve as a model for the generations of pediatricians who graduate from the residency program. Many of our graduates have themselves contributed to the Department's tradition, assuming positions of leadership at home with us, or going on to serve as leaders within other programs throughout the United States.

The philosophy guiding the Department today has its roots in our tradition: like our founders, we believe every infant, child and adolescent, both in health and in disease, must be understood not only as an individual, but also as a member of a family, a community and a culture. Only by trying to see each patient in all these lights can residents learn to be humane and comprehensive in their practice of pediatric medicine.

Consistent with this philosophy, our Department pioneered the development of continuity clinics for residents, so that house officers would experience not only the episodic needs of the seriously and critically ill patient, but also the day-to- day problems of children and their families. This commitment continues today, as the Department dedicates itself to creating new models for the delivery and teaching of pediatric primary care, while serving as the mainstay for the subspecialty and tertiary care needs of the children of our region.

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The Albert Einstein College of Medicine / Montefiore Medical Center Complex

The Albert Einstein College of Medicine and the Montefiore Medical Center, together with their affiliated institutions, constitute the major health resource for the 1,200,000 people of the Bronx. In addition, the Einstein/Montefiore Complex serves as a tertiary care referral center for southern New York State, southern Connecticut and northern New Jersey.

Today's Department of Pediatrics grew from two programs originally affiliated separately with Einstein and Montefiore. The two institutions began to create unified clinical departments under the direction of single chairpersons in 1977, and the unification of the Department of Pediatrics was effected in 1980, bringing a vast biomedical resource together in a single organized unit.


THE CHILDREN'S MEDICAL CENTER

Gerald Nathenson, M.D.
Pediatrician-in-Chief
Nathan Litman, M.D.
Assoc. Pediatrician-in-Chief

The Children's Medical Center, located at Montefiore's Moses Division and at North Central Bronx Hospital, is a consolidated 145 medical-surgical bed facility, providing comprehensive child care services. It functions as the primary residency training site of the AECOM/MMC program in pediatrics. The Moses Division, a 745-bed full service teaching hospital located in the northwest section of the Bronx, is the largest component of Montefiore Medical Center. The North Central Bronx Hospital, a modern 420-bed municipal facility, is directly connected with the Moses Division by a set of walkways, providing easy access between the buildings. For the Pediatric Residency Program, these two institutions function as one, thus creating a single Children's Medical Center within their walls.

Patients receive care on seven distinct units, including a 25-bed Infants' Unit, housing patients from birth to two years of age; a 19-bed Children's Unit, for patients two to 12 years of age; the 20-bed Susan G. Benson Adolescent Unit, among the first inpatient facilities in the country devoted exclusively to the treatment of young people from 13 to 21 years old; and a 37-bed General Pediatric Unit, for children of all ages.

Also part of the Program's inpatient training service are a Level III 30-bed Neonatal Intensive Care Unit and a 14-bed Pediatric Critical Care Center, providing state-of-the-art medical and surgical care to critically ill newborns and children. A Well-Baby Nursery, supporting an active Labor and Delivery Suite, completes the complement of inpatient units housed at the Children's Medical Center.

Integral to the care of children hospitalized on any of the Center's inpatient units is a wide range of psychosocial and educational support services, including a school and an extensive Child Life Program. In addition, there are Child Protection Services and a Lead Screening Program. The Children's Medical Center also provides a full array of pediatric subspecialty programs, both medical and surgical, offering care to children on the inpatient units as well as in a variety of ambulatory settings. Pediatric laboratory services, with sophisticated microchemical technology, and a full complement of pediatric imaging facilities also contribute to the broad diagnostic and therapeutic capabilities available for the care of our patients and the education of our house officers.

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COMPREHENSIVE PEDIATRIC PRIMARY CARE CENTER

Ruth E. K. Stein, M.D.
Pediatrician-in-Chief
Andrew Racine, M.D., Ph.D.
Asst. Pediatrician-in-Chief

An enduring strength of the Department has been its responsiveness to the changing needs of patients and trainees, through the development of innovative and creative programs that have become models for pediatric care and education beyond our own institution. Continuity clinics in which residents learn the practice of primary care, comprehensive case managed home care for children with serious chronic illnesses, clinics for teenage mothers in which adolescent women and their babies receive care together, coordinated medical and social care by a multidisciplinary team for children infected with HIV -- our Department has shared in pioneering all these programs.

In this tradition the Comprehensive Pediatric Primary Care Center was developed at the Jacobi Medical Center to serve as the Department's principal training site for primary care. Directly adjacent to the campus of the Albert Einstein College of Medicine, about four miles from the Children's Medical Center, the Primary Care Center affords an exciting integration of ambulatory and in-patient care delivered by teams of attending pediatricians, nurse practitioners, physician assistants, house officers and medical students. The teams function as model group practices within a busy municipal hospital, with more than 45,000 pediatric clinic visits and about 3,000 admissions each year. The Comprehensive Pediatric Primary Care Center provides coordinated, ongoing and personalized health services to a needy population of children. At the same time, it is a major training resource for residents and students within a model that combines community-based care with all the advantages of medical school proximity. As part of their experience at the Primary Care Center, residents also learn emergency pediatrics on a service that manages more than 50,000 visits each year as part of the Jacobi Medical Centers New York State-designated Trauma Center.

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Divisions of the Department

The Department of Pediatrics has a faculty of 150 full-time members, with another 150 voluntary attendings. We also host about a dozen visiting faculty members at any time, and nearly 25 individuals who have primary appointments in other departments at the Albert Einstein College of Medicine hold secondary appointments in Pediatrics.


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Allied Services

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THE PEDIATRIC RESIDENCY PROGRAM

Henry M. Adam, M.D.
Director
The Department of Pediatrics offers its residents a rich training experience within a wide variety of clinical settings. While we expect our house officers to develop extensive skills in the complexities of tertiary care medicine, our fundamental objective is to educate physicians who are comfortable with all the elements essential to excellent health care for children. By training our residents as outstanding general pediatricians, we prepare them for every possible opportunity, for primary or subspecialty care, for private practice or fellowships leading to academic careers.

To complement the clinical training offered in our two major learning sites, the Department's Division of Pediatric Education has developed a comprehensive program of teaching rounds, conferences, lectures, seminars, workshops and journal clubs. Together, these provide a solid didactic grounding for the practical clinical experience, as well as prepare the house officer for successful completion of the requirements for certification prescribed by the American Board of Pediatrics.

To personalize the residency even further, each house officer has supervision sessions with a faculty preceptor from the Division of Education. The Division also organizes off-site retreats for PL-1 and PL-2 residents, which afford the house staff an opportunity for program appraisal and feedback in a relaxed and supportive environment away from the hospitals.


The PL-1 YEAR

Appointments to the first-year program are open to graduates of accredited medical schools. Each group of PL-1 residents includes house officers in the general pediatric track, as well as those from the special training tracks that are described below. The clinical experience during the PL-1 year provides an in-depth exposure to pediatric medicine in three basic settings: inpatient units, nurseries and ambulatory centers. The experiences are carefully structured to assure extensive contact with children of all ages who have a wide variety of problems.

On the inpatient rotations, which comprise approximately six or seven months of the first year, the PL-1 resident joins two or three other PL-1s and a supervising second or third year resident, as well as several medical students, on a clinical care team. The day is a blending of direct patient care and educational activities, with early morning work rounds directed by the supervising resident, formal teaching rounds led by the team's attending pediatrician, as well as radiology rounds and didactic conferences. The first year resident has the closest contact with the patient and family, as the direct care giver responsible for the initial evaluation and then for the implementation of each child's ongoing management.

For two months during the year the PL-1 works in the neonatal intensive care unit, again participating on a clinical care team with other PL-1s under the direction of a supervising resident and a fellow in neonatology, along with an attending neonatologist. In addition to direct patient care, the day is devoted to a variety of educational activities, including both work and formal teaching rounds, radiology rounds, and a curriculum of conferences devoted to teaching major issues in the assessment and management of the critically ill newborn.

The experience in ambulatory care is enriched for the PL-1 by the diversity of its components, each of which incorporates formal didactic sessions as well as direct clinical care:
  1. Each PL-1 spends significant blocks of time in the Pediatric Emergency Room of the Comprehensive Pediatric Primary Care Center. This experience, supervised by faculty with specific expertise in pediatric emergency care and by fellows in pediatric emergency medicine, allows the first year resident to develop the knowledge and skills necessary for the "first-contact" assessment of sick children with a diversity of presenting complaints.

  2. PL-1 residents likewise participate in the outpatient care of children with illnesses requiring subspecialty skills. Both at the Comprehensive Pediatric Primary Care Center and at the Children's Medical Center, there is a full array of pediatric subspecialty clinics which serve as teaching sites for the house staff.

  3. Most importantly, each house officer in the first week of residency joins a primary care continuity team, an experience that carries through all three years of the residency. Along with other house staff, nurse practitioners and supervising pediatric faculty, the PL-1 begins to develop a panel of patients who will provide substantial training in preventive health care, developmental and behavioral pediatrics, and in the issues related to long-term management of infants, children and adolescents with an array of chronic illnesses.

A TYPICAL PROGRAM FOR A PL-1 RESIDENT

(under construction)

First year residents, like PL-2s and -3s, have four weeks of vacation, divided into two blocks of two weeks during months assigned to ambulatory care. The on-call schedule varies with the rotation: on inpatient units and in the nursery, PL-1s work every fourth night, with early sign-out on days following call; during their ambulatory care rotations they also take call on average every fourth night -- in the emergency room, from 5 PM only until midnight.

PL-1 residents have available to them at all times the immediate support of more experienced pediatricians, including second and third year residents, chief residents and attending faculty members. At all clinical sites within the Department, house officers have 24-hour access to a pediatric library and to MEDLINE, a computerized literature search system.

The Residency Program also places serious emphasis on the role of the house officer as teacher. During their Pediatric Clerkship students from the Albert Einstein College of Medicine are assigned to PL-1 residents on the inpatient services. We encourage the house staff to accept this responsibility with enthusiasm, as an important element in their own learning experience.

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THE PL-2 YEAR

The second year of training is open to individuals who have successfully completed a full accredited year of pediatric residency. In addition to about three months of inpatient work intended to bring the PL-2 resident into a supervisory role, a significant segment of the second year provides a variety of experiences within the pediatric subspecialties. Of course, the resident continues to have experiences in the ambulatory setting, both in the emergency room and in continuity clinic.

During the second year, the resident is on-call every fourth night, with early sign-out on days following call.

A TYPICAL PROGRAM FOR A PL-2 RESIDENT

(under construction)

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THE PL-3 YEAR

PL-3 residency positions are available to individuals who have successfully completed two years of accredited pediatric house staff training. The third year of residency provides the house officer with an increasing level of responsibility, for the educational supervision of their junior colleagues as well as for more independent management of their patients. Senior residents also have elective opportunities that are not available earlier in the program. Just as in the first two years of training, PL-3 residents continue to benefit from their experience in continuity clinic, where they will have developed a panel of children with a wide variety of medical and psychosocial problems, and with many of whom they will have formed significant relationships.

The on-call responsibility for senior residents remains every fourth night, with early sign-out on days following call. There are two "free-elective" rotations in the third year, when the house officer has no night call at all.

A TYPICAL PROGRAM FOR A PL-3 RESIDENT (under construction)

Another critical component of the training program is the Chief Residency. Each year our chief residents, all of whom have completed three years of training in general pediatrics with us, play an integral role in both the educational and clinical activities of the house staff. The chiefs not only organize and coordinate the day-to-day operation of the program, but they serve too as the most immediate resource to the residents, providing clinical expertise as well as personal support. They also act as diplomatic liaisons between house staff and faculty or administration, when the need arises.

Career counseling is available to all our residents, usually beginning in the PL-2 year. Along with preceptors from the Division of Education, faculty members from subspecialty, ambulatory and general pediatric divisions offer career guidance to the house staff. Our graduates have chosen a wide range of rewarding paths: over the past 10 years, approximately 30% have entered into the practice of primary care pediatrics, while about 70% have opted for fellowships in the full array of specialty areas at excellent programs throughout the country.

AFFILIATED FACILITIES AND PROGRAMS

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ROSE F. KENNEDY CENTER FOR RESEARCH IN MENTAL RETARDATION AND HUMAN DEVELOPMENT

The Rose F. Kennedy Center, a 9-story building connected to the Jacobi Medical Center Center by a series of bridges, is an integral part of the Albert Einstein College of Medicine and the Department of Pediatrics. A site for basic pediatric research in genetics, perinatology, nephrology, biochemistry, psychology, sociology and the neurosciences, the Center also houses clinical activities involving evaluation and treatment of children with developmental disabilities. The Children's Evaluation and Rehabilitation Center (CERC), which occupies most of the first two floors of the Kennedy Center, is the major program in the Bronx for the diagnosis and treatment of children with disabilities. Residents spend one rotation in CERC, where they have a supervised experience in CERC's interdisciplinary units evaluating children of different ages with developmental problems, as well as observing various intervention and treatment programs.

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PEOPLE'S REPUBLIC OF CHINA ROTATION

Through an arrangement with Beijing Children's Hospital, one or two of our chief residents-elect have the opportunity to spend two months of their PL-3 year visiting in China. The residents observe in-patient and ambulatory pediatric services, both in Beijing and at more rural sites throughout the country. The Department of Pediatrics, in return, trains young Chinese scientists in our research laboratories. This exchange program has proven to be an enriching experience, culturally as well as medically, for the residents who travel and for those who spend time with our guests from abroad.

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NEW YORK CHILDREN'S HEALTH PROJECT

The Department's Division of Community Pediatrics operates the nationally-known New York Children's Health Project, an innovative program delivering desperately needed pediatric care to homeless and medically under-served children in the metropolitan area. Working from mobile vans, physicians and nurses provide comprehensive primary care including immunizations, health screens, and coordination of more sophisticated medical services to some of the most vulnerable infants and children in New York City. Residents may elect to spend a one month block with the Project, a unique opportunity to work with an alternative health care delivery system designed to meet the very special needs of the city's growing population of homeless children. The Project has now become a model in both urban and rural settings, as it is being replicated widely throughout the country.

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PEDIATRIC OUTREACH PROGRAM (POP)

Created in 1970 as a distinctive pediatric ambulatory care program for children with chronic illnesses, POP has developed into a nationally recognized model for the delivery of services to children with special health needs. Teams of pediatricians and nurse practitioners, based at the Comprehensive Pediatric Primary Care Center, provide long-term coordinated primary and specialty medical services, as well as health education, family support and community advocacy, for children with complicated diseases. Medical students, residents and fellows have the opportunity to participate in the Program during elective time.

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PEDIATRIC CONSULTATION SERVICE (PCS)

Also based at the Comprehensive Pediatric Primary Care Center, PCS is a multidisciplinary team of general pediatricians, nurse practitioners, social workers, a pediatric immunologist, a child psychologist and other support staff devoted to providing comprehensive care to children infected with the Human Immunodeficiency Virus. In addition to direct services for the children and their families, in both the ambulatory and inpatient settings, the program offers consultation and education to primary care providers and house staff in their encounters with HIV-infected patients. PCS is also available to students, residents and fellows as an elective experience.

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BLYTHEDALE CHILDREN'S HOSPITAL

Located in Westchester County, just north of the Bronx, the Blythedale Children's Hospital is an independently run pediatric rehabilitation center that provides inpatient and outpatient services for children with orthopedic, neurologic, pulmonary and cardiac disorders. Blythedale is home to an outreach program of the Department's Center for Congenital Disorders, and is the site for our Spina Bifida and Marfan Syndrome Clinics. Residents in the Department of Pediatrics may elect to spend time at Blythedale.

AFFILIATED RESIDENCY PROGRAMS

The richness and variety of the clinical and educational resources at Einstein/Montefiore have given the Department of Pediatrics the opportunity to develop a series of innovative affiliated residency training programs, designed to meet some of the special challenges child health care providers will face in the coming century. Residents in these affiliated programs, for at least part of their training, work and learn within the Department, indistinguishable from our residents in the general pediatric track. Acceptance to one of these affiliated programs may involve specific arrangements with the program's own coordinator, and possibly a separate match through the National Residency Matching Program. Each of these programs fulfills the requirements of the American Board of Pediatrics, as well as those of other specialty boards where applicable. For more information, please write to the Director of the Division of Pediatric Education, or to the appropriate Program Coordinator listed below.

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THE RESIDENCY PROGRAM IN SOCIAL PEDIATRICS

Established in 1970, the social pediatrics residency training track is dedicated to preparing primary care physicians who will address the needs of underserved and impoverished children and the communities in which they live. The three year training program combines rigorous inpatient activities at the Children's Medical Center with a strong experience in community-based primary care. The program accepts four to six trainees each year. For further information, please write:

Lydia Gonzalez, M.D.
Director, Social Pediatrics Program
Montefiore Medical Center
3544 Jerome Avenue
Bronx, New York 10467

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PEDIATRIC-GENERAL PSYCHIATRY-CHILD PSYCHIATRY TRACK ("THE TRIPLE BOARD PROGRAM")

The Einstein/Montefiore complex is one of six sites in the United States at which this five-year innovative training program has been accredited through special arrangements with the American Boards of Pediatrics and General Psychiatry, and the Committee on Certification in Child Psychiatry. Successful graduates of the Triple Board Program are board eligible in all three of these specialties. The program, which accepts two PL1 residents each year, offers two years of residency training in pediatrics followed by three years in a combined general and child psychiatry experience. For information, please write:

Audrey Walter, M.D.
Director, Triple Board Program
Department of Psychiatry
Jacobi Medical Center
Nurses' Residence, 4th Floor
Pelham Parkway and Eastchester Road
Bronx, New York 10461

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PEDIATRIC REHABILITATION TRAINING PROGRAM

This program, administered jointly by the Departments of Pediatrics and Rehabilitation Medicine, is designed to prepare physicians in the specialized field of pediatric rehabilitation and is specifically directed toward care of handicapped children. The program, which accepts one or two PL-1 residents each year, encompasses a five year training experience, half in general pediatrics and half in rehabilitation medicine. Upon successful completion of the residency, trainees are board-eligible in both Pediatrics and Rehabilitation Medicine. For further information, please write:

Henry M. Adam, M.D.
Director, Residency Program
Department of Pediatrics
Montefiore Medical Center
111 East 210 Street
Bronx, New York 10467

E-mail: < adam@aecom.yu.edu>

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PEDIATRIC SCIENTIST TRACK

Developed to prepare physicians for a career in either clinical or basic scientific research, the Pediatric Scientist Training Track accepts two PL-1 residents per year. The program includes an initial two year general pediatrics training experience, followed by three years in a subspecialty area. Subspecialty training usually consists of two years in a research laboratory and one clinical year. Graduates of the five year program are eligible for certification by the American Board of Pediatrics, as well as by most of the subspecialty boards. Because of the nature of the training experience, candidates who have attained both the M.D. and Ph.D. degrees are preferred. For information, please write:

Marshall Horwitz, M.D.
Department of Pediatrics
Albert Einstein College of Medicine
1300 Morris Park Avenue
Bronx, New York 10461

E-mail: < horwitz@aecom.yu.edu>

FELLOWSHIP TRAINING

The Department of Pediatrics has a strong commitment to training post-graduate fellows, supporting programs in 19 subspecialty fields. More than 70 fellowship positions are available to physicians who have completed three years of general pediatric residency at accredited institutions and to other doctoral recipients. Each fellowship training program is administered by the appropriate departmental Division. The Fellowship Director, in conjunction with faculty members within each Division, is responsible for choosing fellows, for setting the training curriculum, and for supervising each fellow's course of study. In addition to providing inpatient consultation services and gaining experience in outpatient management of subspecialty patients, fellows learn to develop and carry out focused research in a particular area of interest. To help prepare the fellows for their research experience, the Department sponsors a formal course in research techniques, including statistical analysis and ethical issues.

For information regarding a fellowship, please write directly to the specific Division Director, in care of the Department of Pediatrics, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, New York 10461.

ANNUAL PATIENT CARE STATISTICS

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NEW YORK LIVING

The Children's Medical Center and the Comprehensive Pediatric Primary Center are located in pleasant residential communities in the north Bronx, easily accessible to Manhattan by car or by public transportation. There are excellent leisure time activities just a short distance away from both campuses: the world famous Bronx Zoo, the New York Botanical Gardens and, of course, Yankee Stadium. For golfers, the Van Cortlandt Park course is only a block away from Montefiore, while tennis, horseback riding and sailing off City Island are a few minutes away from the Comprehensive Pediatric Primary Care Center. For the culturally inclined, the nearby Lehman College Center for the Performing Arts offers opera, concerts, theater and dance.

The recently opened Falk Athletic Center on the Einstein campus is available to the Department's residents and fellows. The gym features an Olympic-sized indoor swimming pool, as well as a running track, a weight room, and regulation basketball and racquetball courts.

Beyond the program's immediate vicinity, but within an hour or two, are many miles of beach along the shores of Long Island and New Jersey. Skiing and other winter sports are convenient to the Bronx, just upstate in the Catskills and Adirondacks, or west of the city in New Jersey and Pennsylvania. New England's ski slopes are a bit further away, but certainly in easy reach for weekends.

Only 30 minutes away by subway, bus or car is Manhattan, with its theaters, museums, concerts, sports activities, historical landmarks, restaurants, shopping, night spots, and an endless variety of other attractions.

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HOUSING

Adjacent to the Children's Medical Center two apartment towers, Montefiore I and II, provide housing for residents: 553 air-conditioned studio, one- and two-bedroom apartments, with garage parking available. Another apartment building owned by the Montefiore Medical Center in Riverdale offers housing in a more residential setting, no more than 15 minutes from any of the hospitals. Finally, just about every type of housing is available within fifteen miles of both the Children's Medical Center and the Comprehensive Pediatric Primary Care Center: in the past, house officers have chosen to live in Manhattan, in Riverdale, on City Island (a seaside community only minutes away), and in Westchester County, a suburb just north of the Bronx.

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RESIDENCY APPLICATION PROCESS

All applications for general pediatric residency training should be submitted to:

Henry M. Adam, M.D.
Director, Residency Program
Department of Pediatrics
Montefiore Medical Center
111 East 210 Street
Bronx, New York 10467

E-mail: < adam@aecom.yu.edu>

Applications for the Social Pediatrics Training Program, the Triple Board Program, the Pediatric Rehabilitation Training Program and the Pediatric Scientist Track should be directed to the specified Program Coordinator. Similarly, applications for fellowship positions should be addressed to the appropriate Division Director.

The Albert Einstein College of Medicine and Montefiore Medical Center do not discriminate on the basis of race, religion, creed, color, national origin, sex, age, handicap, marital status, or sexual orientation as provided by law.

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