Pediatrics

Last updated October 2013

Pediatrics is a very positive rotation. The pediatricians are generally nice and supportive, and the kids are great, and very forgiving of how much we don't know as students. Also, most of the patients get better, which makes the clinical work more upbeat than some other specialties. If you don't have a lot of experience with children, just relax. Kids like people and they love attention. Take the chance to be playful during your physicals and you will leave the rotation with a lot of new 3 foot friends.

Schedule Overview:

 * Week 1: Lecture and orientation week, nothing but lecture, 8:00 to 5:00 Mon thru Fri
 * Every Tues. afternoon of the clerkship except the first will be with an assigned outpatient primary care preceptor/mentor. A good chance to work with the same person throughout the clerkship so they see your improvement.
 * Week 2 through 4: Three weeks of either inpatient or outpatient specialty clinics.
 * Week 5 through 7: Switch from inpatient to outpatient or vice versa
 * Inpatient: ~7:00am - 5:00pm, Mon-Sat (you pre-round on all patients before rounds, which are attending-specific). You will also be on call (only until 10pm) 1-2 times each week of inpatient pediatrics. This is at Carle. Most attednings will send you home early on Sat.  If you are on call, try to work with the doctor in the ED.  This will give you the opportunity to do the workup yourself, plus it shows the doctor you're interested and not just wanting to sit up on the floor. During the week, you should get to the unit before 7 (around 6:40-6:45 is best) so that you have time to chat with the night nurses and aren't in the way while the nurses are doing shift change.
 * Outpatient: 1 week each of 1) Nursery, 2) Neuro / Developmental and 3) GI / Other (and you should do some other stuff, like genetics, pulmonology, or cardiology, because you see the same stuff over and over in GI). Outpatient week feels a lot like shadowing - you generally will observe the specialists and ask questions between visits.
 * Nursery: early mornings (could be anywhere from 5 to 9am, depending on your attending), but usually done by noon. This is at Carle.  The hospitalists recently took over this service, so this may be different.
 * Friendly Tip: Be sure to find out who is on in the Nursery the week prior to your week to go in to be sure to email/page/call the preceptor so you can be on the same page as them and arrive when they expect you to.
 * Neuro / Developmental: 8 to 5. This is at Carle South Clinic (Neuro) or Curtis clinic (Dev.)
 * GI / Other: 8 to 5. GI is at Carle South Clinic. "Other" may include pulmonology (Dr. Davison), Dr. Schneider (Genetics) or anyone else you can find that you'd really like to observe.
 * Note that the non-nursery weeks are very unstructured, and you frankly have complete control over your own schedule (though you'll be asked to log how you spent your time). Feel free to take a couple of afternoons off to study.
 * Week 2-7 (overlapping with in and outpatient duties)
 * Tues afternoon clinic: Each Tues you'll work with the same faculty mentor in a general pediatrics (primary care) clinic. Most mentors will allow you to go in to see the patients first, then you will observe their visits.
 * Thurs afternoon "grand rounds": The entire group meets together on Thurs and each student will present one of their patients, M2 tutorials style. You will also turn in a complete (very thorough) H&P for that patient. In addition, as of October 2013 you are expected to submit 2 additional H&Ps for patients you did not present to the group (8 H&Ps total). Each H&P will be in the format of an extensive SOAP note, and will include a learning objective of your choosing, related to the case. You should also include a copy of a primary literature article you used for your learning objective.
 * Miscellaneous requirements:
 * You will need to complete 24 "CLIPP" cases (on-line case simulations). These take 30-60 minutes each. I strongly recommend not putting these off until the end, as you'll want to be focusing on the Shelf exam. Doing them too early, however, is less helpful because you won't know enough for the cases to be cohesive for you. Some students have found that these are helpful as an introduction if you complete them early in the clerkship.  Some students get more out of these than others. In general, they are helpful for clinical knowledge, but not for Shelf prep.
 * You will fill out a logbook of interesting cases and account for how you spent your time during outpatient clinic. I recommend keeping this book handy and filling it out as you go, rather than trying to remember your patients at the end of the clerkship. You can also create a patient list in Epic and add patients to that, then fill in the logbook at the end of the week.

Lecture week:
The first week is strictly lecture and orientation, 8:00 to 5:00 each day. The lectures are high yield stuff, but can be pretty disorienting since they're all crammed into 1 week and the separate lectures aren't necessarily coordinated with each other. You will get the most out of this week if you study like crazy at home, so that you've read the chapters for all the topics you cover in lecture. You'll be a lot less exhausted this week than you will during your inpatient weeks, and you're never on call, so it's about the best chance you'll get to study hard. You will also be better prepared for pimping on the hospital weeks. One thing to be prepared for is that there is a significant amount of overlap in the lectures so it can be tedious at times.

You'll also get oriented to some of the different locations this week (which is good for familiarity, but be prepared to drive around town quite a bit).

Text books:
The review books available for peds are very good, and sufficient for both the shelf and clinical knowledge for the wards. This should be obvious, but you'll retain the most if you study the chapters relevant to whatever part of the rotation you're on and / or study your patients' diseases.

Inpatient:
Each attending rounds at a different time, but in general you should plan to be ready for rounds by 8:30 or 9. Show up at 7am your first day and divide all the patients among your group. You will want to review your patients' admission H&Ps in Epic, as well as their summary sheet for vitals, current prescriptions and any relevant labs. You'll need to go visit the patient, performing a focused history and physical. Follow up thoroughly on their chief hospital complaint, and make sure to ask every patient about appetite / intake / stools / voids / wet diapers / fever / etc. You should then start a note for each patient, that you can 'pend' BEFORE rounds. Spend the rest of the time before the attending arrives reviewing and researching basic and clinical sciene information on your patient.

Your attendings will expect you to know everything there is to know about your patients; however, when you present the patient you will want to carefully follow the SOAP format (including your impression and plan, even if you're not very sure!) and be very brief and pertinent to the reason they are in the hospital and on any changes or new complaints. Attendings will usually ask you a couple of questions about the patient, both to get relevant information you left out and to check that you did your work, and you will all go see the patient together. The attending will then write new orders / discharge instructions, which you'll want to follow carefully to put in your daily note. Most attendings will copy your note and modify it. Make sure you read their final note to learn from their changes.

You will split up any new admissions during the day with other students, and you will be expected to perform a more thorough (but still focused) H&P, and write an admission note. If you are on call, page the attending to let them know and ask where they would like you to be (some want you very close, others want you within 30 min). If your attending on call is also working in the ED that night, you will get a chance to work up medical pediatric cases in the ED (but not trauma cases, etc.).

I strongly recommend that you go in a little bit extra early your first day and try to find a progress note from your current attending that you can emulate. A good way to do this is if you have a 'frequent flier' on the floor, who'll have a note from most of the attendings from the past. Regardless, read a few notes from any attending on any patient before you try writing your own blindly.

Most attendings will expect you to know your patients ins and outs for the last 24h. Ins are always reported in ml per kg body weight for the day, and outs (urine) by ml per kg body weight PER HOUR (should always be >1.0)

Inpatient Attendings:
Rounds is also conducted differently by each attending. In general,

Outpatient (specialty clinics)
The outpatient pediatricians don't pimp you, but it's important for you to show interest and enthusiasm by asking questions when you get a chance. The best kind of question is one that shows what you already know / that you've been reading. Also, if you wait to be invited to do a physical, it won't happen. Just wait until the physician is done with their physical, and then repeat any interesting parts of the physical yourself. This shows you're interested without being intrusive to the visit. The neuro, genetics and GI clinics will have interesting physical findings for you to see. The specialists are all good teachers, but are variable in terms of how much time they spend teaching. Again, you can nudge an attending into teaching you by asking a question when they have a moment. They won't expect you to know the cases or a lot about the diseases you see, but you can impress them if you do.

You are the master of your own time for these two weeks - no one will hunt you down if you don't show up one afternoon, and the director will even tell you it's acceptable to take some time off to study. Just log your hours and don't take off a conspicuous amount of time. You can also look ahead at the physicians' schedules and the chief complaints for the appointments and stack your schedule to see the most interesting cases in each clinic.

Nursery
Fairly different experience depending on who your attending is. Plan on showing up around 7:00 the first day, or page the attending and ask when they want you to show up. You won't be expected to pre-round on day 1. Your attending may or may not have you pre-round on all the babies, and may or may not have you write notes. Almost everyone coming through here is healthy and normal, but if you see an interesting case, you can impress your attending by looking into the mother's chart to get a more complete prenatal and birth history, then telling her about anything pertinent as she examines the baby.

The general order is the nurses bring in all the babies for rounds, the physician does a newborn physical on everyone, notes are written, you go talk to the parents, you do a few circumcisions and then you're done some time between 11:00am and 1:00pm. Take advantage of these open afternoons to study, finish your CLIPP cases, or spend extra time with outpatient physicians.

Tuesday clinic
1:00 or 1:30 to 5:00 each Tues afternoon from week 2-7 you'll follow your preceptor, a general pediatrician, in their clinic. In the summer, this will be mostly annual physicals / well baby checks. In the winter, this will be mostly common infectious disease (cold, flu, otitis, etc.). Your experience here is also very specific to your preceptor. Asking for 'homework' (ie, "what would you like me to study for next week?") is an easy way to show you're interested and that you're studying / working hard. Your Tues afternoon preceptor is one of the most influential contributions to your clinical grade. They generally will not pimp you, but like anywhere else, you can impress them by reading the chart for a few patients ahead of time and knowing the diseases that you're going to see that day. If the opportunity to show your knowledge doesn't come up, force it to happen by asking questions. (eg, "I read that the first line treatment for this is ______. Is that still true in an infant?")

Thurs 'grand rounds'
For better or for worse, this will be the only interaction you have with the people who ultimately assign grades. It's important to actively participate, to try to present interesting cases, and to show you put thought into your learning objectives. Your write-ups should be very thorough, and include a detailed assessment and plan. This is not just a bulked up version of an admission H&P note, and you are absolutely not to copy or even paraphrase a note from one of the physicians about your patient. Your assessment is your chance to show your clinical thinking and your studying on the case's disease and similar diseases. You should state the most probable diagnosis, then explain why it's most probable. After that, you should go through a fairly thorough differential diagnosis, explaining why each of the alternatives are less likely. You should include some information about the prognosis. Finally, your plan should reflect what was actually done, but also your own thought process, and the justification for each step. These write-ups can be very time consuming, but again, they are an important part of the impression you leave with the people in charge.

The Shelf
This subject exam has a reputation for being one of the harder ones. Keep in mind that the clerkship itself will help your clinical knowledge, but it really does not prepare you for the Shelf. Pretest and BRS -OR- blueprints are the most consistently recommended resources.

First line drugs for common pediatric disease are consistently tested, as are developmental tasks (eg, a baby should be sitting without help at 6 mo). Keep in mind that the exam is different each time it's administered, so just because someone tells you they got a lot of questions about some random topic doesn't mean you will.