Pediatrics clerkship

Pediatrics overview

What is pediatrics?

  • Pediatric medicine treats patients from birth to late adolescence or young adulthood in both outpatient and inpatient settings.
  • It involves a 3-year residency training program, at the end of which residents are eligible to become board certified in pediatrics.
  • After completing residency, pediatricians have the option of:
    • Providing general pediatric care, where the focus is on:
      • Providing preventative care
      • Treating common childhood illnesses in the outpatient setting
      • Managing a variety of acute/chronic conditions in the inpatient setting
    • Training in a wide variety of subspecialty fields
      • Subspecialties are usually counterparts of adult medicine (e.g., gastroenterology, endocrinology, pulmonology, cardiology, hematology/oncology, rheumatology, infectious diseases, nephrology, PICU, NICU).
      • Specialists often have outpatient clinics and inpatient consult services.

What does a pediatrician do?

Pediatricians are privileged to work with a patient population that is generally healthy and resilient. However, these patients present unique challenges.

  • Children are often unable to articulate how they are feeling, advocate for themselves, or implement their own treatment plans.
  • Pediatricians must be able to establish a good rapport with both children as well as the adults who care for them at home.
  • Parents/caregivers are the most accurate source of information regarding their child's health. While these individuals rely heavily on the pediatrician for reassurance and anticipatory guidance (e.g., prognosis, home care, long-term consequences of illness), clinicians reciprocally depend on them to ensure the patient receives appropriate care outside of the clinical setting.
  • Pediatricians function as sentinels of a vulnerable population’s well-being. For example, a toddler is unable to articulate that he or she is being abused or neglected; however, a pediatrician must look for the telltale signs of unusual injuries, delayed growth, and developmental abnormalities during a well-child checkup.
  • While pediatric patients are thought to be more resilient than adults, this is not a license for clinical complacency and it requires the pediatrician to be vigilant for escalating care needs.

Clerkship overview

Clerkship structure

The length of the clerkship varies between 4–8 weeks, depending on the medical institution. The rotation can comprise the following:

  • Inpatient portion: general pediatric medicine wards
  • Outpatient portion: general pediatric clinic
  • Additional rotations, such as:
    • Newborn nursery
    • Neonatal Intensive Care Unit (NICU)
    • Pediatric Emergency Medicine (PEM)

Clinical skills

Pediatrics clerkships are structured to give medical students a comprehensive understanding of the specialty and to allow them to acquire a number of relevant clinical skills such as:

Daily schedule

The following schedules are meant to provide a general idea of a pediatric clerkship timeline and will vary among different medical institutions and programs.

Inpatient service

  • 06:00–08:00 a.m.
    • Pre-rounding on patients
    • Sign-out of the overnight patients by the overnight residents/healthcare providers
    • Morning lectures
  • 08:00–noon
    • Family-centered multidisciplinary teaching rounds with the department's attendings, residents, and fellows
    • Patient consultations
  • Noon–01:00 p.m.
    • Noon lectures
    • Lunch break
  • 01:00–04:00 p.m.
  • 04:00–05:00 p.m.: evening sign-out

Outpatient service

  • 08:00–08:30 a.m.: review of patients' charts and history prior to visit
  • 08:30–noon
  • Noon–01:00 p.m.: lunch break
  • 01:00–05:00 p.m.
    • Afternoon patients consultation and examination
    • Finishing outpatient notes and/or teaching

Evaluation and grading

  • Varies among institutions but usually is pass/fail, and (typically) also high pass and honors. It consists of:
    • Clinical grade
    • Examination (usually shelf exam)
    • Possibly other assignments

AMBOSS study plans

  • AMBOSS has created study plans with recommended articles and questions for all clerkships and some subspecialties, including:

Clinical tasks

Pediatrics clerkships are structured to give medical students a comprehensive understanding of the specialty. After the clerkship, students should be able to:

  • Perform a comprehensive pediatric history and physical exam.
  • Present cases and write notes for newly admitted patients as well as summaries, updates, and trends of previously introduced patients.
  • Demonstrate communication skills that facilitate interaction with children and their parent/caregiver.
  • Exhibit knowledge regarding:
    • Differential diagnoses and initial management of common, acute, and chronic pediatric illnesses
    • Normal growth and development (physical, physiologic, and psychosocial)
  • Assist with minor surgical procedures (e.g., laceration repairs, circumcision).

Pre-rounding

As the term suggests, pre-rounding is a part of the inpatient service that precedes the work rounds. There is a section on “Pre-rounding” in the clerkship guide article for general information. Here are some additional things to consider for pediatrics:

  • Introductions
    • Introduce yourself and give everyone in the patient's room a chance to introduce themselves as well.
    • Identify the child's legal guardian.
    • Clarify if it is okay to talk about the child's condition in front of the other people in the room prior to doing so.
  • History
    • See the “History” section in the Pediatrics: history and physical examination article.
    • Start by asking the patient or their parents/caregivers about overnight events.
    • Address the following points, even if the patient's caregivers do not readily volunteer this information:
      • Fever
      • Behavioral changes (lethargy, fussiness, playfulness)
      • Eating and drinking
      • Bowel and bladder movements
  • Physical exam: Always complete a physical exam of the relevant system even if this requires waking/disturbing the patient momentarily.
    • See the “Physical examination” section of the Pediatrics: history and physical examination article.
    • Try to coordinate examining the child with the resident.
    • If the child is very uncooperative and refuses to let either the student or resident examine them, the attending will perform the physical examination during rounds.
    • If the parent/caregiver or nurse specifically asks you not to wake up the patient at this time (e.g., the child was up screaming all night and just went to sleep), then do not disturb the child for a physical exam. Inform the resident and attending of the situation.

Rounding

For information regarding rounding, see the “Rounding” section in the clerkship guide article.

Notes

Common abbreviations for patient notes

Subjective

Medications are typically dosed by weight and should be recorded as such. This is a potential source of error when notes are inappropriately copy-forwarded.

Objective

  • Review of systems
  • Vital signs
    • Pediatric vital signs have appropriate ranges based on age (e.g., an infant's resting heart rate is normally higher than that of an adult).
    • Appropriate reference ranges should be considered before marking the vital signs as “normal.”
  • Physical exam
    • It is important to only document exam maneuvers that have been performed.
    • Begin by taking a moment to establish rapport with the child: For example, ask the child about their interests/hobbies, school, etc.
    • When examining children that do not easily comply with commands, be sure to keep a detailed record of the child's behavior (e.g., “Child plays with toy trucks and screams when asked to put them away, but can be consoled by the parent.”).
    • See the “Physical examination” section of the Pediatrics: history and physical examination article.
  • Labs: List important laboratory values.
  • Imaging: Record interpretations of relevant pediatric imaging.
  • Microbiology
    • Provide a summary of bacterial/viral/parasitic cultures with the source.
    • Note any ongoing antibiotic treatments if applicable (e.g., ”day 3 of vancomycin”).

Assessment

  • Pediatric assessments should summarize relevant portions of the pediatric history and physical exam (H&P) to make a differential diagnosis for the stated problem.
  • Document the interpretation of important relevant lab values and imaging findings.
  • In well-child checkups, pediatricians simply document that the child is healthy (e.g., “Patient is a healthy, well-developed 10-year-old boy.”).

Plan

  • Pediatric plans should be patient-focused and include medical decisions to be implemented.
  • Always document medication doses based on weight (ml/kg or mg/kg) in pediatric patients.
  • Include information regarding dietary recommendations and discharge plan for inpatient visits.

Presenting

Family-centered rounding (FCR)

It is useful to understand the standard method of patient presentation before proceeding to FCR. Many institutions conduct FCR. If the institution does not follow this style, rounding will be similar to that of other rotations. To review this information, See “Presenting patients” in the “Clerkship guide” article.

  • Description
    • A style of rounding that allows for real-time dialogue between the healthcare team and the patient and their parent/caregiver. FCR takes place at the patient's bedside, where a plan of care can be jointly agreed up.
    • FCR is different from standard rounds, which happen outside of the patient's room and generally do not involve the patient and their family until after the assessment and plan have already been discussed outside.
    • Pediatrics is unique in that the patient receiving treatment and the person formally consenting to treatment are seldomly the same. FCR allows for a spatially and temporally coordinated discussion, finalization, and communication of the assessment and plan to improve compliance.
  • Challenges
    • It requires medical students to exercise both their developing clinical skills and bedside manner while also making a positive impression on residents and attendings.
    • Medical jargon must be avoided when addressing the patient and their family, as such language may be unfamiliar.

Prior to presenting

  • Outside of the patient's room, begin with a brief summary.
    • It is helpful to add a few details so that the whole team can understand what direction you would like to take on rounds with the family. For example, “An 8-year-old boy with sickle cell disease admitted for an improving pain crisis. I would like to reduce his morphine dose and work towards getting him ready to go home.”
    • If the patient is new to the whole team, use this time to give a condensed history and physical examination presentation, so as to avoid repeating it in the patient room.
  • While the plan should not be finalized outside of the room, this is the time to ensure that your team will present unified ideas to the patient and their family.
  • Sometimes, the patient and/or family members ask difficult questions or have an emotional reaction to medical updates. If you anticipate this, mention it to the team after your summary, before entering the room.

Beginning the presentation

  • Knock and enter the patient's room.
  • Introductions
    • If this is the patient’s first day with your team, introduce yourself, the resident responsible for the patient, and the attending.
    • If the resident/attending changes on another day, make sure to introduce them, even if you think they might have already met.
    • Introducing the other residents/med students is usually optional and at the attending’s discretion.
  • Try to sit down (if possible) with the family while giving your presentation, as it helps create a more comfortable atmosphere.
  • Note that the attending has to examine the patient and this will probably happen at the beginning of the presentation.

Subjective

  • Present overnight events/morning issues.
  • Avoid discussing issues that are not immediately relevant, including events prior to the night before, even in the case of a new admission.
  • For example: “It looks like Johnny had a pretty good night. It was the first time since his admission that he did not wake from pain during the night. He reports still feeling some discomfort, but he finished his breakfast without issue and even got a bit of homework done.”

Objective

  • General tips
    • Before entering the patient room for a presentation, ask the attending what level of detail they would like for the vitals and physical exam.
    • Avoid using medical jargon when addressing the patient and their family, and instead, speak slowly and use language that is clear and simple.
  • Vitals: body temperature, blood pressure, heart rate, respiratory rate
  • Physical exam findings: The order generally follows that of an adult physical exam and proceeds in a head-to-toe manner.
    • General: e.g., “Johnny seemed a little fussy this morning but was alert and doing some homework.”
    • Respiratory: e.g., “His lungs sounded clear.”
    • Heart: e.g., “His heart sounds were normal.”
    • Abdomen: e.g., “His belly was soft when I pressed on it, but he said he felt a little bit of pain near his belly button when I pushed.”
    • Hydration status: e.g., “I do not see any signs of dehydration; his fingers are getting good blood flow, and his eyes and mouth look moist.”
    • Musculoskeletal: e.g., “Johnny allowed me to move his left arm for the first time this morning, and he seemed to be able to move it around a lot more freely than yesterday.”
  • Lab values
    • Present the newer lab values first, and discuss them in relation to the older lab values; be sure to explain any unfamiliar terms.
    • For example: “His hemoglobin was 9, which is still slightly low; but it's up from 8.5 earlier this week.” rather than “Hemoglobin was 9.”
  • Imaging
    • Mention the imaging modality and provide an interpretation without medical jargon.
    • For example: “The x-ray of his arm yesterday evening looked normal, and there were no broken bones or signs of infection.”

Assessment and plan

  • Name and reason for admission: e.g., “Johnny came in with a lot of pain in his left arm due to a sickle cell pain crisis.”
  • Progression
    • Is the patient's condition improving, worsening, or stable?
    • For example: “Based on what I have heard about his night and what I have seen him do this morning, I believe the pain crisis is improving.”
  • Problem-based plan
    • Pediatric plans should be problem-based and include medical decisions to be implemented.
    • What has been done for the patient so far? Are there any plans to be put into action?
    • It is helpful to organize this section problem wise. For example:
      • Pain: “Johnny has been getting scheduled morphine through the IV in his arm. I would like to change him to a different pain medication that is just a little less strong and can be taken orally.”
      • Constipation: “Johnny has not had a bowel movement in a while, which is probably why his tummy is beginning to hurt a little. This is likely due to the morphine he has been getting and also from being stationary/immobile these last few days. There are a few things we can do about this. If we reduce the morphine dose, that should help improve his constipation. We can also give him a stool softener to help things move along. If we can get Johnny to walk around, even go to the activity room, that would also help with the constipation.”
    • Include information regarding the discharge plan for inpatient visits.

Concluding the presentation

  • Discharge plan
    • It is important to establish a timeframe for discharge and communicate this clearly with the patient and their parent/caregiver.
    • Conversely, if discharging the patient is not possible in the near future, convey this to the family while also giving them an estimate of when discharge can be expected.
    • E.g., “Johnny is improving, which makes me think we can start working on the process to get him home. The primary reason for keeping him in the hospital is his need for IV medications, and that's why I've suggested switching him to oral pain medication at this time. Once his pain improves to a point where he only needs oral meds to get through the day, you'll all be on your way home.”
  • Give the patient and their parent/caregiver a chance to discuss any questions or concerns.
  • Thank them for their time as you all exit the room.

Family-centered rounds require medical students to develop and exercise their clinical skills and bedside manner simultaneously. To put the patient and family at ease, avoid medical jargon. Instead, speak slowly and use language that is clear and simple.

Placing orders

For information regarding orders, see the “Orders” section of the clerkship guide article.

Newborn medicine

Newborn nursery and NICU rotations provide an opportunity to become proficient in the examination of the newborn and management of the common questions and problems that come up in clinical practice. Clinical tasks for these rotations include:

  • Conducting the physical examination of newborns, including screening for congenital abnormalities
  • Assisting with procedures (e.g., placement and removal of umbilical artery/vein catheters)
  • Acting as a liaison between the OB/GYN and pediatrics teams
    • These rotations place you in close proximity to OB/GYN teams that are responsible for the postpartum care of the mother.
    • Utilize your role as a medical student to maximize efficiency and communication (e.g., encouraging conversations with new mothers regarding breastfeeding, vaccination, circumcision, and contraceptives).
    • Assist during deliveries classified as high-risk, and participate in neonatal resuscitation.
  • Addressing anxieties of new parenthood
    • Warning signs: when to call their healthcare provider with concerns regarding the newborn
    • Proper breastfeeding technique
  • Using your time to engage with nurses as much as possible in their care of infants
    • These nurses are often “baby experts” and can teach you how to be comfortable with this patient population.
    • Learn how to properly feed, change, diapers, and administer medications in newborns.
  • For more information regarding newborn medicine, see “The newborn infant” article.

Attending conferences

  • For additional information, see the “Attending conferences” section in the “Clerkship guide” article.
  • The nature of the content discussed during pediatric morbidity and mortality conferences can be sensitive, given the nature of the patient population, and medical students are occasionally discouraged from attending out of emotional consideration.

Outpatient experience

  • General pediatrics clinic forms a portion of the core clerkship.
  • Pediatric clinic comprises a single pediatrician or a group of pediatricians, residents, interns, and nurse practitioners, with medical students being primarily involved in well-child visits.
  • Medical students are expected to:
    • Collect an outpatient history.
      • Since visits are short, time is of the essence. You will likely only have about 10 minutes to interview each patient, so your time must be focused on:
        • Collecting relevant information
        • Directing toward “can not miss” questions (e.g., “How is your mood?” can potentially reveal self-injuring behavior).
    • Two unique portions of the outpatient interaction are developmental history/developmental milestones and social history. For more information, see the “History” section of the “Pediatrics: history and physical examination” article.
    • Performing an outpatient physical exam: See the “Physical examination” section of the ”Pediatrics: history and physical examination” article.
    • Typing a summary of notes from the visit: See the “Notes” section above.

Professional behavior

Communication

  • Unlike other specialties in which patients often come alone and may at times seem somewhat unconcerned with their well-being, pediatrics frequently involves patients with very concerned parents/family.
  • Choose your wording carefully as sometimes seemingly harmless words can trigger strong emotions or reactions among caretakers.
  • Each family is unique in their reaction to healthcare information.
    • Some families with otherwise healthy children may become inconsolable at the mention of a minor diagnosis, or even the suspicion of one.
    • Those with chronically ill children, while appropriately concerned and attentive to the patient’s needs, may view hospitalization as a routine occurrence in their family life.

Adolescents

  • Although unable to legally provide consent for most things, keep in mind that they will soon become adults who are wholly responsible for their own medical care.
  • Know the state's laws regarding when parental consent is required and what are the exceptions. See “Informed consent in minors” in the “Principles of medical law and ethics” article for more information.
  • It is important to include adolescents in developmentally-appropriate discussions with their parents/caregivers regarding their care and to obtain their approval for treatment plans.
  • Be prepared to counsel them about safe sex, contraceptives, substance use, and other sensitive issues.

Developmentally delayed children

  • These children are commonly seen in a variety of care settings for both routine/preventative care and acute illness.
  • Interactions with them can be challenging because of impeded communication and the unique complexities related to their care (e.g., a teenage boy who is unable to swallow his pills).
  • Look past physical appearances and interact with the patient based on their cognitive age.
    • The parent/caregiver can also facilitate how best to interact with the child (e.g., by providing cues).
    • For example, if you see a 15-year-old patient brought in with preschool toys, the patient will probably respond better to those who try to build a rapport with him/her as one would with a preschooler.
  • Keep in mind that many of these parents/caregivers have spent more time in the healthcare system than the average medical student.
  • Parents/caregivers generally know their children’s behavior best. Try to respect their concerns and ensure they are listened to.

Child maltreatment

  • Be familiar with signs of child maltreatment, including physical abuse, sexual abuse, psychological maltreatment, and medical neglect.
  • You should know how to deal with such circumstances and immediately inform a physician if you suspect child maltreatment.
  • See “Child maltreatment” for more information.

Top 10 pediatrics topics

  1. The newborn infant
  2. Congenital TORCH infections
  3. Child development and milestones
  4. Immunization schedule
  5. Acyanotic congenital heart defects
  6. Cyanotic congenital heart defects
  7. Inborn errors of metabolism
  8. Congenital immunodeficiency disorders
  9. Asthma
  10. Rheumatic fever

Evaluation and grading

General

  • The system of evaluation and grading varies among clerkship programs and institutions. It is usually a pass/fail system, with high pass and honors.
  • The grading system involves the following two components:
    • Clinical grade
      • Determined by preceptor evaluations from attendings, residents, and interns
      • Evaluators award a grade based on the student's patient presentations, clinical skills, patient notes, admission orders, and clinical logs.
    • Examination grade
      • Determined by performance in the shelf exam (NBME® or NBOME®)
      • Some institutions have in-house exams and standardized patient experiences.
  • Additionally, programs may have graded final projects for the clerkship, such as a case report or lecture on a patient's rare disease/presentation.
  • See the “Evaluation and grading” section of the “Clerkship guide” article.

Impress your preceptors

General tips

  • Be ready to provide the parent/caregiver with anticipatory guidance (e.g., prognosis, home care, long-term consequences of illness). If you are not quite comfortable giving them on your own, then express interest in learning how to.
  • Empathetic communication: Not everyone wants to work with kids, and that's okay. If you are not naturally playful with children, there is no need to force it. Shift your focus to being an empathetic communicator with children and their families.
  • Try to have direct interaction with preceptors.
    • Although your core clerkship is not necessarily structured to facilitate one-on-one interaction between you and your attending, look for opportunities when they arise.
    • If you did not perform as well as expected in your core clerkship and would still like to specialize in pediatrics, take advantage of additional opportunities (e.g., electives, sub-internships) to remediate this performance.
  • For further information on clerkship grading, refer to the “Grading” section in the “Clerkship guide” article.

Preparing for questions from attendings

  • See the “Clinical evaluation: how to impress your preceptors” section in the clerkship guide article for more information on preparing for questions/quizzing from attendings (sometimes referred to as “pimping”).
  • For information regarding other topics to study in preparation for quizzing, see the “Overview of the top 10 topics” section below.

Exams (NBME® or NBOME® COMAT)

  • Overview
    • The objective of the pediatric shelf exam is to assess a student’s ability to administer medical care to infants, children, and adolescents.
    • Not all students have to take a standardized pediatrics shelf exam. Instead, a program may have an in-house exam.
    • In some cases, both an in-house exam and a standardized shelf exam are taken.
  • Shelf exam content [3]
  • Preparation
    • Be wary of tricky phrasing in the question stems. Children and adolescents are not as likely to clearly articulate how they are feeling, and what appears abnormal could indeed be completely normal.
    • Focus on patient presentation and know the classic illness scripts.
    • Genetics, embryology, and infectious diseases will be more emphasized than other specialties.
    • A lot of questions focus on determining a diagnosis or cause.
    • Use AMBOSS to practice plenty of high-quality sample questions. The more questions you go through, the more likely you are to score high on the exam.
  • High yield review
    • The pediatrics shelf exam is similar to other shelf exams, you can be tested on any content related to the clerkship.
    • Pediatrics features difficult topics: children and adolescents come with their own set of medical issues, and many of the rare conditions covered on the exam might not ever come up while on the wards. With that in mind, it is best if students give themselves a head start and try to cover as much material as possible.
    • Master the differential diagnoses of high-yield topics like gastrointestinal complaints and gait abnormalities.
    • Review high-yield topics such as those mentioned in the “Overview of the top 10 topics” section below, prior to the exam.
  • For additional information: See the “Exams: what to expect” section of the “Clerkship guide” article.

Preparing for residency application

Residency applications

  • Pediatrics is traditionally not a competitive specialty to match in, and there are no specific strategies that applicants should be aware of unless trying to match into a prestigious program.
  • Subspecialty pediatrics
    • Most pediatric subspecialists first match into a 3-year general pediatrics residency, after which they decide on their subspecialty of choice and apply to fellowship during the fall of the third year of residency.
    • Though applying to fellowship is usually a less stressful experience than applying to residency, certain fellowships are known to be more competitive to match into than others (e.g., cardiology).
    • If you are very interested in a pediatric subspecialty, it is advisable to get in contact with a faculty member of that specialty to fully understand what must be done to match.
  • Combined residency programs
    • There are some exceptions to the separation of residency and fellowship programs, including:
    • In these specialties, general pediatrics and the specialty’s fellowship are combined into one program (5–6 years).
  • If your school does not offer an adequate representation of these categorical match specialties in which you are interested, try to:
    • Develop faculty contacts at other institutions.
    • Complete away elective rotations.
  • A genuine interest in working with children is necessary to become a pediatrician. Try to volunteer with children and/or research to help reinforce your commitment to pediatrics.

Letters of recommendation (LOR)

  • In pediatrics, the rotation from which the LOR comes from is not as important as the attending who wrote it, and how much they observed and interacted with the student.
    • Electives or sub-internships: The majority of students will ask for LORs from these rotations.
    • Core clerkships: Some students will ask their core pediatrics attendings for letters but request that they hold onto it until the application season arrives.
  • Not all of your letters need to be from pediatricians, but usually, at least two should be.
  • Departmental chair letters are generally not necessary while applying for pediatrics residency.
  • For further information, see the “Letter of recommendation” section of the “Residency applications” article.

Research opportunities

  • For further information, see the “Research opportunities” section of the “Residency applications” article.

AMBOSS study plans

AMBOSS has created study plans with recommended articles and questions for all clerkships and some subspecialties, including:

Resources

AMBOSS

You can use AMBOSS (browser and apps) as both your clinical reference and exam study resource. It contains hundreds of articles with multimedia for pediatric topics, an ANKI addon app, curated study plans (see “AMBOSS study plans” above), and over 500 questions to help you shine in the clinic and exceed on your shelf exam.

Reading materials

Websites

  • American Acadamy of Pediatrics: Membership includes access to PediaLink® for Medical Students. [4]
  • Bilitool [5]
  • Online MedEd [6]
  • University of Chicago’s Pediatrics Clerkship website [7]
  • Stanford University’s Newborn Nursery [8]

Phone applications

  • Pedi QuikCalcIt
  • SymptomMDTopics: