The pediatrics clerkship serves as a learning experience for both students interested in the field and students who want to pursue a different specialty. During this clerkship, you will certainly learn the value of patience. In addition, the pediatric rotation will hone anyone’s ability to communicate.
“The soul is healed by being with children.” – Fyodor Dostoyevsky
This guide will cover the pediatrics clerkship, including when to place this rotation, how to make the most of your rotation, pediatrics clerkship resources, the Shelf exam, and the pros and cons of pursuing this specialty.
Intro to the Pediatrics Clerkship
Clinical clerkships, also known as clinical rotations, are when med students have the chance to practice medicine under the supervision of an established doctor or practicing physician. Rotations give students first-hand knowledge of what different medical specialties are actually like. With this knowledge and experience, students are better able to determine which field of medicine they feel the most passionate about and want to pursue in their future medical career.
Most US medical schools require the following rotations:
Pediatrics is a field of medicine that deals with providing care for babies, children, and adolescents, from birth until the age of 25. While the age range used to only extend to 18, new research about human brain development has expanded this range.
Pediatrics is essentially the equivalent of internal medicine, but instead of adults, you’re treating children. But pediatrics patients are not just little adults. Children have their own unique physiology, and it is important to differentiate this from adults. This physiology also continues to change as an infant grows from a toddler to a child to an adolescent, and this means that certain medications you would prescribe to adults could be dangerous for children.
Plus, children are more resilient than adults. While this sounds good at first, what it means is that young patients often crash hard and abruptly. They may seem like they’re stable, but out of the blue, they will suffer a sudden decompensation that requires immediate intervention.
It’s difficult to generalize the field of pediatrics because it’s so massive and features a variety of subspecialties. You could be caring for your patients in a wide range of settings, from premature babies in the ICU to healthy children at regular PCP visits to hospitalized children living with a variety of rare genetic anomalies.
As a pediatric physician, you could be a generalist or a specialist. Generalists handle a wide variety of presenting pathologies that do not require sub-specialized care. If you work in an inpatient setting, you’ll be a pediatric hospitalist, which means caring for children admitted to the hospital. This may be for infectious diseases like pneumonia, metabolic problems like diabetes, or neonatal issues like hyperbilirubinemia.
If you’re an outpatient generalist, you will see patients in the clinic, usually for regular checkups, vaccinations, and less acute conditions like allergies, ADHD, and more.
As a specialist, you’ll focus on one organ system of the body, which could be gastroenterology, cardiology, endocrinology, rheumatology, and others. Neonatologists specialize in caring for neonates (infants less than 4 weeks old.)
Generally, the pediatrics clerkship is full of supportive attendings and staff. Most of them get into the specialty because they are passionate about the field. Since you will have access to great support from your attendings during this rotation, it is high time you improved any clinical skill you feel is lacking.
When to Place the Pediatrics Rotation
Deciding on where to place the pediatrics rotation depends on whether or not you want to pursue it as a specialty. If you do want pediatrics to be your specialty, it’s most strategic to place it second or third out of the total of four quarters of the year. Do not place this rotation at the end if you want to pursue it.
This will make sure you have a foundation of experience before you enter the rotation you feel the most passionate about. Placing it first, when you’re just getting the hang of your third year clerkships, may not be the best time for you to impress your seniors and attendings. Not placing it last ensures you’re able to get enough references for applying to away rotations and residency programs.
Since the pediatrics rotation is filled with supportive attendings and staff, it’s an ideal opportunity to work on any skills you want to improve.
Making the Most of the Pediatrics Rotation
There are two components to the pediatrics rotation: the inpatient and the ambulatory. This organization resembles the internal medicine clerkship.
The inpatient component of pediatrics is much more varied than the internal medicine inpatient component.
The general pediatrics ward will be a melting pot for any pathology. On any given night, you can expect to treat a patient for meningitis and treat the next patient for pneumonia from cystic fibrosis. This has two main advantages and one disadvantage.
Firstly, whatever subject you choose to study at home for boards, you will most certainly have a patient on the ward to get a first-hand experience of the pathology. Secondly, there is a wide variety of cases, forcing you to switch between various organ systems and their diseases. This interspersed learning will improve your knowledge retention, which means you will be able to rapidly refer to actual cases on the Shelf. The major disadvantage is the steep learning curve in the beginning.
While having a general pediatrics ward is common, many clerkships provide subspecialty wards. Therefore, there will be a correspondent in the pediatrics wards for whichever medical or surgical specialty you’d like to pursue further.
For instance, if you would like to improve your gastroenterology knowledge, you can ask the clerkship director for an appointment in the gastroenterology pediatric unit. On the other hand, pediatric orthopedics provides huge benefits to future orthopedic surgeons, both in terms of skill growth and knowledge development.
Whichever department you choose, and if given the opportunity, opting for NICU is a good choice, whatever your desired specialty. The emergency treatments given in NICU are largely applicable in all specialties.
For instance, for a cardiogenic shock on a 1-week-old patient, the dobutamine treatment is the same as the one used for an adult coming to the ER with this type of shock. The difference is the dose. Another example is the management of mechanical ventilation complications, such as tension pneumothorax.
In the ambulatory component, the patient population will not be as preorganized as it is in the wards. Your first patient could be a toddler, the second could be a child, and a third could be an adolescent going through puberty.
The ambulatory component is a test of mental flexibility. It tests the knowledge you have accrued in the domain up until that point and also your ability to switch between sets of pathologies common for each age range. For this reason, it is highly advisable to schedule the ambulatory work at the end of your clerkship.
In the ambulatory setting, there is an emphasis on well-child examinations. Here are a few key points that will help you through them.
- Use weight and height curves to assess for normal development. Any deviation greater than 2 SD is pathologic and requires further investigation.
- Introduce solid foods at 6 months. Food products are introduced one by one in order to see how the child becomes acquainted with it. If there are allergic reactions or poor tolerance (colicky pain), stop the product. Also recommend the introduction of grains at more than 4 months, as this can predispose to celiac disease.
- Strabismus is normal until 3 months of age. If the child still has strabismus after this period, recommend an ophthalmologic consult.
- Recommend interrupting all household smoking. Also, instruct to let the baby sleep on his back without any stuffed animals or pillows in the crib. Both smoking and ventral positioning are risk factors for sudden infant death.
Although there are multiple conditions specific to the pediatric population, the most important aspect in neonates and young children, which not only appears on wards but also on the Shelf and on Step 2 CK, is the vaccination scheme.
- It starts with the hepatitis B vaccine after delivery. It is a 3-dose vaccine, with the next ones at 1-2 months and at 6-18 months.
- Another early vaccine is the rotavirus vaccine, which is a 3-dose vaccine. It is one of the few vaccines with contraindications (contraindicated in patients with a history of intussusception). This is how the doses are spaced out:
- 1st dose – 2 months
- 2nd dose – 4 months
- 3rd dose – 6 months
- Hepatitis A vaccine is a double dose vaccine, both administered between 12-24 months.
- MMR and VZV have the same schedule. They are 2-dose vaccines administered at 12-15 months and 4-6 years.
- There are 4 bundled vaccines – poliovirus, PCV13, diftero-tetano-pertussis, and haemophilus influenzae B. All of these vaccines are given in 4 doses at 2, 4, and 6 months. The last one is given at 4-6 years for polio and DTaP. By contrast, the vaccine for Haemophilus influenzae type B Hib and PCV13 are administered at 12-15 months (last dose).
- The HPV vaccine is indicated in females 11-12 years old or older, while the N.meningitidis vaccine is administered at 19 years old, when the young adult enters college.
A frequent ambulatory condition seen in children is acute otitis media (AOM). It will impress your attending if you know how to diagnose and treat it.
- Diagnosis – AOM can present 3 key findings on otoscopic examination.
- Bulging tympanic membrane – it usually indicates an acute bacterial infection. The most common pathogens are Strep, Pneumoniae, Moraxella, and nontypeable Haemophilus influenzae.
- Inflamed tympanic membrane (i.e., erythematous) and middle ear effusion.
- Tympanic perforation – it presents alongside purulent discharge from the middle ear.
- AOM resolves spontaneously in approximately 3 days. Therefore, the symptomatic management includes oral ibuprofen or acetaminophen.
- In populations at risk (immunodeficient children, children with facial anomalies such as cleft palate, children < 6 months old, and children with toxic appearance), an antibiotic treatment is warranted. It consists of amoxicillin-clavulanate.
Trachoma is one of the conditions that can be seen in the neonatal department. It differentiates from N. gonorrhoeae by the fact that the latter appears in the first week after birth with purulent discharge, while trachomas are typical for the second week after birth with clear discharge. The diagnosis requires only clinical findings. Prophylactically, neonates are given at birth erythromycin ointment. However, if the infection occurs, the treatment for trachoma is an oral administration of azithromycin.
Review this list of high-yield topics before your rotation.
Congenital disorders – cystic fibrosis, Hirschsprung disease, Tay-Sachs, sickle cell anemia.
- Cystic fibrosis
- Diagnosis criteria – Genetic mutation or positive sweat test with one of the following clinical criteria.
- Meconium ileus
- Bronchopulmonary infection
- Failure to thrive
- Family history of CF
- Ivacaftor + Tezacaftor
- Pancreatic enzymes
- Diagnosis criteria – Genetic mutation or positive sweat test with one of the following clinical criteria.
Common rashes of childhood – measles, erythema infectiosum, scarlet fever, chickenpox, rubella, roseola.
- Erythema infectiosum
- Clinical – pathognomonic slapped cheek, followed by lacy erythematous eruption.
- Symptomatic – NSAIDs, topical antihistamines for pruritic lesions.
- During the “slapped cheek” phase, the patient is contagious, which means they must avoid kindergarten.
Congenital heart disease – tetralogy of Fallot, transposition of great vessels, patent ductus arteriosus, coarctation of the aorta.
- Coarctation of the aorta
- Echocardiography with Doppler is sufficient.
- The classic chest X-ray sign of notched ribs is only seen in advanced cases (older children).
- When the coarctation is severe, consider maintenance of ductus arteriosus patency in the neonatal period.
- Monitor the patient.
During the pediatric clerkship, there are 3 skills you will undoubtedly develop.
1. Communication skills
No patient from this point on will be as difficult to approach. Learning how to deal with two patients (the patient and the parents) will be useful during future encounters with patients of any age. Explaining the problem the child has in both simple terms for the 5-year-old and more specific terms with the parents is also a good way to solidify your knowledge. This is a chance for you to emulate the Feynman technique.
2. Clinical reasoning
Now is the chance to hone your clinical reasoning skills, which you developed previously during IM wards. ****Since pediatrics is medically-oriented, it provides the right medium to supplement your clinical reasoning gaps from IM.
When presenting to the attendings, keep in mind the SOAP process (subjective, objective, assessment, and project). The subjective side includes the main complaint of the patient (usually given by the parents) as well as adjacent symptoms. By contrast, the objective component consists of the physical exam. The assessment consists of diagnostic tests—labs, imaging, and genetic tests. The project is the treatment given to the patient.
Some SOAP aspects particular to pediatrics are:
- History taking – normal or cesarean birth, the gravidity and parity of the mother, how the pregnancy was surveilled.
- Physical exam – there are special tests and tools for children. In regards to tools, use a pediatric membrane on your stethoscope and a pediatric hammer for reflexes. Concerning the special tests, you may test the developmental dysplasia of the hip with the Ortolani and Barlow maneuvers. Also, assess for psychomotor development (e.g., Did they walk at 1 year of age? Did they use two-word sentences at two years of age?)
3. Diagnostic tool use
With the agreement of the attendings, you can learn to use the ultrasound for kidney, cardiac, or even bowel evaluation (conditions such as autosomal dominant polycystic kidney disease, patent foramen ovale, or even intussusception). Moreover, there is an opportunity to learn classic radiography images, ultrasound, and CT findings. For example,
- Double bubble sign – duodenal atresia
- Triple bubble sign – jejunal atresia
- Target sign – intussusception
- Thickened pylorus walls – hypertrophic pylorus
- Radiography and CT
- Ground-glass appearance – chest x-ray in neonates with neonatal respiratory distress syndrome
- Cystic cerebellar cavity – pilocytic astrocytoma
- Sigmoid colon dilation – Hirschsprung disease
- Corkscrew sign – malrotation with volvulus
Pediatrics Clerkship Resources
Recommended pediatrics clerkship resources include AnKing Anki Deck or Step-Up to Medicine, depending if you prefer flashcards or books. If you prefer videos, the Board and Beyond videos + White Coat Companion study aid or OnlineMedEd are both great resources as well. Choosing one resource should provide you with enough information.
Try pre-reading some of these resources quickly to understand general concepts, then jump into questions. After a UWorld block and review, refer back to these resources to fill in any gaps.
The recommended question bank is UWorld. AMBOSS is another great question bank. Pick either UWorld or AMBOSS. Either pediatrics section is sufficient to prepare you for both the Shelf and Step 2 CK.
When approaching the questions, create two lists. One list serves to mark down the topics you have problems with (incorrect answers or guessed answers). This list will come in handy when rapidly reviewing for the exams. For each topic, expand the list systematically with history, physical exam, diagnosis, and treatment. The second list comprises subjects that differ from internal medicine. These pediatrics-specific subjects are another required read before the exams.
On the wards, UpToDate is your best ally when diagnosing and treating patients. That said, the best way to develop your knowledge is by applying it. Give yourself some time at the end of each consultation to fill in your knowledge gaps with a rapid UpToDate query.
For a more in-depth learning experience, a secondary resource is highly desirable. Two books frequently recommended are BRS – Pediatrics and PreTest Pediatrics. Both provide valuable content. If you don’t like studying with books, we recommend sticking to the UpToDate app on your phone/tablet to supplement your UWorld notes or Anki cards.
Lastly, Anki decks are invaluable as an on-the-go resource. For decks used for IM, see above. You may also create Anki flashcards based on the questions you miss in UWorld or AMBOSS.
Useful Apps for the Wards
- MDCalc is a free app that allows you to calculate different risk/score calculations.
- UpToDate helps you find the most up-to-date information in medicine.
- Hospitalist Handbook helps you quickly learn how to approach different diseases or conditions that are common in the hospital setting.
- Journal Club allows you to look up summaries of key clinical trials that are relevant for different diseases or conditions to present them on rounds.
- Bates’ Physical Examination allows you to look up how to approach various chief complaints in terms of history taking and physical examination.
Pediatrics Shelf Exam
The pediatrics Shelf is difficult since there are multiple sub-groups of patient populations, each with different types of pathology to consider. For example, infants (1-12 months old), toddlers, school age children, and adolescents.
For the Shelf exam, it is sufficient to use the resources mentioned above. Before the exam, take a second pass through UWorld. During the rotation, aim for 1 to 2 blocks of UWorld over each week, including both reviews and execution. The timed and random option is the default choice, as it simulates the conditions of the Shelf exam.
For the rapid review phase, refer to the two lists you made during the rotation. This will allow you to save time on the second pass by actively studying the subjects that did not stick the first time. Also, it will spare you time on refamiliarizing yourself with information found on the IM Shelf exam.
Lastly, treat the Shelf exam as the real Step 2 CK exam. This will help you accommodate your pre-exam jitters and identify the gaps that require more attention before the real deal. Make sure you are well-rested before you take the exam.
Residency Choices: Pursuing the Pediatrics Specialty
Pediatrics gives you a wide array of subspecialties to choose from. For example, you could become a pediatric gastroenterologist or a pediatric cardiologist. This provides you with the opportunity for long-term patient-attending relationships, meaning you will attend to the child’s needs from their start in life up until their young adulthood.
Pediatrics is one of the most accessible specialties, as it’s near the bottom of our list in terms of competitiveness. It ranks 20th of 22 in our MSI Specialty Competitive Index. This is because the average Step 2 CK score amounts to 245, it has a very high match rate, and it has a below-average number of publications.
View our comprehensive Specialty Competitiveness Index, which assesses specialties based on USMLE Step 1, Step 2CK, Top 40 NIH, publications, and more.
The majority of pediatric practitioners have an academic practice. This environment offers great opportunities for doctors who want to carry out their own research. It’s also ideal if you enjoy helping children.
There are some downsides. Pediatrics is one of the lowest paid specialties, earning an average $221,000 a year. This type of doctor works an average of 47 hours per week, yielding an average hourly wage of $94. Pediatricians, on average, have some of the lowest annual salaries of any specialty, but keep in mind they also work fewer hours than most specialties.
Pediatrics is not a competitive speciality, but it’s one that attracts passionate people. Although community and private practice forms exist, there are few possibilities outside the academic environment.
Whether or not you want to become a pediatrician often comes down to your passion for helping young people. Working with the pediatric population, and their parents, is not for everyone, yet it offers a deeply rewarding experience. Being a pediatrician gives you a unique opportunity to make an impact early in someone’s life, which can yield tremendous changes over their lifetime. For this reason, pediatrics could be considered one of the most powerful forms of preventive medicine.
Learn more about whether or not the pediatrics specialty is right for you: So You Want to Be a Pediatrician (video and article).
Final Thoughts on the Pediatrics Clerkship
Pediatrics is a great clerkship for honing your clinical and communication skills. The pediatrics clerkship will teach you a great deal about communication, as you will always essentially have two patients—the child and their parents. Obviously, no parent wants anything to be medically wrong with their children, so managing their expectations and emotions will be challenging.
Moreover, it’s the right mix of conditions to improve your internal medicine knowledge. Plus, the attending pediatricians you will be working under are generally extremely passionate about their chosen field, so this clerkship is an ideal time to get help on your diagnostic skills. You do not know how much the pediatrics rotation could improve your medical skills and knowledge, so remain curious and ask plenty of questions of your attendings.
Pediatricians are often mission-driven; they don’t just diagnose and treat conditions—they think about the entire health of the child, from nutrition to living situations to their families. Because their focus is on medicine as well as the context in which the child grows up, pediatricians often feel passionate about advocacy work and public health; they want to help build a better system to support children’s health.
At the end of the day, if you love children and love the idea of taking care of them, pediatrics could be a very rewarding specialty to pursue.
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