Third Year Clerkship Review: Pediatrics

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Introduction to Third Year

Ahh, third year…when 8-hour lecture days are a thing of the past; when your mornings are early and your coffee is strong; when you work longer and harder than you thought possible, but when it all becomes worth it because you’re finally participating in patient care. Third year, in my opinion, has been the hardest year of medical school thus far. It is physically exhausting, as the hours can range from as little as 8 hours per day to as much as a 30-hour overnight shift, but generally land somewhere in the 12-14 hour range. It’s mentally taxing, as you’re challenged intellectually on a daily basis, encountering new patient cases, seeing complications of ‘bread-and-butter’ cases you thought were simple, and still having to fit time in to study for standardized tests. It’s emotionally demanding, as you finally feel a sense of ownership over your patients, you see firsthand the plight of the sick individual, you struggle to find time for your loved ones outside of work, and it might even be the time when you see your first patient pass away. Conversely, it has also been the most rewarding year. Having an active role in patient care for the first time is truly intangible. It’s humbling, being the first face they see in the day when you wake them up at 0400 for pre-rounds. It’s invigorating, when your treatment plan gets validated by the team and you see the patient improve. It’s worth the extra hours when you see a patient you’ve taken care of get discharged after a long hospital stay, who proceeds to thank you for your role in their care.

With your feelings being at the extremes, each rotation can feel like a whole new world. This special MedSchoolInsiders (MSI) mini-series aims to provide a 30,000-ft view of the various clerkships that you will encounter during your MS3 year to better prepare you for your time on the wards.

 

Pediatrics

These are the tiny humans. These are children. They believe in magic. They play pretend. There is fairy dust in their IV bags. They hope, and they cross their fingers, and they make wishes, and that makes them more resilient than adults. They recover faster, survive worse. They believe.” -Grey’s Anatomy (sorry!)

“How many of you have ever changed a diaper?” Our faculty asked this question of my class during our Pediatrics orientation, and much to their chagrin, less than half sheepishly raised their hand. Pediatrics offers a completely different perspective on patient care. It brings a new “normal” to vital signs, offers a plethora of new diseases and pathology to consider, and even allows you to use the other end of the stethoscope you’ve been itching to explore. Let’s dive in and explore what the rotation looks like!

 

The Rotation

As with many MS3 rotations, you will have outpatient and inpatient experiences during your Peds rotation, and may get to rotate through the Emergency Department, NICU, PICU, or newborn nursery depending on your school.

Outpatient

Outpatient month(s) are typically regarded as easier, in the sense that outpatient clinics are typically 8a-5p or they run half day clinics. Either way, you get a nice break for lunch, and should be home in time for supper. If your program is anything like UC San Diego’s, you will get to submit a series of preferences for what types of outpatient clinics you want to rotate through including things like Peds Neuro, Endo, Heme/Onc, Ortho, Emergency Medicine, and General Pediatrics.

Use your outpatient month to study for the NBME. Since the hours are less demanding, use your spare time to prepare yourself for the exam. Personally, I was at a different clinic every half day. For example, I would have Endocrinology clinic in the AM, followed by general pediatrics PM clinic. One study strategy I used was to prepare the night before each clinic for the most likely diagnoses I would see the next day. Using the same example: For endo clinic, I would look through the textbooks and see what would be most common: Diabetes Type I, congenital short stature vs constitutional delay, hypothyroidism, etc. I would target my reading for the night to those diagnoses and their management so I would be prepared, rather than overwhelmed, during clinic the next day.

Inpatient

Our inpatient months were more demanding of our time. They come with early mornings and late evenings and leave you with little time on either end to study. That being said, it’s not impossible to study during your inpatient months and is often team-dependent (which service you’re on, how busy it is, etc). Some of the best learning on pediatrics will come from managing patients that are admitted. You will see bread-and-butter diagnoses like asthma exacerbations, pneumonia, mood disorders, appendicitis, sepsis, and more. An interesting publication from 2014 shows some of the most common diagnoses and trends in disease in the U.S.

If you’ve used your outpatient month to study, focus on the patients you are following while on your inpatient months.

      1. For each kiddo you are managing, know other possible diagnoses and how they would differ in presentation.
      2. Don’t be afraid to practice pending orders in your electronic health record (EHR) if your team and program allow.
      3. Pick up a wide variety of patients, then pick up others with the same diagnoses later in the month to attempt to be more autonomous with managing them. By doing so, you will solidify the concept of ‘next best steps’ that go beyond just finding the diagnosis.
      4. Find the heart of “why” – meaning why the patients are managed and treated the way they are, as this will often facilitate learning the pathophysiology of their disease.

 

The Patient Population

During your rotation, you can expect to see everything from newborns to 18-year-olds. With each age group, you must consider a new differential. For example, a 15-day-old newborn with a fever and a rash brings a scarier, larger differential requiring a lumbar puncture (LP) and other invasive testing, whereas a 17 year-old vaccinated individual with the same symptoms would have few people very worried. This skill, in my opinion, is one of the more difficult aspects of the clerkship. You must rapidly and accurately group the large variety of patients into their own sub-group to allow further management. One proposed breakdown, originally adapted from the PALS 2015 Guidelines is as follows:

    • Neonate: 0-28 days
    • Infant: 1 – 12 months
    • Toddler: 12 months – 2 years
    • Preschool: 3 – 5 years
    • School Age: 6 – 11 years
    • Adolescent: 12 years-18 years

For each of these groups of children, it becomes necessary to build symptom-specific differential diagnoses. One tactic I used in my studies was for each patient that I was managing, I’d review the vitals, their milestones, and their chief complaint that evening. With each chief complaint, I’d reflect and study other diagnoses that may present in a similar manner. Again, for each of these groups, you should be familiar with:

  1. Normal vital sign ranges – difficult (and maybe unnecessary) to memorize, but good to have a solid understanding of normal and abnormal, especially for the Emergency Medicine, NICU, or PICU aspects of your rotation.
  2. Normal developmental milestones – a great resource (not to memorize, but to aid in your studies) is the Dever II Developmental Chart, which shows expected ranges for developmental milestones from birth to 6 years old. Getting used to these milestones is not only clinically helpful but also makes reading question stems during the shelf exam infinitely easier.
  3. Appropriate history-taking questions – as the groups change, you will have to tailor your questions to what is important for that age group. For example, HEADSS (Home, Education/employment, peer group Activities, Drugs, Sexuality, and Suicide/depression) questioning for adolescents, birthing history for the younger age groups, and vaccination status especially given the outbreaks recently. Practice this early so by the end of your rotation it will be like second-nature.

Parents Are Your Patients, Too

If you thought you were just going to be treating cute babies all day long, you were mistaken! Keep in mind that throughout the rotation, kids are nearly always accompanied by a parent. Parents are the patient’s primary historian, especially at the younger ages, and will be your partner in treating the patient. Always remember that they’re in the room. Involve them in the care of their child, keep them informed, and be mindful of what you are saying to your team around the parents. This is of paramount importance! As medical students, we are inquisitive learners. But rather than blurting out differentials of all the scary things the child could be diagnosed with on rounds, or talking about patient prognosis, use family-centered language, and read the room. Approach your team with any questions that may not be appropriate at a later time. You will likely encounter Family-Centered Rounds (FCR), which is fairly unique to your pediatrics rotation, for the first time, which adopts many of these principles.

 

Pediatrics Shelf Exam

At my school, UC San Diego, the Pediatrics shelf exam is commonly regarded as one of the tougher exams, second only to Medicine, mainly because of the reasons listed above – there are multiple sub-groups of patient populations, each with different types of pathology to consider (not to mention the whole ‘different vitals’ thing). The first thing I like to glance at for any shelf exam is the NBME-published breakdown. This gives you an idea of where to start. At the time this blog post was published, NBME attributed a whopping 65% of your shelf to ambulatory care patients, while saving only 12-16% for inpatients! Focus your studies accordingly.

If you are anything like me, you will feel pressed for time on this shelf. Don’t spend too much time on any one question – remember, you’re allotted 90 seconds for each question, so keep that in mind. If you find yourself going over that mark, mark it using the in-test feature, and revisit it later. Other questions may trigger you to remember something about that question or provide useful mental cues to help you better answer it.

 

Study Resources

I really enjoyed using Case Files for this rotation, as it helped break down problems the way I mentioned above. Pretest was common among my peers, as it usually is for most rotations. However, to really be well-rounded and to recall all your embryology and congenital diagnoses you had to learn for STEP 1, UWorld is going to be essential during this block. At the time this post was published, there were 477 questions for the Pediatrics rotation – that is not an insignificant number, so start early, and be consistent! As always, Anki is a popular, hand-held way to memorize-as-you-go on your rotations.

 

Final Remarks

Whether you enjoy being around kids or are intimidated by them, whether you have changed 0 diapers or thousands of them, whether you have kids yourself or babysit your siblings’, or whether you avert from the glances of every tiny human that walks your way, Pediatrics provides you with the opportunity to participate in the scariest moments of their lives. No parent wants to see their child sick, nor do they want to be in the hospital with their little child. Use this rotation as an opportunity to take your empathy to the next level, practicing care for your patient and their parents along the way. If you are enthusiastic about learning, humble in your care plans, and exhibit empathy for your patients and their families, this rotation will be no problem for you. Don’t hesitate to reach out to us at MSI for additional help to maximize your chances at achieving honors. And remember…though most kids do not like to share, they will readily share their communicable diseases with you, so wash your hands, change your scrubs, and wear a mask when indicated!

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