Episode Transcript
Hi and Welcome to Clerkship Ready - Pediatrics - A podcast aimed at helping you excel during your clinical clerkship in Pediatrics. I am:
Dr. Rachel Moon -- I’m a general pediatrician and Professor of Pediatrics at the University of Virginia.
Also, welcome to Pediatrics! As a pediatrician, I’m biased, but I think that this is the most fun clinical rotation!
It is also one of the most challenging. Why? Because every single patient will be different. You will see patients from birth until their early 20s. That’s a big range in terms of size and development. The physical, developmental, emotional, and mental issues at each age are different, so there is a lot to learn! As an example, your differential diagnosis for a 3 week old patient who presents with bloody diarrhea will be very different from your differential diagnosis for a 3 year old patient or a 13 year old patient with bloody diarrhea. Even the infectious organisms are different at different ages.
Essential Resources. Many of these resources also are available through apps. All of these are also listed in the show notes.
Podcasts:
Clerkship Ready-Pediatrics
Charting Pediatrics - from Colorado Children’s. They discuss a particular topic each week, and there is a lot of bread-and-butter pediatrics discussed.
AAP’s Pediatrics on Call - They discuss the most recent research and the newest policy updates from the American Academy of PEdiatrics.
Books
Red Book (also an app for AAP members) - this is the definitive source for pediatric infectious diseases.
Harriet Lane (also an app) - handbook that comes out of Johns Hopkins pediatric program that is used by many pediatricians. It has drug doses, commonly used charts, and algorithms.
Websites:
Peditools for bilirubin : helpful when you’re on newborn rotation or seeing a newborn for whom you’re concerned about hyperbilirubinemia.
Uptodate
CDC website is a great source for vaccine guidelines, particularly when the guidelines change frequently, as was seen when the COVID vaccines were approved.
Apps:
PedsScripts App: specifically to work on illness scripts
General Tips and Tricks that are relevant to any rotation:
- Be Proactive—talk to students who just finished the rotation about what to expect, the day to day logistics, and ways that you can be helpful.
- Expectations: Ask for them to be set at the beginning. Clarify as needed.
- Become familiar with the electronic medical record system. Know how to access former visits, both at your institution and outside institutions, and information about medical problems, medications, allergies, and vaccinations.
- Be Self-sufficient, but ask for help when appropriate. There is a balance of being proactive and knowing your limitations.
- Before leaving for the day, ask when you should come in to round, who to pre-round on and where to meet. Pair up with an intern to pre-round.
- Once or twice a week ask for feedback when everyone has a down moment. Be aware of the right time/situation to ask.
Pediatric-specific Tips and Tricks:
Pediatrics is different from any other rotation. At every age, children act differently - and you need to adjust appropriately.
First, remember that children are not little adults. Depending on their age and developmental status, they may or may not act the way that you are anticipating. A 15 m/o will likely scream as soon as you approach them. A 3 yo may try to kick you or pull your hair. A teenager may just play on their phone the entire visit unless you engage them.
Second, you have to adjust how you do what you usually do. If you can, get as much of the history from the child, but you will likely need to supplement that with history from the parent or guardian.
When you do your physical exam, depending on age, you may not be able to do the exam head to toe. For school-aged children, you can usually start with the head and make your way down. You can’t do that with younger children. First of all, don’t make the child move if they are comfortable and feel safe. You can do much of the exam while the child is sitting on the parent’s lap. Take advantage of when the child is quiet to listen to the heart/lungs. I usually start with heart and lungs, then move to the abdominal exam.However, if I need a good eye exam, I may start there, and then move to the heart/lungs, and abdomen. I then go to the head and neck exam. I usually save the ear exam for the end. If the child starts crying, you can then have an opportunity to look at the mouth and throat. Even if you do the exam in reverse order, always try to present your physical exam in head to toe order.
Vital signs change with age. For instance, in a newborn, a normal heart rate is 120-160/minute and respirations about 40/minute. This is very different from what we expect to see at 4 years old, when the normal heart rate is 80-120/minute, and respirations about 25/minute. Look up or ask about what is a normal vital sign in the age you are seeing. We consider the growth chart to be the 5th vital sign so always look at growth, length/height and/or head circumference and report both percentiles and trends.
If an infant has been born prematurely, then you will want to adjust your expectations for growth and development to account for the prematurity. In the first 2 years, we correct for gestational age. For instance, if a baby was born at 30 weeks, that is 10 weeks early. So at 6 months of age, you would expect this baby to attain the growth and development of a 3-½ month old.
Because we take care of a wide range of ages and sizes, we also have to make sure that the amount of fluids, medication, or anything is right for the child’s size. Almost everything is dosed per kilogram. However, for older or larger children, you have to double-check what the adult dose is, because that is usually the maximum dose, and you don’t want to exceed that, even if the child’s weight would call for more than that.
Family centered rounds are a unique important part of pediatrics. The goal on rounds is not to repeat the entire medical record but to get both the team and family up to date on the patient’s diagnosis and overall course, and to formulate a plan for the day together with the family. Just like it sounds like, in FCR, the focus of the rounds is the patient/family, not just the passing of information to the medical team. This allows us to both provide information to the family, increase their health literacy and understanding of the child’s medical issues, and involve them in decision-making. Everyone, including and especially the family, should be encouraged to ask questions, clarify information and review the daily plan. Since this may be the first time you’ve been a part of FCR, and because different institutions may do it a little bit differently, here are a few tips:
Usually there is a brief summary that occurs outside of the patient room. This is where any sensitive information is shared and where you review the plan, so that the whole team is on the same page before they go into the patient room.
One team member lets the family know that we are rounding, and asks them if they would like to participate. While FCR usually occurs at the bedside, depending on what’s happening at the time, family members may join the team outside of the patient room for rounds. Others may decline to participate.
Remember that, because you are talking to the family, language needs to be conversational and not include medical jargon. You want to be concise and clear so that everyone in the room can follow along.
Outro:
Thanks for listening to Clerkship Ready - Pediatrics. Hope you found today’s episode helpful. Don’t forget to subscribe below and rate the podcast!
