Michael Dworkin, MD
How to crush the pediatrics clerkship
Updated: Sep 27, 2018
The pediatric clerkship can be daunting. Don't let it be. Follow these simple tips to crush your pediatrics rotation.
How to prepare for your pediatrics clerkship
Know the clinical setting you will be placed in. You may be placed in an outpatient office or the pediatric cardiology neonatal ICU for your first day. Ask around and determine the age and patient population you will be dealing with.
One week before the rotation, email the resident or attending you'll be with and briefly introduce yourself in one sentence. Ask where and when to meet on the first day of the clerkship.
Here’s an example email you can send before your pediatrics rotation:
Subject: Medical student starting on pediatrics next Thursday. Body: Hello, I'm an MS3 looking forward to starting on my pediatrics clerkship next week on Thursday. I was wondering: what time and where should I meet you? Is there anything I should know before starting? Thanks! -Your Name
If you will be working with neonates, make sure to review the neonatal history and physical exam before starting. Look a table of the normal pediatric vital signs (below) and familiarize yourself with it for the patient population you expect to see. Roughly, the vital signs should be as follows:
Age < 1 month: HR 90-180, systolic BP 60-80, respirations 30-50
Age 1-12 months: HR 80-160, systolic BP 70-100, respirations 25-40
Age 1-5 years: HR 80-120, systolic BP 75-110, respirations 20-30
Age 6-12 years: HR 70-100, systolic BP 80-120, respirations 20-30
Age 13-18 years: similar to an adult
Review a table of the developmental milestones. MedSchoolGurus has put together its own one page table of developmental milestones which is available for students who have a MedSchoolGuru.
In addition, check out our blog post on the best clinical resources to help you crush your clerkships and USMLE Step 2 CK exam, our post on how to use Anki during medical school, and our page about the MedSchoolGurus Pediatrics Anki Deck.
What to study early on during your clerkship
Do the UWorld Step 2 CK pediatrics questions during the first two weeks of the rotation. After you finish this, complete the Pretest pediatrics question book over the course of a week or two.
For video resources, check out the 25 OnlineMedEd pediatrics videos and the pediatrics shelf review from Emma Holliday. Do these as soon as possible and then review them throughout the clerkship.
If you’re on a sub-specialty service such as pediatric neurology or cardiology, make sure to skim the relevant chapters in First Aid for the Pediatrics Clerkship.
Expect to be pimped on simple questions about developmental milesones, the physical exam of the newborn, and vaccinations.
What to do on the first day of your clerkship
On your first day, ask your resident for advice on the rotation. This will vary a lot depending on the service you're on. If you have a reversible stethoscope and will be dealing mostly with infants, rotate the head of your stethoscope around to allow for better ascultation.
If you are in an inpatient setting that utilizes family centered rounds, read below for tips.
General tips for a successful clerkship
You'll want to adjust your clinical technique to match that of pediatricians.
First, be a good student. Meaning, be on time, clean and well groomed, professional with everyone you encounter, and willing to work hard and help out. Be straightforward and communicate clearly and deliberately with teammates. Don’t lie or make stuff up – if you didn’t examine something and are asked about it, just say you didn’t examine it. Know your patient very thoroughly – better than anyone on the team. Ask questions or for advice during downtime or when walking somewhere with your resident as opposed to when things are hectic.
Observe the behavior of your resident carefully. Take note of the questions they ask of the patients and family, and which answers they report when presenting to attendings. Try to meet them at their level and emulate their behavior.
If you’re told to go home for any reason, say “Ok, thanks! I’ll see you tomorrow!”.
If you are asked to do something you don’t know how to do, say you’ve never done it before and ask if you could be walked through it. For example, if you are asked to if you would like to perform a lumbar puncture for a febrile infant, say you would love to, but say you haven't done it before and ask to be walked through the steps.
How to start a day on pediatrics
If you are in an outpatient setting, arrive 15 minutes early.
In the inpatient setting, go to your team's workroom (20 minutes + 7 minutes per patient) early. This will give you time to pre-round on all of your patients.
How to obtain a history in pediatrics
Since children often cannot communicate their complaints and symptoms clearly, one must often obtain a history directly from or with the help of mom/dad/other. For patients under 4, you'll have to rely on these external sources of information. Make sure to ask how the person taking the patient to the doctor is related to the patient ("How are you related to little Sammy here"). Often, the chief complaint is reported by mom/dad (notice the use of patient centered words?). This means that dad is telling you a perceived issue with his child. Ask him "What brings you in today" to assess the chief complaint and its duration. While listening, take mental note of whether there is cause for concern or if you simply need to reassure him that everything is normal. Make sure to get a clear chronological list of events and symptoms, associated symptoms, previous treatments, etc, for these symptoms. Dad won't know when Sammy's hip pain started, so don't ask that; ask "When did Sammy start limping"?
Assess prenatal and birth history (mom's health and risk factors during pregnancy, labor and delivery, complications of the neonatal period including APGAR scores, jaundice, etc), developmental history (normal or, if abnormal, ages at which milestones were completed), feeding history for infants (use of formula vs breastmilk, frequency and amount, presence of solid foods and when they were introduced) past medical and surgical history, current medications, drug and non-drug allergies, social history and risk factors (location, daycare, who does the patient live with, parental occupations), and immunization history.
Use patient centered words
Do not say "the patient's mother" or "the mom". Instead, say "mom". Example: "Mom reports baby John has vomited three times since last evening". Example: "Does dad help you with your homework in the evening?"
The pediatric physical exam
The physical exam you perform will be highly dependent on the chief complaint and clinical setting. Generally, perform a very thorough exam for patients who you have not seen before or who have an unclear diagnosis. Ask your resident or attending to help you through the physical exam. You will not impress anyone by knowing how to to a full pediatric physical exam on day one. Do not attempt to examine a child alone if you have not done so before. You will develop these competencies throughout the clerkship.
How to present a during family centered rounds
Family centered rounds are when you present the patient to the team in front of the patient and their family. These require special care. Ask your resident or attending before attempting to lead one of these discussions. If you do get to lead a family centered round discussion, first, make sure everyone is present who should be present, including the mom, dad, relevant caregivers and loved ones, as well as the nurse, and your residents and attending. Ask the family they would like for anyone to leave or be present during rounds. Introduce yourself, stating your full name and rank (E.g., I'm Michael Dworkin, a 3rd year medical student), and each member of the team or have members of the team including the nurse all introduce themselves. If you've done this several times with the family already, you can skip this step.
Discuss in non-alarming layman's terms your assessment and plan. Example below.
"This is Sam Smith, our 3 year old who came to the hospital yesterday with three days of peeing a lot, loosing weight, and who we found to have high blood sugar and a new diagnosis of diabetes. Diabetes in children is a disease where the body has trouble making insulin. Both Sam and his lab tests look a lot better after he got treated with with fluids and insulin. If Sam continues to do well today, and his labs tomorrow look ok, we think he can go home tomorrow. In the meantime, we want to make sure you all are set up at home to treat his diabetes, and know what to expect. Our nurse Sarah here will come by this afternoon and teach you how to measure Sam's blood sugar at home as well as how to inject insulin. We will also schedule you to have a follow up appointment with a diabetes doctor close to where you live who you help you manage Sam's diabetes on a regular basis. (Turn to family) What questions do you have? (Answer questions, turn to team) What questions do you have? (Read back the orders to the team) Ok, so I'll order Sam's labs for tomorrow and schedule an appointment with a diabetes expert"
How to study for the pediatrics shelf
Redo your UWorld incorrect questions in pediatrics. Re-watch the OnlineMedEd videos. Re-watch the Emma Holliday Shelf review video. Do all of the NBME Clinical Science Mastery Series practice exams for pediatrics.
Take home points
Be prepared. Set yourself up for success. Do practice questions daily. Be a good student and follow the lead of your residents. Be sensitive and in tune with families. Be careful not to overstep your roles as a medical student.
Enjoy your pediatrics rotation!
For more information about our shelf exam and USMLE tutoring services, or the MedSchoolGurus Pediatrics Anki Deck, check out medschoolgurus.com. To schedule a free 15 minute consultation session, visit medschoolgurus.com/contact.