Medical Program

PEDIATRICS

The clerkship in pediatrics provides a learning experience that fosters the highest standards of professional behavior and provides students with a clinical experience that prepares them to understand, evaluate and treat children from newborn through adolescence.

The clerkship integrates a foundation of medical knowledge with clinical and communication skills to enable the student to identify and perform quality pediatric care.

After completion of a six week rotation during the third year, in conjunction with an additional four weeks of education in the fourth year, students will demonstrate a firm understanding of the competencies required to evaluate and provide care for children who are both sick and well.

This six-week clerkship allows students to gain clinical experience in evaluating newborns, infants, children and adolescents (both sick and well) through clinical history taking, physical examination and the evaluation of laboratory data.  Special emphasis is placed on:  growth and development, nutrition, disorders of fluid and electrolytes, common infections, social issues, and preventative care (including immunizations, screening procedures, anticipatory guidance).

Pediatric ambulatory and in-patient services provide the student with the opportunity to observe medical and surgical disorders of pediatric patients.   Admission histories and physical examinations teach the student how to approach the patient and family.  The student must learn specific skills regarding the interviewing of parents and pediatric patients.  Furthermore, the student will develop the skills necessary to examine children from infancy through adolescence.  The adequacy and accuracy of the students’ clinical skills and professional behavior will be measured and evaluated by their supervising physicians and preceptors. There will be formative evaluations and discussion of the students’ progress. Attendance and active participation in didactic learning opportunities, clinical seminars, self-directed learning modules, and conferences will expand the student’s concept of providing care for the pediatric patient. 

Multiple learning opportunities are provided to the student to explore in depth the issues of pediatric care.

In the well child out-patient services, the student learns the milestones of growth and development, infant feeding, child nutrition, preventative care (including immunization, screening procedures, anticipatory guidance), and the common ailments of childhood.  In the pediatric specialty clinics, the student observes the progression and participates in the management of a wide variety of serious and chronic pediatric illnesses.
Emergency department and urgent care experiences permit the student to be the first to evaluate infants and children with acute illnesses. Emphasis is placed on the evaluation of febrile illnesses, and common emergencies of childhood (e.g. poisonings, injuries).

The initial management of the newborn is learned in the delivery room.  Students must then practice the examination of the newborn and learn about the initiation of feeding, neonatal physiological changes, and common newborn related conditions.  In the newborn intensive care unit, the student is an observer of the management of the premature and term infant with serious or potentially serious ailments.  Emphasis is placed on observing and understanding the role of the pediatrician in the multidisciplinary team approach to critical care.

 

Learning Objectives

Guidelines

  • Length:  minimum of six weeks.
  • Sites: general pediatric unit, ambulatory care unit, pediatric emergency unit, nursery, PICU, private office practice, and other sites, as available.
  • At   the   start   of the   clerkship   an orientation is given. The  SGU clerkship director or designee  discusses  with  the  student  the program, the responsibilities of the clerk, the schedule and assignments to residency teams and preceptors. The student is introduced to the key preceptors and staff members in the department.
  • The student must participate in the night, weekend, and  holiday on- call  schedules.  The   
    clerkship director will set the number and timing of calls. 
  • The   student  must attend scheduled clinical conferences, Grand  Rounds,   subspecialty   
    conferences, and learning sessions.
  • A  preceptor should meet with each student  at least twice  a week for  a total  of three hours per week, minimum.
  • The student is involved with all patient care activities whether the patient is seen in the ambulatory facility or on one of the inpatient units.
  • The student will be observed performing a physical examination on a newborn and a child.
  •  As an absolute minimum, each student should examine at least five term newborns.  This includes reviewing the maternal medical record, performing a physical examination on   the infant, and talking with the parent about basic care of the newborn and anticipatory guidance.
  • As an absolute minimum, each student should be involved in the care of a child with:
    • a gastrointestinal illness, such as dehydration.
    • a child with a neurological or neurodevelopmental problem.
    • a child with a respiratory and/or cardiac problem (chronic illness is preferable).
    • a child with fever.
    • a child suspected as being the victim of child abuse/neglect or where the           differential diagnosis includes child abuse/neglect . There should be a discussion of the recognition and reporting requirement and the child protection response and services.
  • Involvement in these cases should include gathering history, performing a physical   
    examination, discussing the differential diagnosis and a diagnostic and treatment plan.  These cases may be from the inpatient unit, the nursery, the emergency room, or the ambulatory care setting.
  •  As an absolute  minimum, each  student  will participate  in the care  of  at  least two adolescents.  This includes gathering history and performing a physical examination as well  as  reviewing the  immunization record  and   assessing  the  adolescent’s health, behavior,  educational and  environmental issues.  It is  preferable that  one ofn the two adolescents described will have a chronic illness.
  • The student will give, at a minimum, one major presentation during the rotation. The presentation will be evaluated by the preceptor.
  • A minimum of four complete clinical write-ups is required per student.  These write-ups  
    will be critiqued by the preceptor and returned to the student.  It is preferable that the patients selected for these write-ups be examples of the case mix cited in guideline #8 above, the paragraph numbered 1 through 5.
  • Each student must have a formative mid-core evaluation with a written assessment; the latter  will address  his/her progress with  appropriate comments  or  suggestion.   (Mid- core evaluations must be submitted to the school). 
  • Each  student will maintain an electronic Patient Encounter Log to include the required  data  and diagnosis  of  each  patient  evaluated  or  followed by  the  student. The   student  will submit their log to the preceptor at mid-core evaluation and for the final oral examination.             
  • The student also maintains a Manual Skills and Procedures Log in which are listed the procedures performed or witnessed.  The  following   procedures   are   recommended  to  be  performed  or  witnessed  during  the   pediatric rotation:
    • vision and hearing screening
    • otoscopy
    • administration of inhalation therapy (Metered Dose Inhaler/MDI/Spacer/Nebulizer).
    • throat culture
    • immunizations: intramuscular injection, subcutaneous injection.
    • mantoux testing: PPD
    • nasopharyngeal swab
    • peak flow measurement
  • The  students   are  responsible   for    completing    the   introductory  modules   of   the Communication Skills course  prior to  the  start  of  the 3rd  year  core rotations. This self - directed learning  computerized  course can   be   accessed   through  the SGU website at My SGU   (click  Communication Skills  Course,  upper left corner). In addition, required for the pediatric Rotation are modules:   #21. Communication and Relationships with Children and Parents. #22. The Adolescent Interview.
  • The student will participate in a self-directed learning course and will complete cases as assigned by their preceptor, on the self-directed learning website: CLIPP (Computer-Assisted Learning in Pediatric Programs). The student is encouraged to complete as many additional cases as they choose.
  • A written examination is taken at the  end  of   the  rotation. The  examination   is  based on  the  core  curriculum as  described in  this  Manual and  in  the required reference material  
  • An  oral   examination is taken  at  the end of  the rotation.   The  examination  will  last a minimum  of  15  minutes. The  student  will  submit  a copy of his/her Patient Encounter Log. The  student will prepare and present a structured presentation and discussion of a case  of  their  choice from their log. The  student  will  include relevant knowledge of pathophysiology  and  research of the subject in the discussion. In the second part of the examination  the examiner  will use the  student’s log to  ask additional  questions and discussion regarding the cases documented.
  • The department  of  Pediatrics  places  special   emphasis  on   professional  behavior  as  Well  as knowledge  and developing  student  skills  in clinical  problem solving, problem,interviewing techniques, presentations,  and  physical  examinations.

Educational Objectives

Medical Knowledge

  • Gain knowledge in the core topics of the curriculum.
  • Gain supplementary information and data from journals, texts, research, the internet and other resources.
  • Demonstrate knowledge regarding the major illnesses and conditions that affect newborns.
  • Demonstrate knowledge of health maintenance and preventive pediatrics, including: immunization schedules, newborn screening, lead testing, TB testing, vision and hearing screening.
  • Demonstrate knowledge of growth and development with special emphasis on puberty. (Tanner Stages)
  • Compare and contrast the feeding and nutritional requirements of each age and stage of childhood.
  • Demonstrate knowledge of fluid and electrolyte balance.

Clinical Skills

  • Demonstrate  the ability  to approach the  patient and family  in an  empathic   and  focused manner to form a positive and informative relationship.
  • Demonstrate the ability to perform an accurate and organized diagnostic interview and record the information precisely and concisely.
  • Perform complete physical examinations on newborns, infants, toddlers, children and adolescents.
  • Participate in the selection of relevant laboratory and radiological tests.
  • Interpret results to support or rule out diagnoses and arrive at a working diagnosis.
  • Actively participate in formulating a management plan and participate in carrying out that patient care plan.
  • Communicate orally and in writing, the information necessary to educate the patient and family regarding the situations or conditions they are involved with.
  • Participate in making decisions regarding management, discharge and follow-up plans.
  • Interpret laboratory values according to age-related norms.
  • Accompany and observe senior staff to the delivery room for high risk births.
  • Communicate with families regarding education and anticipatory guidance during outpatient visits.
  • Evaluate common infections and acute illness of children of all ages in the urgent care or emergency setting.
  • Evaluate children with serious illness in the inpatient setting.
  • Evaluate children with chronic and unusual illness in the outpatient and sub-specialty centers.
  • Demonstrate your ability to research topics and apply clinical research to your understanding of patient issues.
  • Participate in clinical research when possible, either by participating in an ongoing project or initiating a new line of inquiry.

Professional Behavior

  • Establish rapport with patients and families that demonstrates respect and compassion.
  • Demonstrate honesty, integrity and respect in dealing with patients, families and colleagues.
  • Demonstrate that you are a responsible team member and carry out all of your assigned duties in a timely manner.
  • Offer assistance when and where it is needed.
  • Demonstrate that you are an effective member of the team by fully participating in discussions and contributing to learning endeavors.
  • Demonstrate sensitivity to issues related to culture, race, age, gender, religion sexual orientation and disabilities..
  • React appropriately to conflicts and ethical dilemmas by working toward solutions.
  • Demonstrate a commitment to professional behavior and high ethical standards.

CORE TOPICS

General

  1. Pediatric history

  2. Pediatric physical exam

  3. Patient write-up (problem oriented approach)

  4. Begin to formulate a differential  diagnosis that  relates to  the  presenting

    complaint,symptoms and findings on history and  physical examination.
  5. Formulate a plan for further evaluation (i.e. laboratory, radiology), treatment and management.

Well Child Care

  1. Immunizations
  2. Routine screening tests
  3. Anticipatory guidance
  4. Nutrition

Growth and Development

  1. Developmental milestones (when and how to evaluate)
  2. Failure to thrive
  3. Short stature

Neonatology

  1. The normal newborn
  2. Neonatal problems (jaundice, respiratory distress, sepsis, feeding issues)
  3. Newborn screening
  4. APGAR scoring/Ballard scoring.
  5. Fetal Alcohol Syndrome
  6. Sudden Infant Death Syndrome

Common Childhood Illnesses and Their Treatments

  1. Respiratory
    1. URI
    2. Pharyngitis
    3. Otitis media
    4. Sinusitis
    5. Cervical adenitis
    6. Croup/epiglottitis 
    7. Bronchiolitis
    8. Asthma
    9. Foreign body
    10. Pneumonia
    11. Cystic fibrosis
    12. Tuberculosis
  2. Eyes
    1. Conjunctivitis
    2. Ocular trauma
    3. Amblyopia
    4. Strabismus
  3. Cardiac
    1. Fetal circulation
    2. Congenital anomalies (VSD, ASD, tetralogy, transposition, coarctation, POA, PPS) as isolated findings and as they relate to genetic syndromes.   
    3. Acquired heart disease (RF, myocarditis)
  4. G.I.
    1.  Gastroenteritis
    2. Constipation/Hirschsprung’s disease
    3. Acute abdomen (appendicitis, intussusception, volvulus)
    4. Inflammatory bowel disease
    5.   GERD
  5. Endocrine
    1.  Diabetes, DKA
    2.  Thyroid disease
    3.  Adrenal disease/CAH
  6. Neurology
    1.  Seizures
    2.  Meningitis
    3.  Head trauma
    4.  Cerebral palsy
    5.  Tumors
  7. Hematology/Oncology
    1.  Anemias/hemoglobinopathies
    2.  Pediatric malignancies (ALL, lymphomas, neuroblastoma, Wilm’s)
    3.  ITP
  8. Renal/G.U.
    1. UTI’s
    2. Nephritis/nephrosis
    3. Fluid and electrolyte balance
    4. Congenital anomalies
  9. Dermatology
    1.    Seborrheic dermatitis
    2.  Atopic dermatitis
    3.  Impetigo
    4.  Fungal Infections
    5.  Exanthems
    6. Neurocutaneous stigmata (neurofibromatosis, etc.)
  10. Ingestions and Toxidromes
    1.   Lead poisoning
    2.   Salicylate, acetaminophen
    3.   Iron
  11. Common Pediatric Orthopedic Problems
    1.   Developmental dysplasia of the hip
    2.   Osgood Schlatter
    3.   Slipped Capital Femoral Epiphysis
    4.   Legg-Calve-Perthes disease
    5.   Torsions
    6.   Dislocated radial head,(Nursemaid’s elbow)
    7.   Fractures
  12. Musculoskeletal System
    1.  Osteomyelitis/septic arthritis
    2.  Muscular dystrophies
  13. Adolescence
    1. Tanner staging
    2. Precocious/delayed puberty
    3. Stages of adolescent development
    4. Sexually transmitted infections
    5. Pregnancy/menstrual irregularities
    6. Vaginal discharge
  14. Child Maltreatment Syndrome
    1. Physical abuse
    2. Sexual abuse
    3. Emotional abuse
    4. Neglect
  15. Genetics
    1.  Down Syndrome, # 21 trisomy
    2.  #13 trisomy
    3.  #18 trisomy
    4.  Turner Syndrome
    5. Klinefelter Syndrome
  16. Collagen Vascular
    1. Juvenile Rheumatoid Arthritis
    2. Systemic Lupus Erythematosus
    3. Henoch Schonlein purpura
    4. Kawasaki disease
    5. Hemolytic Uremic Syndrome
  17. Miscellaneous
    1. Fever without focus
    2. HIV infection and AIDS

Reading

Suggested Approach to Reading for Medical Student Pediatric Rotations

“Reading” is an essential part of medical education.  How to best benefit from the time spent reading for pediatrics may vary among individuals.    More important than the reading per se is the retention of what has been read and the ability to recall and return to the source of the material – to create a “library” of important material in your notes, in your files and in your memory.

The following suggested reading materials – comprehensive textbooks, condensed textbook, specialized topical books, reference books, synopses, journals, internet sites – may be available at your Pediatric site and should constitute sufficient resources for your basic and applied Pediatric reading.

As you start your rotations, important preliminary reading should be done in the earlier chapters devoted to growth and development in one of the comprehensive textbooks.  One must formulate a sense of the normal parameters of each stage of development so as to appreciate how illness affects children differently during different stages of the pediatric years.

These textbooks, journals, as well as internet sites, provide in-depth descriptions of all new aspects of pediatric care.

Students should use the most recent edition of the following:

Required

Pediatrics for Medical Students – Most recent edition, edited by Daniel Bernstein and Steven P. Shelov, Lippincott Williams and Wilkins.

Comprehensive Textbooks

Nelson’s Textbook of Pediatrics, Latest Edition, Saunders publisher, edited by Behrman, Kliegman, Jenson

Rudolph’s Textbook of Pediatrics, Latest Edition, McGraw-Hill publisher, edited by Rudolph, Rudolph, Hostetter, Lister, Siegel

Illustrated Textbook of Pediatrics by Tom Lissauer and Graham Clayden

Pediatrics and Child Health by Rudolf and Levene published by Blackwell.

Condensed Textbooks

Pediatrics:  A Primary Care Approach, 1st Edition, Saunders publisher, Editor C. Berkowitz

Manual of Pediatric Practice, Saunders publisher, Editor L. Finberg

Growth and Development, Watson and Lowrey

Essential Pediatrics, Hull and Johnstone

Useful Subspecialty Books

Textbook of Pediatric Emergency Medicine, Lippincott, WW publisher, edited by Fleisher, Ludwig, Henretig, Ruddy, Silverman

Clinical Pediatric Dermatology, Elsevier publisher, edited by Paller & Mancini

Atlas of Pediatric Physcal Diagnosis, Mosby publisher, edited by Zitelli and Davis

The Requisites in Pediatrics, Mosby publisher, series of small topical subspecialty volumes edited by L  Bell, including Nephrology , Urology, Pulmonary, Endocrinology, and Cardiology

Red Book, (Infectious Diseases) American Academy of Pediatrics, Edited by Pickering et many

Abbreviated Reference Books

Harriet Lane Handbook, Mosby publisher, edited by senior pediatric residents at The Johns Hopkins Hospital

Pediatric Secrets, Hanley & Bellis publisher, edited by Polin and Ditmar

The 5-Minute Pediatric Consult Series, CHOP, edited by M. William Schwartz
Resource Materials pertaining to Cultural Competency

  • Bigby J. Cross Cultural Medicine. New York: American College of Physicians, 2003 p. 1-28
  • Miller S.Z.  Humanism and    Medicine Acad  Med Vol 74, N07/July 1999      p. 800-803
  • Coulehan JL. Block  MR. The Medical  Interview; Mastering Skills for Clinical  Practice.  4th ed. Philadelphia, Davis, 2001.  Chapter 12 Cultural Competence  in the Interview p.  228-245
  • The Spirit Catches you and You Fall Down; A Hmong  Child,  Her American  Doctors,  and the Collision of Two Cultures.  By Anne Fadiman. Farrar, Straus.

Journals

Pediatrics
Journal of Pediatrics
Academic Pediatrics
Pediatrics in Review
Pediatric Clinics
Journal of Pediatric Infectious Disease

Internet Sites

www.comsep.org – Provides  curriculum and  lists topics  in pediatrics.   This  site is primarily for faculty members, but has relevant sections for students. There is an excellent video demonstrating how to perform a physical examination on a child.

 www.aap.org - Offers access  to all  American  Academy of Pediatrics  Policies  and Guidelines.

www.brightfutures.aap.org - Offers  information  about developmental milestones, anticipatory guidance, and mental health.

www.geneclinics.org - Sponsors a database for genetic diseases and newborn screening methodologies.

www.doc.com - Communication skills course.
Basic Modules and Essential Elements (required for all rotations)
Required for Pediatrics:
#21.   Communication and Relationships with Children and Parents
# 22.  The Adolescent Interview

http:///med-u.org/virtual_patient-cases-clipp 
Self-directed learning.
Pediatric clinical cases.