Department of Pediatrics

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• Pediatric Clerkship
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  • Pediatrics Clerkship Information
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Pediatric Clerkship Table of Contents and Information

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GOALS FOR PEDIATRIC CLERKSHIP

The pediatric clerkship should foster in the student:

1. Acquisition of basic knowledge of growth and development (physical, physiologic, and psychosocial) and of its clinical application from birth through adolescence.
2. Development of communication skills that will facilitate the clinical interaction with children, adolescents and their families and thus ensure that complete, accurate data are obtained.
3. Development of competency in the physical examination of infants, children, and adolescents.
4. Acquisition of the knowledge necessary for the diagnosis and initial management of common acute and chronic illnesses.
5. Development of clinical problem solving skills.
6. An understanding of the influences of family, community and society on the child in health and disease.
7. Development of strategies for health promotion as well as disease and injury prevention.
8. Development of the attitudes and professional behaviors appropriate for clinical practice.
9. An understanding of the approach of pediatricians to the health of children and adolescents.

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GUIDELINES FOR M3 PEDIATRIC CLERKSHIP

I. STRUCTURE OF CLERKSHIP

The pediatric clerkship is roughly divided into two sections: one month of in-patient experience and one month of out-patient experience. While on the in-patient month the student will become an integral part of the in-patient ward team, consisting of the attending(s), supervising resident(s), interns and other students. Students will be responsible for writing H&Ps/progress notes and caring for all patients assigned to them.

The ambulatory rotation will be spent rotating through general pediatric and sub-specialty clinics evaluating patients and presenting to supervising residents or faculty.

II. RECOMMENDED TEXTBOOKS

This is a misnomer since there is no specifically recommended text in Pediatrics. If the student is already sure that he/she will be going into Pediatrics as a career then the more expensive comprehensive text would be most appropriate. However, for simple general review, the less expensive review texts are adequate with no one particular book having any more advantage over the others. The text should therefore be selected for ease of reading and the style that suits the student.

A. Comprehensive Reference Texts (~ $110):

1. Nelson Textbook of Pediatrics (Behrman and Vaughn)
2. Rudolph's Pediatrics (Rudolph, Hoffman and Rudolph)

B. Fairly Thorough Texts (~ $70):

1. Principles and Practices of Pediatrics (Oski et al.)
2. Comprehensive Pediatrics (Summitt)

C. "Meat and Potato" Text (~$42):

1. Essentials of Pediatrics (Behrman and Kleigman)
2. Handbook of Pediatrics (Merenstein, Kaplan and Rosenberg)

D. Miscellaneous Texts (~ $25):

1. Annotated Clinical Problems in Pediatrics
2. Current Pediatric Diagnosis and Treatment (Kempe)
3. Manual of Pediatric Physical Diagnosis (Barness)
4. The Harriet Lane Handbook (Greene)

III. GRADES:

Inpatient Rotation	50%
Ambulatory	Pass / Low Pass/ Fail
SLIDE Exam Newborn Nursery	Exam #1 = 3%; Exam #2 = 7% 5%
Shelf Exam	35%

IN-PATIENT ROTATION: (50% of total grade)

This grade is determined by your attending(s) and supervising resident with input from your interns based on patient work-ups, daily progress notes, participation in rounds, presentations, etc. To give you an idea of how you are performing, your attending physician(s) and/or supervising resident will provide written mid-month feedback during your in-patient month. If the faculty fails to provide this feedback, the student is expected to ask the attending for the current evaluation.

Please, carefully review the evaluation form included in your packet. Note the types of attributes that your attending and residents will be evaluating during your rotation. Listen carefully to the explanation given during orientation concerning how a numerical grade is calculated using these forms.

AMBULATORY or OUT-PATIENT ROTATION: (Pass / Low Pass/Fail)

This grade is determined by:

1. The ambulatory faculty with input from the supervising residents, private pediatrician preceptors and subspecialty physicians through whose clinics you will rotate. Once again you are evaluated on patient work-ups, physical examination skills, participation, and preparation prior to the clinic, etc.
2. Out-patient Examination. At the end of the two month rotation an out-patient exam will be given and the score counts: Exam #1 = 3% and Exam #2 = 7% of the clerkship grade. This test may either be oral or computerized.
3. Case Conference Sessions: Students will be given cases to prepare for problem solving sessions with faculty each week. Details are provided in the out-patient orientation. These sessions are both instructional and evaluative, so be prepared.
4. CLIPP cases -The Computer-assisted Learning in Pediatrics Project (CLIPP) is a comprehensive Internet-based learning program for use by third-year medical students during their pediatric clerkship. CLIPP's 31 interactive cases are designed to cover all of the core content of the curriculum of the Council on Medical Student Education in Pediatrics (COMSEP). It is expected that each CLIPP case will take a student approximately 45 minutes to complete. To access the CLIPP cases go to the CLIPP home Page. There is also a link in the Clerkship Home Page Table of Contents. See directions below for registering.

OUT-PATIENT GRADING

Pass- requires documentation of experience and participation in clinic

Fail - 2 or more unexcused absences or serious concerns expressed by various residents or faculty concerning students' performance during the ambulatory rotation.

Low Pass - Multiple concerns expressed by various residents or faculty concerning students' performance during the ambulatory rotation.

Comments from faculty and house staff gathered during the out-patient month will be included in the pediatric evaluation that will be sent to Academic Affairs for inclusion in the Dean’s Letter.

The Clerkship Director retains the right to discuss with the attendings any serious infraction, extenuating circumstances or positive behavior not previously known to the attendings and may advise the attendings to alter the student’s grade accordingly.

ATTITUDES

In contrast to the first two years of medical school where much of a student’s grade is based on objective criteria obtained through written testing, the second two years base much of the grade on subjective evaluation. Perusal of the evaluation form reveals that at least forty percent of the grade is based on evaluation of professional and personal attributes. Physicians-in-training must possess certain necessary attitudes and interpersonal skills. Some of these are inherent, but much can be cultivated particularly in an environment filled with the appropriate role models. The administration of the University of Tennessee feels strongly about this and has published guidelines for Professional Behavior and Conduct in the Centerscope reproduced here.

• Code of Professional Conduct
• General Guidelines for Professional Behavior and Conduct

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WRITTEN EXAMINATION: (35% of total grade)

At the end of the clerkship the students will take the National Board of Medical Examiners Pediatric Shelf Exam.

Important Notes

A score of less than 65 on this test requires repeat testing. The NBME shelf exam is used as the written re-exam.

Re-examination must occur as follows: if failed during Block 5/6, 7/8, or 9/10 you must retake the exam before the beginning of Block 1 of your M3 year; if failed during Block 11/12, 1/2, or 3/4 you must retake the Shelf exam before September 1 of your senior year.

Failure to be re-examined will result in a failing grade for the rotation. The original test score will be averaged into the final overall grade. Failure of the re-exam, failure of any portion of the clerkship or an overall D for the clerkship, requires that the entire rotation be repeated. Failure of the first exam, or any segment of the evaluation, negates the ability to receive an “A” as a final grade no matter in what the ultimate grade average results.

Students who fail the written Shelf exam are required to retake the exam at the regularly scheduled times of the exam at the end of the Pediatrics Clerkship rotation. If a student desires to retake the Shelf exam other than at the regularly scheduled time, 4 weeks advance notice must be given.

All portions of the pediatrics clerkship including clinics, exams, etc. must be completed and passed within one (1) year of starting the pediatrics clerkship or by September of the senior year, whichever comes first.

GRADING SCALE

The following scale will be used to assign final grades for the clerkship. Grades will not be curved or rounded.

• A: 90-100
• B: 80-89.99
• C: 70-79.99
• F: 69.99 or lower

The standard deviation for final grades is historically very small. Therefore, a difference as small as 0.2 points is significant and will not be curved or adjusted upwards.

Additional Grading Information

You will be notified by email when grades are ready and have been posted. If the grades are not posted, it means that they are not ready. Please, do not call the office to find out your grade. No grades will be given out over the phone.

Student Academic Support Services (SASS) - Any special testing accommodations need to be arranged at the beginning of the rotation. If not it may not be possible to honor requests (i.e. testing in the SASS office, etc.) NO special accommodations will be given for the SLIDE exams.

Students failing to complete and turn in their Pediatric Patient Log cards (white clinic cards), their H&P Card and their Night Call card (all with appropriate signatures) will receive a failing grade for the rotation. Cards are required to be submitted the Wednesday before the Pediatrics Shelf exam. There will be no guarantee that card documentation will be satisfied if cards are submitted at any other time other than the Wednesday before the exam.

Each student is required to complete a Hall Tackett evaluation. These evaluations must be completed before student grades can be turned into the registrar's office. If you do not complete your Hall Tackett by the time grades are being reported, an “I” will be submitted for your grade and you will have 30 days from that point to complete it. If you fail to complete your Hall Tackett by the end of the 30 days, you will receive an “F” for the rotation.

IV. BASIC CLERKSHIP ETIQUETTE

Dress Code

During the week, proper hospital attire is expected.

Inpatient
Daily dress should be business casual (men - trousers, shirts, ties are preferred but optional depending on the attending; women - skirts/slacks, blouses or dresses). No provocative clothing (call me if you don’t know what that means). Scrubs may only be worn after 4pm on call days. You may wear your scrubs post-call and on weekends, however, they should be clean. T-shirts may be worn with your scrubs, however, shirts with holes, dirt, blood stains, and advertisements are not acceptable.

ED/PICU/NICU
Scrubs are acceptable in these areas.

Outpatient/Electives
Daily dress is business casual. Scrubs should never be worn in the outpatient clinic.

Athletic shoes may be worn if clean and not excessively worn. No open-toed shows may be worn. On weekends, jeans and other casual attire as well as scrubs may be worn provided they are clean and without holes, free from inappropriate graffiti or blood-staining, etc. Students MUST wear white coats and ID badges at all times.

V. IN-PATIENT RESPONSIBILITIES

Attendance

Students are to come to the hospital at whatever time necessary to see patients, write notes, help the team and be ready for rounds that morning. Students are allowed two days off during the in-patient month. These need to occur on the weekends and obviously not when they are scheduled to be on call or post call. No unscheduled holidays are permitted. Students are expected to participate in patient care right up to and including the last Thursday of the block. They are to come in, see patients, write notes, participate in rounds and make themselves available for face-to-face summative evaluation with the team in the afternoon. It is unfair to give some students the day off while students on out-patient are still having to attend clinic.

Histories and Physicals

When on call, the student should be assigned to one intern/resident. An H&P should be completed on every patient the intern admits when the students are on call. This should be placed under H & Ps in Cerner online. This includes all patients - service, private or out of town. This includes every patient that the intern admits even if the student will not continue to follow that patient while in the hospital. The point is to mimic the life of an intern as closely as possible. In addition, if the intern is called to the floor to evaluate another patient in the hospital, the student is expected to go with the intern and participate in that evaluation and treatment.

During the course of the in-patient month, the student is required to have the residents or faculty observe different portions of their H&P’s. This may be accomplished all in one setting or more conveniently, during various patient admissions. The observer will initial that portion of the H&P that they witnessed and the student will be expected to turn this into Dr. Jameson at the completion of the month. Completion of the form will be required for passing the in-patient portion of the rotation and it is the student’s responsibility to assure that this is done in a timely fashion. Waiting until the last day of the rotation is inadvisable since the residents and faculty may not have time to observe the student, resulting in an incomplete grade. (See H&P Checklist) If the resident feels that any observed portion of the H&P does not meet expectations, then the resident should not initial the checklist. He or she should counsel the student on areas of weakness and make suggestions for improvement. The student should then be given another opportunity to complete that portion of the H&P. Only when the performance is acceptable, should the form be initialed.

Residents are expected to provide information concerning the student’s H&P skills to the attending at the end of the month to be included in the rotation evaluation.

Number of patients the students should carry. Third year medical students should carry 6-8 patients at any one time but are required to carry at least 4 patients at all times. All service patients should be assigned to students first, and then, if there are insufficient numbers of service patients to fill the requirement, students are to pick up private patients to follow. They should be familiar with these patients and be able to present them to their attendings or supervising residents at anytime. If patients are discharged before the student is on call, then the student should pick up other patients to keep their load at least at 4 patients. Residents should look over the patient list daily to make sure students are carrying at least the minimum load of patients at all times.

You are expected to turn in FOUR H&Ps on patients you have worked up throughout the month, to your attending for feedback and evaluation. These should be turned in weekly so that necessary feedback can be obtained to ensure improvement in H&P skills and to assess your progress. An appropriate journal article should be included.

Daily Rounds

Student attendance is mandatory at rounds conducted by the attending physician and/or supervising resident. Students are also expected to participate in rounds. This may be in the form of presenting a patient, answering a question, presenting a short talk or simply making comments. They are encouraged to become involved in discussions as it not only gives their attending/supervising resident information about their fund of knowledge, but oftentimes stimulates discussion of related topics. The student should never be embarrassed to ask a question as usually there are others who have the same question. Questioning of students during rounds is not meant to be intimidating, but instead it is meant to stimulate thinking and provide the attending with information concerning the student’s fund of knowledge and clinical problem solving skills on which he or she will base the student’s grade.

Daily Notes

Students are expected to write concise notes every day on all patients assigned to them. Guidelines are available in this packet but students should follow the personal instructions of their attending and supervising resident. The student note should precede the residents and attending. If the resident fails to critique their notes in a timely manner, students are expected to ask for that criticism.

Call

Students must complete at least 5 night calls during inpatient month. Students can only be on call with one of their own interns/resiterns so that the patients that are admitted stay with the student’s team. Call rooms are provided for use on the sixth floor of the Children’s Foundation Research Tower. Students are expected to follow their assigned interns all night and assist them in caring for the patients in the hospital as well as their own admissions. Students are also expected to participate fully in the educational and patient care experiences assigned to them on the day post call. They may not admit any new patients the afternoon post-call, but they are expected to participate in didactic lectures or rounds if they occur.

Students create their own call schedule after negotiating with their peers. They then give this schedule to the supervising residents who should look it over to assure that the call requirements are fulfilled (and that assertive students are not taking advantage of their peers.) Do not allow students to “top load” the beginning of the month in order to allow more time to study at the end. Make sure that the calls are distributed evenly over the month allowing the student optimal exposure through presenting and patient care. All potential call nights must be filled before students can “double up” with more than one student on call per team.

If necessary, M-3’s can be assigned to nights when JI’s are on call, but we would prefer them to be on call with our interns.

Student Talks

During the month students are expected to prepare one or more three to five (3 to 5) minute talks dealing with common pediatric problems and present it to their team. This may occur during attending rounds or at another time with the supervising residents. It is suggested that these presentations be derived from the APA/COMSEP Curriculum in the Clerkship syllabus.

Resident Responsibilities

Residents are expected to engage in the following teaching opportunities with their students:

1. The supervising resident should make sure that the interns sit down with students on the first day of the students’ rotation and clearly spell out their expectations for the month. When the supervising residents arrive on a new rotation on the 4th of the month, they are to sit down again with the students and spell out their expectations as well.
2. Supervisors should sit down with students after the first week and give feedback concerning the student progress notes and if possible, presentations and H&P’s.
3. Supervisor and/or interns are expected to prepare students for presentations of patients before rounds.
4. Supervisors are expected to give several very short talks a week to the medical students concerning common pediatric issues such and fluid and electrolytes, feeding issues, febrile neonates, etc.
5. Supervisors are expected to gather information on students’ performance from everyone on the team including ancillary personnel and should participate actively in formative and summative evaluations of the students at the midmonth and end of rotation evaluations. Residents should familiarize themselves with the evaluation form used to critique the students, located on our website.
6. Supervisors should monitor the team to assure that work assigned to the students is appropriate for their level of training and that it has true patient care or educational benefit.
7. Should the residents identify any serious professional or behavioral problems with the students, they should discuss these with the attending and clerkship director as soon as possible.

VI. Attendance at Conferences

1. Neurosurgery Rounds: PICU Rounds: Chief Resident Rounds: required, not optional. See monthly calendar.
2. Jeopardy: While participation is mandatory, the experience is meant strictly for fun and intellectual stimulation.
3. Noon Conference: All in-patient students are expected to attend every day.
4. Grand Rounds: Mandatory attendance is required of ALL students.
5. Clerkship Conference Sessions: On Wednesday and Friday afternoons students are required to attend one-two learning conferences. A schedule is on our web site.
6. Bio-Ethics Rounds: All in-patient students are expected to attend.
7. Professor’s Rounds and M&M: All in-patient students are expected to attend.
8. Morning Report: All in-patient students are expected to attend every Monday, Tuesday, Thursday, and Friday mornings from 9:00 a.m. to 9:30 a.m.

Conferences meet on Wednesday and Friday afternoons: A Schedule is in your orientation packet and on our web site (www.uthsc.edu/pediatrics/clerkship). All seminar times are 3:30 – 5 pm on Wednesdays and Fridays (only exception is 1:00 seminars for Dr. Wall). Students are expected to read and be prepared to discuss vignettes pertaining to the conference topic. Students are allowed time from 1:30 – 3:00 to accomplish this preparation. Case Conference reading materials are no longer printed and handed out at orientation, see the list below for reading. A password is required for each topic. The password will be given to you during orientation.

Case Conference Readings

VII. OUT-PATIENT RESPONSIBILITIES

These will be presented by Ms. Wilson in a separate orientation.

Out-patient Rotation Orientation- (See calendar for specific date and location)

Keep in mind that focused exams are only appropriate if you have reviewed the patient’s chart in detail or know the patient well. Otherwise, a more comprehensive evaluation is required so that you can give a complete and accurate presentation to your supervising resident or ambulatory faculty. Remember to develop your assessment, differential diagnosis and management plan before discussing with the supervisor.

VIII. MISCELLANEOUS

Library Use

The library is located at 850 Poplar, Building 1. We are fortunate to have an excellent accumulation of various pediatric texts and journals. Students are welcome to use the library at any time during the daytime. Please, observe certain rules:

1. Libraries are for reading. Cafeterias are for eating. Home is for sleeping!
2. Copier Use: A copier is available for student use. An access code may be obtained from the librarian. Please, do not use this machine to copy entire texts or your brother-in-law’s property deed. Abuse will result in termination of copier privileges.
3. Respect others’ need for quiet.
4. The library computer is for research, not for games!
5. A student caught removing ANY material out of the library will receive a failing grade for the entire course and will be removed from the rotation immediately.

Parking

During normal working hours on weekdays students must park in their university-assigned parking places.

Lounge Use

For brief periods of relaxation, M-3 students are authorized to use the student medical staff lounge located on the 6th floor of the Children's Foundation Research Building. They should refrain from using the resident staff lounge particularly during “sign-out”. Students are allowed to play video games but are warned that too much playtime could effect their subjective evaluation detrimentally.

Things To Remember

Peds is different . Medical students will experience decidedly less autonomy when dealing with pediatric patients when compared to other clerkships. This should not be taken personally. All efforts are made to limit the procedures performed on children so that painful, frightening intervention is kept to a bare minimum. Students are also advised to make every attempt to attend as many other procedures as possible, such as surgical or radiologic procedures performed on their patients.

Students will be excused from routine duties to be able to attend these procedures provided this privilege is not abused.

The purpose of this rotation is to facilitate the student’s learning about the medicine of Pediatrics, not necessarily to make future pediatricians. If the students have any problems or suggestions on how we can help them learn, they are instructed to call the clerkship director as soon as possible.

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