About the format of this post, it’s sort of odd. Perhaps, one day, I’ll go back and editorialize this entry. For now, I’ll just stick with
the facts my version of reality. Depending on the program, the Pediatric grade structure will vary. Most will have the same elements, clinical evaluations, activities you have to do, shelf exam or in-house exam. The shelf is a national, rotation dependent test, and an exam with standardized convoluted questions — because if they just asked you a straight forward question, and you answered correctly, where would the fun in that be? All of those elements, will be lumped and weighted together to form your grade: Honors, High Pass, Pass, and perhaps Low Pass. At my program, regardless of being on an away rotation, our grade is built mostly by evaluations from attending or resident physicians. In any event, this post will include some details about the structure of my Pediatric Rotation.
Location – a community hospital operated by Awesome General Hospital
Time – 6 weeks total, average work with 50 hrs (including didactics)
- 2 weeks on ED Pediatrics, mostly traige type of thinking; one on-call shift
- 1 week on Special Care Nursery, pre-round, round, write progress notes
- 3 weeks on Pediatric Inpatient Wards, gather vitals, round, check on patients throughout the day to assess the patient and how the plan is going, make lots of phone calls (talk to radiology to get help with a X-ray, make an appointment for the patient for follow-up care, talk to social workers; one on-call shift
- Weekly, half-day, ambulatory Pediatrics,
- One home visit to someone physically and/or cognitively disparity
The structure was dependent upon service and the whim of whoever attending I’m who’s on service.
ED Pediatric – this was my first excursion into Pediatrics, my patient loaded included whoever came in; however this service required very little management from my part as just about everything was algorithm based.
Types of cases: I saw the bread and butter stuff you expect to see: worried parents rushing in their newborns because of a fever (ending up with a urine analysis, blood work, and a lumbar puncture), concussions (I was usually given the task of telling the parents why we weren’t getting a CT), asthma, teenagers impaling themselves with objects (the oddest being a carabiner), sniffles, rashes, and one murmur that I got to diagnose and refer to cardiology for follow-up at Awesome General Hospital.
Structure: there were certainly lulls with nothing to do followed by bouncing around to room to room to see patients. Before seeing the patient, if I was lucky, I’d get the nurse’s “in-take note” (the reason why the the patient came, vitals, and a brief history when they were triaged). I’d walk into the room, introduce myself and role, get a quick targeted (but full) history of present illness and past medical history, do a review of systems, perform a targeted physical, then summarize an initial plan with the parents. The next step was to present the relevant parts of the case to my attending (there were no residents on this service, so medical students were the ‘residents’), and then I’d go over the plan that I thought of (aka winged) — the most important part of this conversation with the attending was to be efficient, they usually wanted a really quick explanation. Sometimes, we’d go back in the room together, the physician would do their own exam, repeating whatever they thought was worthwhile, and they’d either agree or modify my plan.
Summary: the cases were interesting, and I gained a skill at attending telepathy a.k.a. taking a guess at how much to summarize a case.
Special Care Nursery – my second service on this rotation. I was responsible for one to two patients per day.
Types of cases: as a newborn, you’re either put into a nursery if you’re healthy, a NICU if you’re really sick, or a special care nursery if you’re somewhere in between. As such, I saw and managed patients with prematurity complications, jaundice, failure to thrive, observation for murmurs and breathing difficulties, and neonatal abstinence syndrome (NAS). I took a special interest in the NAS babies, I had worked with mothers who were exposed to narcotics while pregnant during my Ob/Gyn rotation (some mothers were even from my home hospital in Boston, World’s Best Safety Net Hospital). So, it was a nice longitudinal experience. My previous rotation was Ob/Gyn, I learned a lot, but nothing about babies (or anything about children for that matter). However, I have a pretty good handle over pregnancy and woman’s health now, it helped that I’ve already been on the giving the baby away side of a birth. Now, on the receiving end of deliveries, performing neonatal resuscitations, the experience felt more complete.
Structure: again, there were no residents on this service, so you expected to perform a lot without much guidance. I’d pre-round on the babies, this essentially meant just copying down what happened over night in their paper chart (yes, I said paper). Then, I’d have about 15-20 minutes to get my thoughts together (aka scourer UptoDate and PubMed), and present the patient to the attending. At the end, I’d make an assessment and plan, sometimes they bought it sometimes they didn’t. After that, we’d round on the patient: check fontanelles, lungs, breathing, red reflex, check their oral cavity, and end with checking their hips for dysplasia. The remainder of my day was spent writing progress notes, most of that was rattling off a differential and justifying my final diagnosis. The day ended with the attending reading my progress note, making edits, and including my note into theirs — the most glorious moment was when an attending would just say, after signing off, “Just put your note into the chart”.
Summary: in a strange way, I enjoyed the neurotic level you have to go to manage special care unit babies. Not being satisfied with the patient monitoring my away rotations EMR had, I developed an excel sheet to finish better follow patients and write notes; I’m ashamed to say it brought out the “type A” in me.
Wards: my last service on Pediatrics, and the only part with residents; and arguably, it was the best way to end. I was responsible for 2 to 3 patients a day, depending on what was going on.
Types of cases: reactive airway disease, asthma, a bunch of pneumonia, croup, jaundice, liver problems, accidental (including some outrageous lead poisoning) or intentional poisonings, smoke inhalation after the patient’s family member tried to kill said patient, syncope, kids with seizures, and a spike in infants with viral meningitis. These were considered to be “bread and butter” cases to learn how to manage. If I had been at my home institution, or just back in my city, I’d probably see a lot of specialty cases and miss a lot of the “bread and butter”. That’s been the experience for some of my classmates who stayed in the medical capitol.
Structure: the name of the game is “family-centered-rounds“. The goal of family centered rounds, at least in theory, is to include the family into rounds. How family centered rounds play out, as I hear from residents, just depends on where you’re at and who s leading your team. In general, you present your patients in the room with the family, ask a few follow up questions, you explain the latest data to assess their child’s health, do a physical, and then tell the parents (or the patient only, if old enough) your assessment and plan for the situation. You leave the room, slip back into doctor lingo, and a period of critiques (positive and/or negative) and education starts (a.k.a. attending pimping). The rest of the day is spent making that plan you talked about come into fruition: leg work, working with the nurses, office stuff, and looking up a lot of things. Your patients on the floor who were admitted over night will need a full history of present illness note, so they can be properly admitted onto the floor. Your patients who you’re continuing to follow, or you’re covering, will usually only need a progress note. The only reason why I bring those notes up is that it’s a hell of a lot more work to finish putting together things for an admission than a progress note. Lastly, since the flow of the day was purely dependent on the whims of the attending physician, everything I said could be changed in any way they see fit — my biggest lesson, figure out what they want before you spin your wheels.
Summary: This rotation was sort of awesome because I learned how to better management patients and do doctor stuff. The difficult part about the this rotation however was differential diagnosis, i.e. the obscure stuff you didn’t learn about during the first two year of medical schools — heck, at best pediatric conditions and managements are foot-notes during the first two-years of medical school. Also, the intern and residents really improved my experience on the floor.
House visit: this was a one-time visit, we go in pairs (two medical students), and only a few medical schools in my city participate. You make one home visit to visit the family and patient as they deal with physical and/or intellectual disabilities — in my patient’s case, they had disparities in both. For my home visit, my patient was a teen with cerebral palsy (and bulbar palsy), and he required a computer to communicate with us. We spoke with the family about how this situation came to be, the affect their other children, how it affected their relationship as a married couple, and how they’re dealing with the finances. Last but not least, we got to know our patient.
Took the shelf today, next week I’ll know how I did. The exam is administered around the same time, in an official process, for many medical schools. Unfortunately, at least in our school and some others, our tests froze today on multiple occasions. This added about 30-40 minutes to our sitting time, while somehow syphoning off our test-time. In the end result, from our post test grumblings, was a reduction in time that left most of us with only a few minutes to 30 seconds on the last question. Fortunately, because I was skeptical about if the clock was running while my questions failed to load, I was too paranoid to take a bathroom break and ended up having a couple of minutes. For this exam, I used Pre-Test Pediatrics, Blue-Prints, some BRS, and a few slide decks gifted to me from others.
Psychiatry at the VA! I’ve recently filled out a mountain of paperwork, I received an email today that I’m ready to go. I start this, after the weekend, this coming Monday.
That’s it for now, have a great weekend!