Welcome to the UNC Pediatrics Clerkship

2014-2015

Objectives for Orientation

Clearly state expectations for clerkship Participation Clinical activities Assignments Grading Policies

Outline clerkship objectives Address your questions For more information, also see the

clerkship webpage

General Expectations

More than 90% of medical students will not become pediatricians

All medical students must develop a basic level of knowledge and skill regarding pediatrics

More than two-thirds of medical students will go into fields of medicine where they will be asked to participate in medical care for children

Goals for the Clerkship

Top 12 List – Peds Clerkship Objectives Take ownership of your patients – know the

history, exam, and lab results at any given time; follow-up on your patients even when they have technically left your care; be responsible for them so that nothing gets missed.

Learn how to talk with children of different ages and their families both to get complete, accurate histories, and to explain clinical findings and plans. Learn how to reassure.

Learn how to perform the PE of children – how to interpret vital signs at different ages, how the pediatric exam is different than the adult exam, and a basic knowledge of what is normal.

Write a complete H&P, including pediatric-focused items such as development, diet, and growth.

Top 12 List – Peds Clerkship Objectives Present orally on inpatient rounds and begin to

pick out what is most important to convey to the team (i.e., do not repeat the entire H&P).

Assess the development of every patient you see and be able to recognize when it is abnormal.

Be able to chart the weight, height, head circumference, and BMI and recognize obesity or failure to thrive and begin a work-up if indicated.

Talk to families about prevention, including immunizations, safety, violence, sex, and substance use. Using the CDC chart, know what immunizations a child needs at a given age.

Top 12 List – Peds Clerkship Objectives Write prescriptions appropriately for children of

different sizes. Be able to clinically recognize a dehydrated child.

Write orders for both re-hydration and maintenance fluid for children based on size and clinical condition.

Recognize when a child is in need of urgent medical attention. Know how to initiate care and who to call for help.

Outline the approach to diagnosis and management of common pediatric conditions.

Overview of the Clerkship

Outpatient Pediatric Medical Education Director: Rasheeda Monroe, MDInpatient Pediatric Medical Education Director:Steven Pattishall, MDOther members of the Pediatric Medical Education Committee:David Adams, MD Stephen Leinenweber, MD

Clerkship Direction:

Basic Clerkship Clinical Structure

Three weeks Inpatient Pediatrics 2 weekday long shifts One Friday long shift One Saturday or Sunday long shift Coordinate your long shifts and weekends to minmize

overlap with AI’s and other 3rd year student

Newborn Nursery With exposure to neonatal intensive care

Minimum 12 half-days of Ambulatory Pediatrics Some pediatric subspecialty exposure

Basic Clerkship Assignments CLIPP cases

Complete 8 required cases Write ups

Complete a minimum of 2 History and Physicals and 1 Discharge Summary You will be assigned an attending to review your

write ups

Cultural reflection (optional) Didactic sessions Documentation of patient encounters/log

on One45 Midpoint feedback and self-assessment Completion of the Patient Log

Clinical Work in the Clerkship

Clinic Attendings

Mythili Rajan

Rasheeda MonroeMedical Director

Susan Sinden

Carrie Dow-Smith

Betty WitmanSAFE Child

Virginia SchreinerSICC

Ward Attendings

David Adams

Ivy Pointer

Badie Clark

Bridget Donell

Stephen Leinenweber Travis Honeycutt Karen Chilton Steven Pattishall Mark Piehl

Scottie Pate

Jennifer Vick

UNC Chief Residents 2014 - 2015

Mark Connelly

Stephanie Permar

Allison Herndon

Inpatient Pediatrics

Typical patients Well children with acute illness Children with chronic disease presenting for

acute illness or chronic disease management

Children in need of diagnostic management

Inpatient Pediatrics - Student Goals Depth Take ownership of your patients and learn

all you can from them Understand their illness, work up, and

management completely Participate fully in the activities of the

inpatient team Become comfortable with children with

special needs Gain exposure to pediatric subspecialties

and general pediatric hospital care

Inpatient Pediatrics - Patient Write Ups Write a history and physical and/or daily note

on each of your patients each day Write notes daily and meet with your

inpatient attending to evaluate them for additional feedback.

2 formal History and Physicals are required and 1 discharge summary. You will be assigned a faculty mentor. Send write ups via email to your mentor. Due within 72 hours after seeing the patient

A Patient write-up should include: History & Physical 1-2 page written discussion on a topic

related to the patient, with at least 2 references cited

Please refer to the clerkship website for detailed guidelines on the format of patient write-ups

Inpatient Pediatrics – Daily activities

Write a history and physical and/or daily note on each of your patients each day

Write orders for co-signature Meet with your intern right after rounds to

divide and conquer the daily work Ask questions and find answers to those

questions – bring new information to the team!

Inpatient Pediatrics - Long Shift Long shift assigned at least four times

2 week nights 1 Friday 1 Saturday or Sunday

On long shift days, you are expected to stay until 8pm then return the following morning as regularly scheduled

On weekends, round with the team on the post-call morning, present your patients, then leave after post-rounds work is completed

Stick with your intern to learn clinically Admit at least one patient for write up each

long shift, but learn from any patient around

Inpatient Pediatrics - Ward Teams Teaching Team: Usually one attending

per week, One senior resident (2nd or 3rd year), Two interns.

Rounds typically start at 8:15 or 8:30 on 4E

You should have reported to the workroom at 6:30am for patient assignment or updates on existing patient from the night team.

Pre-round on all your patients and prepare for your presentation on rounds.

Talk to your supervising intern

Inpatient Pediatrics - Working with the Team

Take ownership of your patients Be proactive and enthusiastic But be gentle

Meet with your intern right after rounds to divide and conquer the daily work

Ask questions and find answers to those questions – bring new information to the team!

Be a dependable part of the team

To get the most out of your inpatient time…

Learn the roles, and what to expect from whom

Get involved – make yourself important to your team and learn by doing

Balance the amount of time you spend on write ups with the amount of time you spend on more broad learning

Get the most you can out of conferences – they are for your learning

Newborn Nursery

Generally the

happiest place

in the

hospital…

Student Activities in the NBN See the specific orientation information

on the web page Arrive in the mornings at 8:30 am Clarify expectations with your team for

the week Prepare a brief presentation for the last

day in the Newborn Nursery (Friday) on a topic of your choice to present to your preceptor and team

Your physical exam skills will be directly observed

Student Activities in the NBN

To get the most out of the NBN…

This is your best opportunity in third year to be the care provider

Work on developing rapport, talking with families, and communication skills

Practice effective use of an interpreter if applicable

Learn what is normal and what is not Examine lots and lots of babies Build your comfort with normal baby

care Review the Newborn Nursery orientation

website link before your week starts http://www.med.unc.edu/pedclerk/

schedules/clerkship-at-unc/newborn-nursery

Outpatient Pediatrics

Well child care in community outpatient practices

Preventive care, anticipatory guidance Acute illness management Chronic illness management

Outpatient Pediatrics - Student Goals

Breadth Examine lots and lots of children Learn behavior and development,

prevention, common acute illness Clarify expectations on the first day in

each setting with each preceptor Challenge yourself to learn and to do Get a picture of what many general

pediatricians do

To get the most out of your outpatient time…

Make sure to clarify the expectations each day

Be flexible, because each day might be different

Seek learning opportunities Challenge yourself Take time to study and to do the CLIPP

cases Refer to your Patient Log to ensure you

are seeing many of the expected cases

Assignments in the Clerkship

Clerkship Assignments - Overview Write ups

Complete a minimum of 3 2 H&Ps, 1 Discharge summary

CLIPP cases Complete 8 required cases

Cultural reflection (optional) Didactic sessions Documentation and completion of patient

encounters/patient log on One45 Midpoint feedback and self-assessment

Inpatient Pediatrics - Patient Write Ups

2 History & Physicals, 1 Discharge Summary With H&P, 3-4 paragraph written discussion

on a topic related to the patient, with at least 2 references cited

H&Ps - focus on Pediatric-specific content Growth and development (including charts),

labor/delivery, etc Due within 72 hours after seeing the

patient Please refer to the clerkship website for

detailed guidelines on the format of patient write-ups

Email them to site directors upon completion. You will receive feedback on your clinical

documentation.

Outpatient Pediatrics Curriculum

CLIPP cases http://www.med-u.org/

Use your med.unc.edu email to login Interactive, web-based curriculum Do at least 8 assigned cases

Some people do lots more Must be completed by the last

Wednesday of the clerkship One question from each CLIPP case will

be on Pediatric Departmental Exam

8 assigned CLIPP cases

Case # 5: 16 year old girl’s health maintenance

Case # 6: 16 year old boy’s pre-sport physical

Case # 15: Two siblings vomiting, 4 year old and 8 weekold

Case # 18: 2 week old with poor weight gain Case # 25: 2 month old with apnea Case # 28: 18 month old with

developmental delay Case # 29: Infant with hypotonia Case # 30: 2 year old with sickle cell disease

Cultural Competence

We expect your cultural sensitivity to improve during your Pediatrics clerkship

Take the opportunity that our diverse patient population provides to develop your skills in working with patients from different cultural backgrounds

If you have questions about how to do this effectively, ask… This is appropriate learning material.

Your Cultural Competency Monday lecture will be a group discussion – bring examples and be prepared to talk about the effects of culture on pediatric care

Working with Interpreters

You will have plenty of opportunities to practice

Get an interpreter when you need one, we now use an internet based interpreter as well as live interpreters – asked to be shown this new technology

Work even harder to establish rapport Look and speak directly to the patient, not

the interpreter Don’t ever say anything you don’t want

interpreted or understood Pause frequently for interpretation Listen to the patient Be patient – it will take longer Attempt to learn some Spanish

Cultural Reflection

This is an optional assignment that can be completed for extra credit

Write a brief reflection on the influence of culture on the care of one of your patients during the rotation. Email it to suzanne_record@med.unc.edu and your WakeMed preceptor

See details and ideas on clerkship webpage

Be ready to discuss reflective statement during small group session

Documenting Patient Experiences

Be sure to complete your Patient Log (One45) of your required clinical experiences

Your patient log will be reviewed at the midpoint of the clerkship with the clerkship or site director to assure you are on track If you are deficient in core patient

experiences, your clinical schedule may be adjusted to provide those experiences

You must complete your Patient Log by the last day of the clerkship

Conferences in the Pediatric Clerkship Morning Report:

Mondays and Thursdays at 7:30am Hicks’ conference room on 4E

Grand Rounds: 1st and 3rd Wednesday at 8:00am-9:00am Andrews Conference Center

Core Medical Student Lecture: Mondays 12:30 to 1:30 3rd FL Andrews

Med./Resident Lecture: Tues., Thurs., Fri. 12:30 to 1:30pm Hicks’ conference room on 4E, occasionally 3rd

FL Andrews Ask a resident/attending daily to confirm

location

Lecture Schedule:

  Monday Tuesday Wednesday Thursday Friday

Week 1 Core #1 Med/Res   Med/Res Med/Res

Week 2 Core #2 Med/Res   Med/Res Med/Res

Week 3 Core #3 Med/Res   Med/Res Med/Res

Week 4 Core #4 Med/Res   Med/Res Med/Res

Week 5 Core #5 Med/Res   Med/Res Med/Res

Week 6 Review Med/Res   Final Exam Final Exam

Core:& Review: 12:30 to 1:30 in 3rd Floor Andrews Med/Res: 12:30 to 1:30 in 4E Hicks’ Conference room, Sometimes 3rd FL Andrews

Core Lectures:

1. Fluids and Electrolytes

2. Child Abuse and Neglect

3. Growth/Development and Common Behavioral Issues

4. Immunizations

5. Cultural Competency (should be week 5)

1. Rasheeda Monroe

2. Travis Honeycutt

3. David Adams

4. Steven Pattishall

5. Chief residents

6. Stephen Leinenweber

7. Melissa Johnson (Growth/Development and Behavior)

Core Lectures Core Faculty

Feedback, Evaluation, and Grading

Feedback

Ask for specific feedback from your residents and preceptors If they say, "good job", follow up for specifics Ask "How are my presentations? Notes? Plans?"

Use the evaluation forms to help you Know that "Good job" DOES NOT mean Honors Continue to push yourself for improvement You will meet with the site director for scheduled

Midpoint Feedback at the end of 3 weeks Update your Patient Log and Self Assessment

prior to your Midpoint Feedback session

Grading in Clinical Education Necessary, but….

often subjective, and sometimes unsatisfying

Most students will NOT get Honors ~30% of students across all the Pediatric

Clerkship Sites will earn Honors UNC, WakeMed, Moses Cone, Carolinas

Medical, Asheville

Grading

Grading system is set-up thoughtfully to evaluate your performance, balancing subjective and objective indicators of performance

Goal is primarily to demonstrate learning of essential material and secondarily to differentiate students

Core Competencies Medical Knowledge Patient Care Professionalism

Practice Based

Learning and Improvement

Systems Based Practice

Communication and Interpersonal Skills

Grading

**Note: The clerkship director reserves the right to adjust final grades if necessary. This is to insure the best consistency possible in student evaluation across all sites.**

Grading is on a 100 point scaleFinal Grade Points Scale NBME Score

Honors 88 - 100 > National Mean

High Pass 75 – 87 >35th percentile

Pass 50 - 74 >10th percentile

Condition 37.5 - 49

Fail <37.5

Grading - Overall

Clinical - Inpatient attending - Inpatient residents - Outpatient total - Newborn nursery

60%30%30%25%15%

Participation 10%

NBME Shelf Exam 20%

Departmental Exam 10%

*This means that one person’s evaluation is never enough to change your grade substantially.

Grading – Participation – 10% Completed by WakeMed Pediatric

Education Committee– Drs. Adams, Chief Resident, Leinenweber, Monroe, & Pattishall Small group participation CLIPP cases completion Cultural reflection completion (optional –

extra credit) Write up evaluations Completion of the Patient Log

Professionalism is pass/fail Failure in professionalism evaluation may

lead to failure of the clerkship

Grading – Shelf Exam – 20%

Shelf test is administered in the afternoon on the last Friday of the Clerkship

The Shelf exam is web-based and administered on-line

Students are required to use their laptops distributed them by the UNC SOM for testing

It is students’ responsibility to ensure their laptops are in appropriate working condition for testing prior to the testing date

Grading – Shelf Exam – 20%

Scores are based on national percentiles NOTE: A shelf test score of <

10%ile will result in an Incomplete grade.

Students who earn <10%ile on the shelf test but pass all other requirements of the clerkship, must retake the shelf test only. Upon successful retake of the shelf exam,

the student will receive a grade of Pass. The Pediatrics shelf test is difficult and

you will need to study appropriately

Grading – Departmental Exam – 10%

Oral portion is administered on last Thursday of the clerkship in individual 15 minute appointments

Written/Multiple Choice portion is given immediately following completion of the Oral portion

Departmental Exam is worth a total of 20 possible points:Oral Exam (6 points)Written Exam (14 points)

6 written questions (6 points)8 multiple choice questions – 1 question based on each assigned CLIPP Case (8 points)

Departmental Exam - Oral

A 10 minute discussion of one of the following possible cases:

A 13 month old with anemia A four month old with failure to thrive A 3 day old with jaundice A 6 month old with lethargy A 1 week old with fever A 9 yo with abdominal pain A 2 yo that refuses to bear weight A 1 week old with vomiting An 18 month old with difficulty breathing A 15 yo girl with weight loss

Departmental Exam – Written

All material is based on Learning Group didactics1. Plot and interpret growth data using

growth curves 2. Write an appropriate maintenance fluid

order for a child of a given size.3. Write an appropriate fluid bolus for a child

of a given size.4. Write an appropriate order for medication,

with use of provided references for dosing.5. Determine necessary immunizations for a

child in a given clinical setting. The immunization chart will be provided.

Departmental Exam – Multiple Choice 1 question from each assigned CLIPP case:

Case # 5: 16 year old girl’s health maintenance

Case # 6: 16 year old boy’s pre-sport physical

Case # 15: 2 siblings vomiting, 4 year old and 8 week old

Case # 18: 2 week old with poor weight gain

Case # 25: 2 month old with apnea Case # 28: 18 month old with

developmental delay Case # 29: Infant with hypotonia Case # 30: 2 year old with sickle cell

disease

Departmental Exam

Oral portion is administered at WakeMed in the 3rd FL Andrews conference room on last Thursday of the clerkship in individual 15 minute appointments

Written/Multiple Choice portion is given immediately following completion of the Oral portion

The End of the Clerkship

Complete clinical responsibilities by the last Thursday of the rotation.

Please remember to turn in your 3 write ups within 48-72 hours of seeing the patient. You should NOT turn in all 3 assignments at the same time during the final days of your rotation. We take time to review your write ups and provide feedback that should be incorporated into the next assignment.

General Principles and Miscellaneous Topics

How to Approach a Child

Interact with the child based on his or her developmental level

Include the parent, but focus on the child Establish rapport before starting the

formal exam Start from a safe distance away

Observe general appearance, respiratory status, all you can while talking

Save the invasive parts of the exam for last

When cooperation vanishes, move quickly

How to Identify a “Sick” Child Learn the vocabulary – “looks sick”,

“lethargic”, “toxic” Yale Observation Criteria:

Quality of cry ColorReaction to parent HydrationState variation Responsiveness

Note all vital signs and compare them to age appropriate norms

Skill will grow with experience

Student Maltreatment

You should not be mistreated during your Pediatrics clerkship

If you experience maltreatment, please bring that to the attention of the clerkship director, the Dean of Student’s office, or one of your assigned liaisons

UNC SOM Ombudsman is Dr. Gary Gala Each clerkship site also has an

ombudsman

Reading

Some textbooks are available for your use Check out http://uncpeds.med.unc.edu/ Read the basics first Add the peer reviewed literature on

selected topics UpToDate has some important limitations

in Pediatrics – make sure you are reading about children

Absences

Note the School of Medicine Absence Policy There are a maximum of 3 excused

absences from the clerkship An excused absence may require make-up

responsibilities based on the clinical duties missed

Absences

If you must be absent for any reason you should: Contact your team (Attending or senior

resident) AND Dr. Monroe (252)375-5170 Call Suzanne Record (919)966-3027regarding

your absence or tardiness Note: Do not email the day of your absence as

this delay notification of the appropriate individuals

All absences are reported to the Dean of Student Affairs (Dr. Georgette Dent) for documentation and approval when necessary.

Evaluating the Clerkship

Please provide us with your feedback throughout and specifically at the end of the rotation

Contacts at WakeMed:

David Adams: davadams@wakemed.org Stephen Leinenweber:

sleinenweber@wakemed.org Rasheeda Monroe:

rmonroe@wakemed.org Steven Pattishall:

spattishall@wakemed.org

Kim Seibel: kseibel@wakemed.org or 919-350-8493

UNC contact information:

richard_hobbs@med.unc.edu wmills@med.unc.edu, Mobile – 919-428-

6382 suzanne_record@med.unc.edu, Phone –

919-966-3027

Pediatric Education Office located on the 2nd floor of MacNider in Rm 230

Phone – 919-966-3027

HAVE FUN!

Remember, it’s your education!