Welcome to the

UNC Pediatrics Clerkship

at Moses Cone

This is the rotation where…

• You get to have fun

• You get the deep satisfaction of helping

sick kids get better

More than 90% of medical students will not become pediatricians

BUT more than 2/3 of medical students will go into fields of medicine where they will participate in medical care for children

The goal of this clerkship: help teach you how to be a doctor, not necessarily convince you to be a pediatrician

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 families and children of different ages 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.

Present 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.

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.

Three weeks Inpatient Pediatrics ◦ 4 overnight calls

Two weeks of Ambulatory Pediatrics ◦ At least 12 half days

◦ Some Subspecialty Clinics exposure

One week of Newborn Nursery

Chronic Illness Project

Clinical Problem Solving Sessions

Core curriculum conferences

A list of the kinds of patients we want you to see over the 6 weeks is on One45

This helps assure you that you are getting to see fundamental, core pediatric cases

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

Children admitted to a community hospital are: ◦ Well children with acute illness

◦ Children with chronic disease presenting for acute illness or chronic disease management

◦ Children in need of diagnostic evaluation

Depth Take ownership of your patients. That means: ◦ You may not know what the next management step is,

but you must know everything going on with your patient (studies, results, changes in symptoms, etc.)

◦ Look for something to learn on every patient ◦ Follow up what happens to the patient after they leave

(when possible)

Become comfortable with children with special needs

Understand what needs to be done in the hospital and what can be done as an outpatient

Write ups ◦ An H&P should be written for every patient

you admit

◦ Three of the write-ups should be turned in to your ward attending

◦ 1st WRITE UP DUE THE FIRST FRIDAY of your inpatient time

All 3 should include a 1-2 pg discussion with at least 2 references cited

Instructions in your packet of information

◦ Please turn in a copy of these 3 H&Ps to Dr. Nagappan to be graded

Note writing ◦ Write daily SOAP notes on each of your patients in

EPIC

◦ Your notes will be reviewed by the ward attending

◦ The intern must write an addendum

◦ Make your SOAP notes meaningful – not just a regurgitation of data

◦ H&Ps and daily notes are very different

Conferences ◦ Grand Rounds, Wednesday, 8:30-9:30 ◦ Noon conference daily 12:30-1:30 ◦ Core Curriculum Student Talks daily, 1:30 or 2:30

Be prepared (readings for each session are on the website at http://www.med.unc.edu/pedclerk/schedules/clerkship-at-moses-cone/readings-and-resources)

◦ Friday afternoon sessions, 1:30 1:30-2 pm: Meet with the clerkship director 2:30-5 pm: Clinical Problem Solving Sessions Be prepared (cases will be handed out to you weekly

and readings are located at http://www.med.unc.edu/pedclerk/schedules/clerkship-at-moses-cone/readings-and-resources/clinical-problem-solving-conferences-readings )

4 calls during your inpatient month (none during outpatient) ◦ 2 weekdays, 1 Friday, 1

weekend Call is overnight; call rooms

available; start 8-830 am leave the next day after presenting your patients (usually 1030)

Stick with your intern Weekend rounds start at 9:00

am Call changes

730 to 800: Pre-round

900 (except Wed): Rounds

1230-130p: Noon Conference

430p: Sign-out

If weekday call – stay until you have presented rounds the next am

If weekend call – same pre-rounding time, stay until you have presented rounds the next am

Peds attending (8 of us)

2 senior residents (UNC Peds, Med/Peds, or Peds Primary Care)

2 interns (Moses Cone FP, or UNC Peds)

1 Acting Intern (usually UNC)

2 (usually) 3rd year med students (UNC)

ASK every family (each day) whether the family is willing to have the team round in the room ◦ Helpful phrase: “There is a team of us helping take car

eof your child and, with your permission, I would like to bring them in with me for rounds this morning so everyone knows you and your child.”

LANGUAGE: Using medical jargon can make families feel excluded. ◦ Use language they can understand. ◦ Summarize important findings in simple language. ◦ Invite the family to correct any information or add

information at any time ◦ Helpful phrase: “We’re going to take about Zeke so that

the day team knows everything about him. If I make any mistakes or you have anything you want to add, you can interrupt at any time.”

PRE-ROUND: FCR does not eliminate the need to pre-round. For some patients (e.g., child abuse), it may be helpful to discuss some issues outside the room prior to entering

TEACHING: Teaching can occur in the patient’s

room during FCR, but there is still the need for conference room teaching (differential diagnoses, brief student presentations) which can be done after rounds

NUSRE INVOLVEMENT: One of the benefits of FCR is that everyone involved in care is there at one time. Having the nurse present is invaluable

• Check your login/password today • Don’t cut and paste forward • It takes some time to learn – it’s OK to feel “slow” in the

beginning • Watch out for note bloat • Route your note to the intern you are working with • The intern will co-sign and write an addendum that

includes PE and A/P

Learn the roles, what to expect from whom

Get involved – make yourself indispensable

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

Remember to wear your badge at all times

This month is time intense

Well child care

Preventive care, anticipatory guidance

Acute illness management

Chronic illness management

Breadth

Examine lots and lots of children

Learn behavior and development (review milestones before well checks), prevention, common acute illness

Get a picture of what many general pediatricians do

Office practices (Mon, Tues, Thurs, Fri morning) ◦ Clarify expectations on the first day

Subspecialty Clinics (Wednesday afternoons) ◦ Often more shadowing ◦ Exposure to subspecialty pediatrics

Seminars (Wed mornings & Friday afternoon) ◦ Wed: Grand rounds 8:30-9:30 followed by

seminars. There are no specific readings for the outpatient seminars

◦ Fri: Meet with director (1:30), Clinical cases (2:30) One weekend shift in the Peds ED (6 hours) No call during this time

CLIPP cases ◦ www.clippcases.org

Interactive, web-based curriculum

8 cases required ◦ See packet/website for assignment

There will be one question from each case on the final departmental exam

Due by the last Wednesday of the clerkship

This is the time to study ◦ Read the textbook, check your list

Make sure to clarify the expectations each day

Be flexible, because each day might be different

Seek learning opportunities

Daily activities begin at 8:30 am

Examine lots and lots of babies

Daily notes

Gain exposure to the NICU

Work on patient relationships, how to talk with families, developing rapport and communication skills

Learn what is normal and what is not

Build your comfort with normal baby care

Your physical exam skills will be directly observed by supervising physicians

Wed Grand Rounds 830-930 (no seminars afterward)

Every afternoon you will have focused sessions on core topics (jaundice, sepsis, etc)

Readings are located here:

http://www.med.unc.edu/pedclerk/schedules/clerkship-at-moses-cone/readings-and-resources/supplemental-readings/newborn-issues

Lots and lots and lots of babies……

Three weeks Inpatient Pediatrics ◦ 4 overnight calls

Two weeks of Ambulatory Pediatrics ◦ At least 12 half days

◦ Some Subspecialty Clinics exposure

One week of Newborn Nursery

Chronic Illness Project

Clinical Problem Solving Sessions

Core curriculum conferences

A chance to see a patient more than once (continuity!)

Find out what the role primary care doctors have in caring for chronically ill children

See details on website

http://www.med.unc.edu/pedclerk/schedules/clerkship-at-moses-cone/chronic-illness-project

During the 1:30-2:30 time, we will fine-tune your presentation skills, practice the EBM skills you have already learned

From 2:30 to 430 pm, we will do clinical cases ◦ You will get the cases a week before the session

◦ Prepare by reading about coming up with a differential diagnosis and reading about the most likely possibilities

◦ http://www.med.unc.edu/pedclerk/schedules/clerkship-at-moses-cone/readings-and-resources/clinical-problem-solving-conferences-readings

This is covered during the afternoon lectures on your inpatient time and the morning seminars during your outpatient time

We will cover the COMSEP curriculum: what every pediatric student needs to know

Each section of readings on the website corresponds to one of the core topics

http://www.med.unc.edu/pedclerk/schedules/clerkship-at-moses-cone/readings-and-resources/supplemental-readings

We provide each student with 3 books to use during the clerkship

These must be returned in good condition at the end of the clerkship or a student will be responsible for the full cost of the lost book(s)

Ask for specific feedback from your residents and preceptors ◦ If they say “good job”, follow up for specifics;

how are my presentations, notes, plans?

You can use the evaluation forms to guide feedback

Know that “good job” doesn’t mean honors Dr. Nagappan will give you feedback

midway and at the end of the clerkship. We will review your patient log on One45 at the midpoint (make sure it is updated)

Necessary, but….

imperfect, subjective, and often unsatisfying

Most students will NOT get Honors (usually about 30%)

Many students will get PASS as a final grade, and many of those will go on to be fabulous pediatricians

Note: The clerkship site director reserves the right to adjust grades as indicated.

Clinical Evaluations -- 60% ◦ Inpatient Attending – 30% of clinical grade ◦ Resident/Intern Evaluations – 30% of clinical

grade ◦ Outpatient Preceptors – 25% of clinical grade ◦ NBN attending evaluation – 15% of clinical grade

Participation in seminars & Write-ups & CLIPP & Chronic Illness & completion of One45 log – 10%

Departmental exam – 10%

Shelf Exam – 20%

**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 scale

Final 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

Shelf test is administered on the last Friday of the Clerkship at 2:00 p.m. in MBRB

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

Oral exam possible cases: (6 points)

Written questions. (6 points)

CLIPP multiple choice questions (8 points)

See details in your packet

Take ownership of your patients ◦ Be proactive and enthusiastic about helping ◦ But try to recognize your limitations

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

Ask questions – it’s expected! Be a dependable part of the team

Nelson’s textbook of Pediatrics (background knowledge)

Harriet Lane (reference) The Redbook (infectious disease) The Clerkship Readings on the website

(core medical student knowledge) UpToDate has some serious limitations in

pediatrics Peer reviewed literature

Get an interpreter when you need one – don’t take shortcuts

Use professional or phone interpreters – not relatives, siblings, etc.

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

interpreter Don’t say anything you don’t want interpreted

or understood Pause frequently for interpretation Listen to the patient Be patient Attempt to learn some Spanish

In Greensboro, you will get experience working with people from different cultures

Think about how this is affecting your care

Being culturally competent does not necessarily require having a special set of knowledge – only that you respect families wishes and involve them in the care of their children

You can write a cultural reflection essay for extra credit (see packet & website)

No tee shirts with logos or writing on them (i.e. Hollister)

Fleeces with UNC logos on them are ok

No open-toed shoes in clinical areas

No excessive perfumes/colognes

Long hair has to be pulled up

White coat and/or tie is optional

You should not be mistreated during your Pediatrics clerkship

If you experience maltreatment, please bring that to the attention of Dr. Nagappan or the Dean of Student’s office or the Greensboro ombudsman (Dr. Michelle Kane)

Maltreatment

Needlesticks

If you need to see a doctor here

see attached FAQs

Wash your hands A LOT!

Please stay at home if you are ill. Get in touch with your senior resident to let him/her know that you will be out and call the office 832-8064

If you have questions…ASK!!!

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

Promptly notify your clerkship site director or administrator of absences from clinical responsibilities.

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

There is an optional shelf test prep review that we will send you the link to

The chronic illness presentation is the last MONDAY of the rotation

The departmental (oral) exam is the last THURSDAY of the rotation in Greensboro

Complete clinical responsibilities here at 2:00 on the last THURSDAY of the rotation.

The last FRIDAY of the rotation you will have the shelf test in the afternoon in Chapel Hill.

Documentation of patient encounters on One45

(due by 3rd Friday -midpoint feedback day- and updated

by last Friday of clerkship)

Write-ups – minimum of 3

(1st due to ward attending by 1st Friday of inpt; #2&3 due

by end of inpt time)

CLIPP cases – 8 assigned

(due by last Friday of clerkship)

Chronic Illness project

(due by presentation day last Monday of clerkship)

Cultural Reflection Essay

(optional – due by last friday)

Midpoint feedback self-assessment (due by 3rd Friday - midpoint feedback day)