Welcome to the UNC Pediatrics Clerkship

1. Welcome to the UNC Pediatrics Clerkship 2014-2015

2. 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

3. 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

5. Goals for the Clerkship

6. 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.

7. 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.

8. 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.

9. Overview of the Clerkship

10. Clerkship Direction: Outpatient Pediatric Medical Education Director: Rasheeda Monroe, MD Inpatient Pediatric Medical Education Director: Steven Pattishall, MD Other members of the Pediatric Medical Education Committee: David Adams, MD Stephen Leinenweber, MD

11. 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

12. 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

13. Clinical Work in the Clerkship

14. Clinic Attendings Susan Sinden Betty Witman SAFE Child Rasheeda Monroe Medical Director MythiliRajan Carrie Dow-Smith Virginia Schreiner SICC

15. Ward Attendings David Adams ScottiePate Ivy Pointer Badie Clark Jennifer Vick Bridget Donell Stephen Leinenweber Travis Honeycutt Karen Chilton Steven Pattishall Mark Piehl

16. UNC Chief Residents 2014 - 2015 Mark Connelly Stephanie Permar Allison Herndon

17. 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

18. 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

19. 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

20. 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!

21. 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

22. 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

23. 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

24. 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

25. Newborn Nursery Generally the happiest place in the hospital…

26. 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

27. Student Activities in the NBN

28. 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

29. Outpatient Pediatrics • Well child care in community outpatient practices • Preventive care, anticipatory guidance • Acute illness management • Chronic illness management

30. 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

31. 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

32. Assignments in the Clerkship

33. 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

34. 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.

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. Conferences in the Pediatric Clerkship • Morning Report: • Mondays and Thursdays at 7:30am • Hicks’ conference room on 4E • Grand Rounds: • 1st and 3rdWednesday at 8:00am-9:00am • Andrews Conference Center • Core Medical Student Lecture: • Mondays 12:30 to 1:30 • 3rdFL 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

42. Lecture Schedule: 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

43. Core Lectures: Core Lectures Core Faculty • Fluids and Electrolytes • Child Abuse and Neglect • Growth/Development and Common Behavioral Issues • Immunizations • Cultural Competency (should be week 5) • Rasheeda Monroe • Travis Honeycutt • David Adams • Steven Pattishall • Chief residents • Stephen Leinenweber • Melissa Johnson (Growth/Development and Behavior)

44. Feedback, Evaluation, and Grading

45. 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

46. 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

47. 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

48. 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 scale

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

50. 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