Your paediatrics clinical rotation is dawning upon you. For some of you, this may be the start of the happiest 1-2 months of your medical degree. For others, it may seem like just another placement to get through. For some, however, this rotation may seem daunting.
Though an interest in paediatric medicine goes a long way towards shaping an enjoyable and fruitful paediatric rotation, there are several aspects of this rotation which set it apart from other specialities.
Paediatrics is not all about parenting children and surviving their tantrums. Medicine is intertwined with comfort, care, and understanding of the terrifying nature of hospitals and illnesses. How we manage and interact with our cute little patients goes a long way towards their health outcomes.
This series will give you the tools and skills necessary to take full advantage of your rotation.
Children are cute, funny, and playful.
Children are also angry, emotionally volatile, wary and judgmental.
They rarely have a filter. Interacting with a child could be the most daunting experience one day and the highlight of the day the next. For many medical students, this may be the first time you will be interacting with newborns, infants and younger children. As with all things, practice is key to becoming more comfortable around children. The more time you spend observing and interacting with children, the better you will become at navigating a conversation with them.
Part 1: Where do I go?
There are 3 main settings in paediatrics: Inpatient, Outpatient and ED – not too different from most other specialities. Each environment uses students differently, and students are given varying expectations due to the setting and nature of the pathology seen.
Inpatients refer to the ‘ward’, where children who require hospitalisation reside after being admitted (often from the ED). Outpatients refer to clinic, where families visit their paediatricians for new problems, follow-up for old problems or check-ups. The ED, as the name suggests, is an environment of most urgency. Children present here acutely unwell and seek urgent attention.
Inpatient/Wards
The inpatient setting as a medical student is the best time to learn the routine of a paediatric physician or registrar. Days begin with a handover and ward round where you, along with an intern, registrar and consultant, ‘round’ on patients. ‘Rounding’ involves visiting each patient and parents in each bed, where the patient is reassessed (through history and examination), and the management plan for the patient is revised.
Handover showcases how the team communicates in structured, informative and concise language in order to accurately ‘hand over’ a patient into someone else’s care. In paediatric handovers, it is important to observe how the team caters to the needs of each child, extending to the parents. Management plans are often catered to what provides the most comfortable experience to the patient, often meaning longer (or shorter) hospital stays, different treatment regimens and involvement of allied services (psychology, social work).
These rounds are a fantastic opportunity to observe the teamwork and communication skills between nurses, doctors and interns. As a student, rounds are often where you can ask questions about each patient and the reasons why they are in hospital. After ward rounds, you will be given opportunities to see patients around the ward to practise your clinical skills.
“There’s a great variety of medicine on the wards, with opportunity to engage with patients and parents who are generally more engaging and helpful”
“Wards gave the opportunity to see patients myself and then read up on their admission and learn about their pathology”
“On ward rounds I was given tasks to write up clinical notes. This helped sharpen my note-taking skills in time for my intern year”
“Great place to ask questions to your registrar and consultant.”
– Medical student thoughts on their placement
How to prepare for it:
The wards are incredibly diverse in terms of what pathologies come through the door. It can often be hard to predict/prepare for what is to come that morning.
However, there are some common presentations:
- Respiratory medicine
- Fevers with rash
- Abdominal pain
- Constipation/Diarrhoea
It would be useful to be aware of an approach to assessing patients with these problems and their associated pathologies. Bring a small notepad in case you need to hand over a patient to your supervisor following a clinical review. Apart from that, bring on an enthusiastic, warm and loving persona to this ward – you will feel out of place if you don’t!
Outpatients/Clinic
The clinic gives med students 1-on-1 time with registrars or consultants. Take advantage! Clinic is where consultations are taken a little slower, are more thorough and have a holistic approach to care.
As a medical student, this is an opportunity to interact with children, get comfortable with asking them simple questions and follow your instructions. Most consultations involve assessing height and weight (sometimes BP), often done by the med students.
Depending on the consultant, they may provide a preface or aftermath debriefing on the consultation and their clinical reasoning. ASK QUESTIONS. If you are confident or brave, try to question their logic. You may seem overbearing or overstepping your boundaries. Still, you will learn so much through how consultants view their patients and how they categorise and address problems that patients present with.
They have to consider:
The child – their physical health, as well as their emotional wellbeing
Parents – their expectations, concerns and opinions about their child’s care
Continuity of care – Paediatricians look toward long-term goals of care, knowing their patient’s development and health in childhood could have permanent effects on their life ahead.
None of these have a simple solution, and a management plan is often multi-faceted, involving a multi-disciplinary approach to providing care.
As a medical student, be keen to observe the nuance in paediatric medicine. There may also be an opportunity for you to run your own clinic by taking histories and exams in a separate room and then handing them over to your consultant or registrar for management advice.
“Clinic is an interesting environment that’s so much more relaxed. You get to see the bond paediatricians make with their patients and parents.”
“Clinic didn’t end up being the most productive time period for me. I could only observe I feel I could’ve asked to do more.”
“I got to take their height and weight while interacting with the patients. Helped me get comfortable with the children.”
“I feel clinic was too repetitive and I didn’t get to see much variety”
“I got to run my own clinic! My consultant allowed me to take a separate room where I assessed them then handed over to the consultant. It was the highlight of my whole clinical year.”
– Medical student thoughts
How to prepare:
Preparing for clinic is largely around gauging or negotiating with your supervisor how involved you want to be during clinic. Showing your enthusiasm and willingness to push the boundaries goes a long way towards gaining opportunity. Just ask! If you’re knocked back, it is usually because there may not be a suitable environment where you can showcase your skills.
Maintaining a positive relationship with your senior doctor is crucial. They will often mimic the energy you bring to the room.
Emergency Department
Paediatric EDs aren’t in every hospital, but if you are lucky enough to have a placement in one, this is the best place to sharpen your targeted history skills and decision-making. In ED, you will see sick children and distressed parents. It’s a skill taking a history with calm patients, but stressful situations present a good opportunity for medical students to manage patient emotions and expectations while trying to provide care.
The usual format of paediatric ED for students involves aiding registrars and interns with the load of patients entering the door by taking histories and physicals, then proceeding to hand over that information to senior doctors. Depending on your registrar and the patients you see, they may ask you to take more responsibility by creating and communicating management plans to patients (approved by the registrars, of course).
“Paediatric ED was my highlight. I felt the most involved and useful as a med student as I have ever been”
“Paeds ED really pushed me to think on my feet, when a distressed parent has a million questions it really tested my knowledge and ability to emotionally support patients”
“In Paeds ED there was a huge emphasis on making the patient as comfortable as possible, even if they were sick.”
– Medical student anecdotes
How to prepare:
Come to ED prepped to have an intense shift, and be ready to work side-by-side with your senior doctors. They are under the pump and need your help. You will be tasked with seeing your own patients, gathering the history and exam, and then presenting your findings (usually through an ISBAR) to a senior doctor. You and the senior doctor will then form a plan for the patient and proceed accordingly.
“The registrars really pushed me during each of my ISBARs, critiquing my style, what I did well and what I could improve on. After about 5 patients, I already felt myself improve my speed and conciseness.”
“Seeing a really sick child for the first time is almost gut-wrenching”
