Paediatric medicine is notoriously challenging for medical students. Not only does it encompass as many different medical fields as we see in adult medicine; but there is also the challenge of learning to manage and care for children of all different ages (as well as managing parents!).
Coming into my first year of medical school with a keen interest in paediatrics, I couldn’t wait to get started and find out what the next 4 years would look like. But it wasn’t long before I realised that I would be waiting until the third year before I actually got any exposure to paediatric medicine.
The first two years of post-graduate medicine in Australia are the pre-clinical years, based around developing foundational knowledge and skills. We then head out on clinical placements for the final two years. I was quite surprised when I realised that during pre-clinical years there is very little taught about paediatrics. In fact, the seven-week paediatric rotation in the third/fourth year (depending on which university) is the only exposure we get to paediatric medicine before internship!
This raised some questions for me:
- How on earth am I going to know enough about paediatrics to do well on my placement?
- How well will my placement prepare me for internship if all the theoretical and practical knowledge of paediatrics is covered in just seven weeks?
- Is there something I should be doing now to better prepare myself for my paediatric rotation?
Time to get prepared
I decided to reach out and chat to some fourth-year students who have already completed their paediatric placement to find out how their experience was.
As I thought, most students were pretty nervous about heading into this rotation. Whilst they felt somewhat prepared for most other core rotations, with paediatrics they had no idea what was coming.
What were the challenges?
Content, content, content
One of the main differences on a paediatric rotation is the amount of new theoretical knowledge that needs to be learned. For adult medicine rotations most of the common conditions have been covered to some degree during preclinical years. However, with paediatrics most of the content is completely new and covered in a very short time frame. Managing this and trying to gain as much practical experience as possible can be quite a juggling act for students.
Learning how to play
A major challenge most students face is actually learning how to handle children. The skills required to examine teenagers are so different from those needed for toddlers, which are different again to the skills needed to handle a newborn. Not to mention, these are all different from those we learn for adult medicine. So, learning how to use different types of play and new communication strategies for children can be quite foreign to most students. And when you are fumbling your way through this for the first time with actual patients, and parents watching on, it can be very daunting.
Send for help
Students found was that most paediatric rotations aren’t completed in tertiary centres. This means that very sick children are quickly transferred out to the larger metro hospitals. Whilst students were able to gain skills in completing the initial assessment and management of very ill children, they usually missed out on following this through with their ongoing care.
This was even more apparent for students who were based in rural clinical schools – and the number of these placements is growing with the focus on promoting rural training for students. For the students located in regional and remote centres, paediatric wards can be quite small and may see a limited number of sick children during their placement. In very far rural and remote areas, students may also be taught by a general practitioner with paediatric training, not a paediatrician. And whilst they are still able to learn the necessary skills to assess and manage acute paediatric presentations, the threshold for transferring children onto larger centres is very low. Similarly, there is very limited exposure to neonatal care in these areas, with most pre-term pregnancies transferring straight away.
But it wasn’t all bad!
Despite some of these challenges, most students had really enjoyed their paediatric rotations and identified some key aspects that had been helpful whilst on placement.
What was most helpful?
Having a great supervisor!
Practice makes perfect
The only way to get comfortable doing paediatric assessments is through practice. This means that having a supervisor who was willing to let students have a go at performing basic interviews, examinations and management skills was vital. A supervisor who acknowledged that most students have never performed these skills on real paediatric patients before made a significant difference. Even in the remote setting, students who were given the opportunity to practice these skills on almost all paediatric presentations that the hospital saw felt that they were well equipped by the end of their placement.
Flexibility is key
Another common factor that students felt was important, was having a supervisor who was open and flexible. For supervisors to be aware of the heavy load of theoretical knowledge students are learning away from the hospital, and to allow flexibility in students timetabling was extremely beneficial. One example of this was a supervisor who allowed students in the group to rotate through a roster where only one student was present at ward rounds each day and this student was responsible for handing over to the other students that day. This allowed students to have additional time to study outside of the hospital when it was not their rostered day on the round.
A motivated teacher
Lastly, in both rural and metro hospitals, students felt a key component was having a supervisor who was as keen to teach as the students were to learn. Supervisors who continually informed students of additional learning opportunities throughout their placements made a real difference to the feedback I got about their experiences. One student had a supervisor who would phone at any point during the day to see if the students were free to see newly admitted patients. Students in rural areas had similar experiences where they were able to gain a lot more hands-on practice if their supervisor was willing to let them have a go at managing any new incoming cases. This willingness to teach allowed students to be exposed to as many learning opportunities as possible and made sure they didn’t miss any chances to practice their basic clinical skills.
To sum it up
Overall, most students expressed that despite some of the challenges, they now felt well prepared for managing paediatric cases as an intern. But they did feel that perhaps work needs to be done to bridge the gap between no paediatric exposure, before diving head first into a seven-week intensive immersion into everything paediatrics.
So, I asked what they thought might be helpful to know before I head into my placement.
What do you wish you knew before hand?
- How to change nappies
- How to play with children – don’t forget the bubbles!
- Techniques to manage children’s behaviour
- Some basic knowledge about common acute conditions and how to assess and manage these e.g. bronchiolitis
- That the more you put in the more you will get back, and in paediatrics you need to seek as many learning opportunities as possible to develop your skills from the get-go.
- You can’t learn paediatric medicine by being passive – you have to be willing to have a go and make the most of the short amount of time
Now it’s my turn
I can safely say that I am now feeling more prepared for how to best approach my paediatric rotation. With the curriculum as it stands, the onuss will be to seek out some basic paediatric knowledge and to keep up with the evidence-based clinical guidelines prior to my placement. This is where resources like DFTB are vital for students.
And aside from keeping up with research, I have two years left to learn how to change nappies!
The number one tip for students:-
The aim of the seven-week placement isn’t to try and become a paediatric expert, but to learn how to manage a presenting child, how to identify when a child is really sick and knowing when you need to ask for more help. The expert part comes much, much later!