Tag: KCUMB

Pediatrics Rotation

Hello!

I wanted to give you an inside look on my pediatrics rotation. I am actually really passionate about kids and they just light up my day. I have to say, I usually feel physically tired at the end of the day, but I don’t feel mentally or emotionally drained when I work with kids. It’s really hard to! They are always a joy to be around (for me anyways).

Pediatrics is another core rotation. This means that I will have another shelf or COMAT exam at the end of my rotation. Most students work with a pediatrician in clinic for their core rotation. That way, you get to see a lot of well child examinations and really get a good look at growth through the ages.

I actually had my core rotation with the pediatric hospitalist group! Thankfully, I got to do well child exams and examine newborns during my ob/gyn rotation in family medicine/ob. I also got to do circumcisions during that rotation as well. For this rotation, there was a much different feel as we were inpatient.

Much sicker children.

Much higher acuity.

Note taking is also very different from your typical outpatient notes. It is still a SOAP note (in theory anyways), but your most detailed note is the H&P when they first get admitted. More on that later.

Schedule/Daily Work Hours

This rotation was a little farther away from my last one, so I did have to get up earlier and drive farther. Not my favorite thing to do since I dislike mornings, but you do what you need to!

Around 7:15/7:20am: I get to the hospital and go up to my floor.

7:20-8am: I am reviewing notes on what happened last night and rounding on my patients. The floor can hold 19 rooms (2 kids per room), but they don’t typically like to double up in the rooms unless they have to. As a medical student, if I don’t have any patients that I’m following I MUST round on two of the patients on the floor. And I need to have seen my patients before huddle and before the provider comes to the floor. Some days I was able to push myself and see more than 2 patients.

8 am: Huddle. Huddle involves everyone in each child’s care to be present so everyone knows what is going on and what the plan is. On my floor, the nurses present their patients and any updates overnight to the physician. Pharmacy, social work, nutritionists, and child life (enrichment and counseling) are all present during this.

Depending on when Huddle ends we will start rounding.

8:20/9am -10:30/11am is rounding. This time is very very variable. And if we get a lot of admits in the morning or consults, rounding will be slid in-between. Generally we take this time to check in on each patient and update the parents on what we are going to do. Not all the patients on the floor belong under the hospitalist. Some patients are under trauma (burn and MVC patients), some are under Hem/Onc (cancer patients). Everyone else is under the hospitalist group. We may also have someone in the PICU (down a few floors from us) to see as well.

After rounding the physician usually works on any discharges that they have. I use this time to work on my notes or look up information on the diseases some of our patients have. Some days we have a lot of discharges, others we have maybe one.

After rounding to 3/4pm. This is where we take consults, the provider calls for other consults to help with patient care, and check up on labs/imaging or order anything new. Most of these patients have a lot going on, and usually take up more time than you would expect. Some days we have barely any consults, some days we have a lot.

When the provider or myself isn’t taking a consult, they usually take that time to teach! The busier the day = less teaching. And after each time I take a consult or round on a patient, I need to write a note.

For example, today we had a kid come as a step-down from the PICU to our unit. So I was sent to the PICU to examine the patient and get a history to get things started while the provider did something else. I was also sent down to the ER as the ER wanted us to admit a child. So I again started that history and physical for the physician. At the same time, we had two transfers come in as direct admits; I took one and my provider took the other. And finally we had another ER admit. While that was going on, my provider was also trying to get a specialty consult appointment set up so we could discharge a patient, and consult another child’s geneticist who was being admitted.

They usually send me home around 3pm, unless we were busy and I would stay a little later. The latest I have stayed is around 5 pm. The unit I’m on has a rule about students not really being there past 3 and not to work on weekends. After discussing my hybrid situation with my attending, most of them are okay with me coming in on weekends to spend some extra time learning.

Notes

So note taking is a bit different for inpatient. It is still a SOAP note, but depending on the type of note will depend on how much information you put in it.

H&P: This is the note you write when admitting someone. So if you get a consult to admit from the ED, see the kid after a transfer to the floor from another hospital, or see the kid from a direct admit from their pediatrician, you do this type of note.

It involves a full HPI, ROS (multiple systems), and PE (multiple systems). The more complete = the better. You need to verify PMHx, SHx, meds, allergies, Family Hx, all that jazz. Some physicians also want a good social history; which for kids involves who they live with, if they go to school/daycare, any pets, any activities they do. If they are still infants or young toddlers, you need a birth history from mom.

Assessment for the H&P isn’t always what you end up diagnosing them with. For a lot of kids that fall under “failure to thrive” I usually put poor weight gain. Because one person’s definition of FTT is different from another. And a lot of times physicians use FTT instead of poor weight gain. So my initial assessment/dx is a working dx or a symptom unless something specific was found on workup.

Plan is much more in-depth and usually involves going by system. So a plan for an admit may look like this:

  • Resp: on RA, oxygen, albuterol q.2 hours, etc.
  • CVS: Hemodynamically stable. Will monitor vitals q.8 hours.
  • GI: (usually includes diet). PO diet as tolerated. Consult dietician and SLP for evaluation.
  • Renal/Endo: I never put anything here unless its a specific case for it.
  • ID: If we did a respiratory panel, stool panel, etc we would put findings here. This is also where we may put antibiotic plan here.
  • Neuro: If there I something specific like EEG or MRI or near consult we put that here. Otherwise usually Tylenol/motrin for pain will be put here as well.
  • Social: where we typically put that we’ve updated the parents on plan.

Any labs or imaging can be put under their associated section OR I usually pt it above with a statement to make it nice and neat. It just depends on how you do it.

Progress notes: So this is what you put on a patient that you’ve rounded on. Since insurance only covers one “bill” a day, only the day shift rounds on patients in the mornings. The night doctor doesn’t do any notes that would fall under progress. Some physicians like to add the day # at the top.

HPI for this is usually any updates since last written evaluation. So this can be that management was switched in the afternoon or evening, and how they did overnight. Did they spike a fever? Did they vomit? Diarrhea? How did they sleep? (very important in gauging kids). Did they eat? Can they tolerate PO? Were they playing yesterday? All of that is important.

ROS you don’t typically do for a progress note since the HPI is an update on how they are doing.

PE can be limited to a few systems. If it is a newborn/infant, you need to do a full exam every.single.time. Otherwise, I usually do constitutional, skin, eyes (if old enough), heart, lungs, belly, and neuro. You can add/subtract from there. Or you can do a full exam each time. It’s up to you.

A&P: similar set up as before. You either define/find a better diagnosis or continue to use the previous working diagnosis. Or maybe you use the working diagnosis and add on more based on findings and how the kid is doing. Plan is set up the same way. Any changes to treatment, any added medications, consults, labs/imaging need to be added. If you have an idea of what you are looking for before you discharge them, make sure that is noted in your plan. Otherwise the next attending on may not remember from sign-out what you’ve told them.

Discharge note: This is a brief HPI, PE, pertinent lab/imaging findings, and A&P. Plan should include follow up with their pediatrician and any other specialists, any follow up labs/tests you need them to get, and what symptoms they should look for that would prompt re-evaluation. Any medications you are discharging them with and how to use them along with any patient education needs to be in the plan and patient papers. Most of the subjective can be wrapped up nice and neat in a summarized “present” during their whole time there. Some providers like to have a full few paragraphs on the course of what happened while there. Others do less involved. PE should be pretty damn near normal or as normal as they can get for their condition before sending them home. Like, you shouldn’t be sending home a kid who is in respiratory distress and it shows that on your exam.

Cool things to see on the floor:

  • Trauma (although I didn’t manage any of those and neither did the hospitalist).
  • Burns (also trauma)
  • hem/onc patients (we didn’t manage this, but interesting to look up and study)
  • pyelonephritis
  • asthma exacerbation
  • bronchiolitis/croup/pneumonias. One pneumonia was chlamydia related!
  • appendicitis
  • LOTS of pyloric stenosis at this floor. Like holy crap.
  • omphalitis and cellulitis
  • scalded skin syndrome vs toxic shock syndrome vs weird allergic reaction
  • osteomyelitis
  • diarrheal diseases
  • so much failure to thrive/poor weight gain. Some of them are due to dehydration, some due to poor feeding schedules/too much given by parents/not enough given/not feeding at night. Some are the kids had a virus and everything got out of whack. Some of them are actually from some pretty serious diseases.
  • Febrile seizures was also pretty common to see.
  • Hirshprung’s disease.
  • rule out Kawasaki’s
  • Seizures (several had associated genetic diseases)
  • Duodenal hematoma (that was actually really interesting to look into management)
  • BRUE
  • Seizure management and workup
  • Abuse cases 🙁
  • Kids with genetic metabolic diseases and the fall out/recurrent issues that occur with those.

I most definitely spent time reading during clinic while my providers were doing phone calls or charting. That allowed me to cement a case with what I saw and with the information about it.

What are some major things I learned?

Well besides how inpatient medicine works and learning about kid diseases, I learned more about interacting with patients than I thought I would.

  1. I need to know my cases well, because parents will still ask me questions. I need to do my best to answer with correct information; and if I don’t know, I need to be able to defer it for when my attending arrives.
  2. Just because you are worried about a disease course for a specific disease/problem, doesn’t mean you need to tell the parents all of that. Lesson learned. That mom didn’t like me very much.
  3. You need to do a full exam. Every. Single. Time. As a student, it is time for you to practice. Not good at listening to murmurs? Listen to all the hearts. Not good at finding pulses? Practice. Plus, since your differentials aren’t fantastic yet, it helps you possible catch something you weren’t sure could be helpful!
  4. I have learned that even though you can complaint or discuss something in person, you cannot write certain things in your notes. Even if it is causing you issue with management of a patient. Word truthfully, but without accusing or painting a non-neutral picture in the chart.
  5. I really really like kids. And I really really like babies. Which is NOT helping me push off having children.

Hope this was helpful, and good luck on peds!

How my First Rotation Taught me to be a Better Medical Student

I recently finished my ob/gyn core rotation at a family medicine/ob practice. Despite not being a typical ob/gyn office, I was able to see my fair share of cases. So. much. ob! I wish there would have been more gynecology, as I didn’t get a good feel for the gynecology field or felt like I learned it well because of that. But in either case, I loved my 2 weeks in clinic there, my preceptor, her partners, and her staff!

This rotation was also my first EVER rotation as a third year student. My first time actually seeing patients on my own. Taking history, looking up their charts, doing a physical exam, the works. And honestly, I tried to stick to just the history and physical parts. I know a portion of third year is starting to nail down the assessment and plan; but honestly, you can’t get that far if you don’t learn to do a good H&P. For the most part, the physicians I worked with were fine with that. They knew it was my first rotation ever. But boy, did they still push me.

Much nerve-racking. Very nail-bitting. A true manifestation of being thrown into it.

But during my first rotation, I learned a lot about how to be a better medical student. What are my expectations? What are my preceptor’s expectations? How am I going to learn in this new environment? Thankfully, I had a decent idea of how clinic ran from being a scribe. I wish the program they used was the one that I had used previously, but alas, it was not. And we really didn’t have a lot of time to mess around on it either to learn. So hopefully that will come with time.

So what did I learn?

1. A new exhaustion.

You will have completely forgotten what physical exhaustion is like. As the student, you will need to find where you fit into the room and around clinic. You need to be close enough to see what is going on, but out of the way enough to let your physician and their staff (such as nurses and MA’S) do their job while not interrupting their workflow. And a lot of times, that means there is no seat for you. So expect to be on your feet all day for long hours. In your first two years of medical school, you are used to sitting for prolonged periods, but mentally exhausting yourself. This leads to a slew of things like anxiety and depression right? Well in third year, you will literally wear your body out from all the standing and running around that you won’t have time for those invasive thoughts to pop up into your mind at night. As soon as you sit or lay down you will be out.

I promise.

At least as someone who has suffered with anxiety and imposter syndrome, my body did not blink twice as soon as I went to lie down. I was just out cold.

Do yourself a favor and get good comfortable shoes with inserts in them. If that is tennis shoes, make sure they fit your foot type. I replaced my inserts and it did help. I also have a pair of Dansko shoes from my scribing days. I have yet to use those, but I’m sure those would be helpful too.

Eventually you will get used to standing, but you may not get used to the physical exhaustion as quickly. And that’s okay! You’ll sleep like a newborn baby.

2. Put in the effort.

Get up early to look up cases for the day or review how to do a procedure that is on the schedule. Pre-round if your attending likes that. Stay late to learn and see that extra case. You are in the position to mess up as much as you’d like without putting someone in harms way (your attendings will usually watch you like a hawk if you get to do anything). Take advantage of this! A hard worker = more likely to get to do the fun stuff. Plus, your attendings will take you more seriously if you show that you are willing to put in the work.

Just because you’ve made it to third year doesn’t mean you are done. You still need to strive.

Oh… and just because a particular rotation isn’t what you want to do, is not an excuse to not give it your all. You don’t have to lie about not being interested. It’s okay to say your interest lies elsewhere. But you should still be hauling ass.

3. Try to be helpful, but know your place.

Despite medical students being the next generation of physicians and needing to learn, you are still going to slow your attending down. It’s truthfully why a lot of physicians don’t take on medical students. It adds extra work, disrupts their workflow, and they usually have to redo everything the student has done. Particularly in the first little bit of your rotation. A lot of times, the students end up shadowing and don’t see patients on their own. That could simply be to not fall behind on schedule in seeing patients or it could be they don’t trust you yet. Other times if your attending is willing to let you do more, they will need to literally ask all the same questions you just did and redo the exact exam you did. That’s okay.

You wanted to scrub in and learn up close? Great. But to an attending, you may contaminate their field or get in the way, particularly if it is a more urgent matter to take care of or a true emergency. With time and experience, you will get to do more.

A good medical student inserts themselves or asks to be present to learn new things, but isn’t overly assertive. At the end of the day, your attending will decide if you get to be there or not. Know what is going on and ask to be there or to be notified if you aren’t with your provider when the procedure/surgery is happening. Ask if you can be in the room. Make sure to give your number to the clinic staff, the nursing staff, the floor staff, and your providers. Its always okay to ask to be notified if something occurs. If they remember, they will call you. If not, don’t take it to heart.

4. Be kind to the staff.

This is a huge one. Even if you just come in with a friendly smile and say hello. Or ask how their day went. Nurses, MA’s and even front desk staff can be great sources of information. During my first rotation, the nurses were very willing to teach me things that I wouldn’t have gotten to do otherwise. That’s how I learned about something called the ‘vagina in a box’…

Being kind to them will also help when you want in on procedures. It will put you in their favor and they are more likely to remember to contact you after the doctor contacts you (or if the doctor forgets).

However if you walk in their like your shit don’t stink and don’t acknowledge them, they are going to take note. And they will not be very helpful to you. At the end of the day, the staff working with your attending help run the clinic and make sure patients are the provider’s workflow runs smoothly. They help play a vital role in patient care. It is important to know and acknowledge that even as a student.

5. Humble Confidence

You are going to have situations where you are completely thrown in. No prep time, no advanced notice. This happened to me several times in my first rotation. One attending would walk in the room with me, tell me nothing, and then introduce me and leave. Like WHAT?!?

Don’t worry she would come back. But there were definitely times where I didn’t know I would be doing the patient visit.

The same thing goes for procedures. One attending was the ‘see one, do one, teach one’ type. Which meant you got one shot to see it, go home and research it, and then it was your turn to go the next time. Nerve-racking? You bet your bottom dollar!

But you do have to have some confidence in yourself to be able to do those things. You are going to be put in new and uncomfortable positions for you. Not as in uncomfortable for your safety; more like you are going to get pushed out of your comfort zone. If you don’t have some confidence in yourself and your abilities you will crumble.

But at the same time, you SHOULD NOT act like you can do something if you’ve never seen or tried it before. It is perfectly okay to jump at the chance to do something. But if you haven’t done it before, TELL THEM! They will be much more receptive to you saying “I would absolutely love to, but I haven’t seen one yet. Can I watch you do one first?” or “It’s been a while since I’ve done this. How do you do this procedure?”

Obviously if it’s in front of the patient don’t say that. I made that mistake this past rotation and got a very stern talking to about it. No problem; lesson learned! If it’s in front of the patient, say something like “I’ll watch you do the first side and then I’ll do the second”. That will usually tip off your provider to saying you haven’t done one before.

Letting them know this shows them that you are RESPONSIBLE enough to admit when you are out of your league and that you aren’t willing to harm the patient in the process.

6. Supplies…

Depending on your rotation will depend on how you can help with this. For my past rotation, I always had a pen or two and a small pocket sized notebook handy. Mostly, this was for me. But my provider usually needed a pen. It was small, but it was enough to be handy. Or they would need a sticky note or piece of paper to jog notes down. I could easily give them a sheet from my pocket book.

In other rotations, it may be helpful to have bandage shears (if you own them), tape, alcohol swabs, bandaids, tongue depressors, etc ready to go. Obviously, do not steal materials. But it could be helpful to stock up in the morning and be able to easily whip that out for your provider instead of them spending time looking for it, or having to send you to go find it in the middle of an encounter.

And lastly…

7. Go with the Flow!

You never know what is going to pop through that door. Or if your provider is on call, how many times you have to run out of clinic. Sure, you may be “scheduled” to be there from 7-4, but you likely will be there a lot later. Or maybe you have to go in early. My point is, your rigorous study schedule that you are used to sticking to from your first two years will be out the window. You are going to have to figure out if you have enough energy at the end of the day in clinic to study. If not, make sure on your day off or over the weekend to double up so you can stay on top of your material. Bring your study aids with you, so if there is true downtime at the hospital or in clinic you can learn in between.

You won’t have a single day the same as the next. So don’t hold yourself to a super rigid schedule. I promise you won’t be able to stick to it very well.

8. Empathy (This was added on after…)

I have always been an empathetic person. And in my medical school, we were graded (or at least needed to work on) being empathetic in our standardized patient encounters. In that case, it is hard to be empathetic because “it’s not real”. However, if you’ve never practice it or learned how to have an empathetic conversation, it is going to be difficult in your third year.

You are going to see real patients. Real patients with real problems. Real patients with real and raw emotions. Happiness. Sadness. Grief. Anger. Frustration. Apathy. All. Of. It.

My first rotation helped me utilize how to lead these conversations. It made me realize that sometimes I had to do most of the talking because the patient wasn’t sure where to go and needed guidance during a difficult time. Other times it meant I needed to listen more. Sometimes it was reassurance. Or an explanation of why something happened the way it did.

Either way, I wasn’t exactly expecting to have to be a part of any heavy conversations with patients in my first rotation. In fact, I didn’t even think that was an option on my radar, simply because I wasn’t thinking about it. But they will happen. And you need to learn how to approach those topics gently.

Because at the end of the day, your patient will remember how you made them feel after an encounter. Not if you handled the medical side of their encounter.

Let me know in the comments below if you found this helpful or have any other insights to add!

Cheers.