Clerkship Information

1. Gather essential and accurate information about patients and their conditions through focused, family-centered history taking and physical examination of infants, children, and adolescents in acute, chronic, and preventive settings.
2. Utilize medical knowledge and available data, including laboratory and imaging results, to create and prioritize the differential diagnosis and formulate appropriate and cost-effective management plans, including recommendations for initial orders and prescriptions.
3. Document a clinical encounter in the written patient record that is accurate, organized, and displays clinical reasoning. Deliver an appropriately prioritized and audience-targeted oral presentation in a variety of clinical settings.
4. Communicate effectively with members of the health care team to deliver optimal patient care. Participate in patient care transitions and handover processes.
5. Demonstrate effective interpersonal and communication skills with patients and families across a broad range of socioeconomic and cultural backgrounds, including utilization of shared decision-making, education regarding normal growth and development, anticipatory guidance, as well as disease prevention and treatment.
6. Make use of self-evaluation and feedback from others to manage uncertainty, adapt to change, and develop habits of continuous improvement.
7. Demonstrate accountability to all patients and a commitment to carrying out professional responsibilities with integrity and compassion.
8. Recognize the impact of patient care on personal wellbeing and identify strategies to mitigate negative effects.

Structure

The 6-week pediatrics clerkship is divided into two sections: 3 weeks of inpatient experience and 3 weeks of outpatient and nights. Please view the Student Assignments for details.

While on the inpatient month, you will become an integral part of the inpatient ward team, consisting of the attending, supervising residents, interns, and other students. The outpatient rotation will be spent rotating through general pediatric, subspecialty clinics, newborn nursery, NICU, and a week of nights.

Things to Remember

Peds is different! All efforts are made to limit the procedures performed on children so that painful, frightening intervention is kept to a bare minimum. Students are also advised to make every attempt to attend as many other procedures as possible, such as surgical or radiologic procedures performed on their patients. Students will be excused from routine duties to be able to attend these procedures provided this privilege is not abused.

Recommended Text

There is no specifically recommended text in pediatrics. You should choose a resource that best meets your needs, such as a more comprehensive text for those interested in a career in pediatrics and a simple reference text for those wanting a review of the highlights of pediatrics.  Practice questions are also a great adjunct for shelf exam studying.

Comprehensive Reference Texts:

• Nelson Textbook of Pediatrics (Behrman and Vaughn) - Available on Clinical Key
• Rudolph's Pediatrics (Rudolph, Hoffman and Rudolph)

"Meat and Potato" Texts:

• Nelson Essentials of Pediatrics (Marcdante, Kleigman) - Available on Clinical Key
• Current Diagnosis and Treatment Pediatrics (Lange)

Miscellaneous Reference Texts:

• Manual of Pediatric Physical Diagnosis (Barness)
• The Harriet Lane Handbook (Greene) - Available on Clinical Key

Most Popular Adjunct Texts:

• Case Files- Pediatrics (Toy et al, Lange)
• Pediatrics PreTest (Yetman and Hormann)

COMSEP Curriculum

The pediatrics clerkship follows the Core Curriculum developed by the Counsel on Medical Student Education in Pediatrics (COMSEP). Here is an outline of the most updated COMSEP Curriculum.

Pediatric Physical Exam

You can view a video on the pediatric physical exam using this Learning Resources link from COMSEP.

Aquifer Pediatrics Cases

The clerkship also utilizes the Aquifer Pediatrics cases, developed by COMSEP, to teach and test the important points of clinical pediatric care. Aquifer is a comprehensive internet-based learning program with 32 interactive cases are designed to cover all the core content of the COMSEP curriculum. It is expected that each Aquifer case will take a student approximately 45 minutes to complete.  To access the Aquifer cases, go to the Aquifer home page. See directions for registering.

Students must complete 5 pediatric Aquifer cases of their choosing. These 5 cases must not have been completed on a prior rotation, and the student must have spent a reasonable amount of time completing the exercise and writing a thorough summary statement of each case. These cases must be completed by the last day of the rotation (shelf exam day).

Instructions for Logging onto Aquifer

Inpatient

The inpatient portion of the clerkship is fun but busy. Students should carry 4 patients each day. Daily responsibilities include attending morning checkout and morning report, pre-rounding on patients, writing H&Ps on the patients you admit, writing daily progress notes on each patient, attending daily rounds and presenting your patients, following up on lab tests, diagnostic studies, consultants, seeing patients again in the afternoon.

H&Ps

Students are required to turn in 4 written H&Ps to an attending on the inpatient rotation; roughly one per week of inpatient and nights. Students may turn in multiple H&Ps on their night shift week. H&Ps should contain a complete history and physical exam, as well as a differential diagnosis with discussion, assessment with working diagnosis, and plan with justifications. This is an example of a pediatric H&P.

Progress Notes

Progress notes on the inpatient wards follow the Interim History, Objective, Assessment, Problem list/Plan format.  This is an example of an inpatient progress note.

Discharge Summaries

Practice writing a discharge summary for one or more of your patients being discharged home. This is a critical skill to learn as this is your communication with the patient’s next care provider, usually the primary care physician. Use this discharge summary template to help organize your discharge summary.

Night Shifts

At the Memphis location, students will complete four night shifts during the inpatient month, usually Sunday through Wednesday nights. For the first week of the rotation, nights will be Tuesday through Friday night.  Night shifts will begin at 7:00 pm and end at 8:00 am after morning report. Students are expected to follow the night intern for all cross-cover issues and new admissions. Students should complete an H&P for each admission and turn in at least one formal written H&P to their attending during this week. Students should also briefly present one of their overnight admissions during morning check-out (handover) each morning after a night shift.

For clinical sites other than Memphis, night shift times and days may vary. Please contact your local clerkship director for more details.

Handovers

Students on days should practice signing out to the night shift student using the I-PASS format. Students on night shift should use the I-PASS format to handover one or more patient(s) during morning handover each day.

Admission Orders

Students should practice writing their own admission orders while on call and compare theirs to those of the admitting resident. This is an example of admission orders.

Presentations

Students may be asked to give 2-4 short presentations (3-5 minutes each) to their team on general pediatrics issues. Choosing topics, which relate to current patients, helps to improve clinical applications of knowledge.

Outpatient

The outpatient portion of the clerkship is designed to provide students with a broad view of outpatient and subspecialty pediatric opportunities. Students will attend clinic one day per week with a general pediatrics preceptor. Students will rotate in the newborn nursery and/or NICU, sub-specialty clinics, and emergency department shifts. To get the most out of this experience, students should be proactive in trying to see patients on their own when permitted. Students are required to have each outpatient attending sign their handbook for EACH CLINIC experience during this month (excluding your community preceptor).

Newborn Nursery/NICU

For information about the Newborn Nursery/NICU, please view the medical students curriculum.

Final Grading Rubric

Students will be graded on a competency-based scale receiving an Honors (H), High Pass (HP), or Pass (P) on each of the three rotation-specific competencies. In pediatrics, the three competencies are: Inpatient Clinical Performance, Shelf Exam performance, and Outpatient/Well Baby Nursery performance.

To receive a designation of “Honors” in the whole Pediatrics rotation, students must: receive Honors in all 3 competencies

To receive a designation of “High Pass” in the whole Pediatrics rotation, students must: receive a High Pass or greater in all 3 competencies.

If a student received a combination of H, HP, or P on the 3 competencies, the overall clerkship grade will be the lowest designation earned. (Ex. Inpatient: H, Shelf: HP, Outpatient: P, Overall grade for Pediatrics clerkship will be P (pass).

Inpatient: Student scores are based on clinical evaluations completed by their inpatient attending. An attending can work with a student ≥ 4 days to complete an evaluation. Inpatient evaluation

Inpatient Grading Criteria

Honors: ≥ 95%, High Pass: ≥90%, Pass: ≥70%

Shelf Exam: scores are adjusted by the NBME based on quarter. (Q1=0-1 clerkships completed, Q2= 2-3, Q3=4-5, Q4=6)

Shelf Grading Criteria

Honors: ≥ 75%, High Pass: ≥55%, Pass: ≥5%

Outpatient/Well Baby Nursery: Student scores are based on clinical evaluations completed by their outpatient preceptor and Well Baby resident. An attending or resident can work with a student for ≥ 1 day to complete an evaluation. Outpatient/Well Baby evaluation

Outpatient Grading Criteria

Honors: ≥ 95%, High Pass: ≥90%, Pass: ≥70%

Inpatient Rotation

This evaluation is completed by your inpatient attendings with input from supervising residents and interns based on patient work-ups, daily progress notes, participation in rounds, and presentations. It will be based on EPAs (Entrustable Professional Activities). Residents will also be completing evaluations on students through a QR code that is posted in each work room. The QR code will link to an evaluation form that will then be sent to the student’s final attending during their inpatient rotation to be collated into the final inpatient evaluation.  Inpatient Evaluation

To give you an idea of how you are performing, your attending physician will provide written mid-month feedback halfway through your inpatient rotation. If the faculty fails to provide this feedback, the student is expected to ask the attending for the current evaluation. This form should be turned into the clerkship coordinator at the end of the second week of the inpatient rotation unless otherwise stated during orientation. Mid-Rotation Feedback

During your week of nights, a resident will evaluate your performance using the following form Resident Evaluation. This form should be returned to the clerkship coordinator at the end of your week of nights.

Shelf Exam

At the end of the clerkship, students will take the National Board of Medical Examiners (NBME) Pediatric Shelf Exam as the written exam. The minimum passing score is the 5th percentile adjusted for the quarter of the year.

Percentile Scores by Quarter

Clerkship	5th				55th				75th
	Q1	Q2	Q3	Q4	Q1	Q2	Q3	Q4	Q1	Q2	Q3	Q4
Pediatrics	62	63	63	64	78	78	79	79	82	82	83	84

Re-examination must occur as follows: if failed during Block C, D, E, or F you must retake the exam in January of Block A of your M3 year; if failed during Block G, A, or B you must retake the Shelf exam by the end of Block 8 of your M4 year.  Under special circumstances, a student may be able to retake the Shelf exam other than at the regularly scheduled time, and if so, 4 weeks’ notice must be given.

Failure to be re-examined will result in a failing grade for the rotation. The original test score will be averaged into the final overall grade. Failure of the re-exam or failure of any portion of the clerkship requires that the entire rotation be repeated.

Creative Writing Exercise

Students will be completing a one-page creative writing exercise in response to one of two short stories: The Use of Force or A Lovely Family... Students are asked to respond to one of several offered writing prompts. These essays will then be read and discussed during scheduled lecture time, at which they will also be handed in for a completion grade.

Outpatient Rotation

The Outpatient portion of the Pediatrics Clerkship (3 weeks) consists of a week of nights, Well Baby Nursery, NICU, Outpatient Preceptor rotations, and Pediatric Subspecialty Clinics. During the Well Baby Nursery, residents will be completing student evaluations which will be averaged with the student’s Outpatient Preceptor evaluation which will be completed by the student’s assigned preceptor. Each resident or preceptor need only work with the student for 1 day to be able to complete an evaluation. These evaluations will be combined to form the student’s final grade for the Outpatient/Well Baby competency, based on the H/HP/P rubric explained above. Outpatient/Well Baby evaluation

• Pass- requires documentation of experience and participation in all clinics
• Low Pass - Multiple concerns expressed by various residents or faculty concerning students' performance during the ambulatory rotation.
• Fail - 2 or more unexcused absences or serious concerns expressed by various residents or faculty concerning students' performance during the ambulatory rotation.

Important Notes on Grading

The Clerkship Director retains the right to discuss with the attending physicians any serious infraction, professionalism issues, extenuating circumstances, or positive behavior not previously known to the attendings and may advise the attendings to alter the student’s grade accordingly.

All portions of the pediatrics clerkship including clinics and exams must be completed and passed within one (1) year of starting the pediatrics clerkship or by September of the senior year, whichever comes first. 

When grades are finalized, you will receive an email notifying you that your evaluations and grading composite are available to review.

Students are required to turn in all assignments and documentation with appropriate signatures (clinic logs, observed H&P card, clinical skills rubrics, time logs and case logs) by the last day of the rotation. Students failing to complete assignments by the last day of the rotation will be notified in email of the missing assignments. If assignments (including time logs and case logs) are not completed by 4 weeks after the end of the clerkship, the Dean of Student Affairs will be notified due to a lapse in student professionalism. If all assignments are not completed by 8 weeks after the end of the clerkship, this will result in a failing grade for the clerkship and the full clerkship must be repeated

Course Evaluations

Each student is strongly encouraged to complete a course evaluation at the conclusion of the clerkship (link will be emailed).

Current Disability Statement 

Any student who feels they may need an accommodation based on the impact of a disability should contact the Accessibility and Accommodations or the Teaching and Learning Center (TLC) to self-disclose and officially request accommodations. Requests for accommodations should be submitted with supporting documentation. Although students may register for services at any time, please attempt to make arrangements within the first two weeks of the semester as it does take time to process the request and review documentation. 

PLEASE NOTE: If a disability is not identified until after a course or clinical experience has begun or been completed, the performance evaluations received up to that point in the course or clinical experience will stand. As disability status had not been previously identified or self-disclosed through the application process for accommodations in the TLC, as accommodations are not retroactive. 

Information regarding applying for accommodations can be found on the Requesting Accommodations page. For additional information, contact the Disability Coordinator in the TLC at ksnyde21@uthsc.edu or 901.448.7745.

In contrast to the first two years of medical school where much of a student’s grade is based on objective criteria obtained through written testing, the second two years base much of the grade on subjective clinical evaluation. Perusal of the evaluation form reveals that a portion of the grade is based on evaluation of professional and personal attributes. Physicians-in-training must possess certain necessary attitudes and interpersonal skills. Some of these are inherent, but much can be cultivated particularly in an environment filled with the appropriate role models.

The University of Tennessee and the College of Medicine have published guidelines for professional behavior and conduct which can be found on OLSEN under Policies and Guidelines and also in the Student Handbook.

Computer Use

It has become standard that all large corporations monitor the computer use in their businesses. Methodist Hospital, of which Le Bonheur is a part, is no exception. Students can be identified surfing inappropriate websites, which will result in dismissal from medical school.

Students are expected to have completed Cerner training and to have obtained access to the electronic medical record at Le Bonheur prior to the beginning of the rotation. Please inform the clerkship coordinator on the first day of the rotation if you have not accomplished this.

For Powerchart (Cerner) access, call (901) 516-0000 #2.

Case Conferences

For students rotating in Memphis, Case Conferences (didactics) are Friday afternoons from 1:00pm-4:00pm. A schedule is in your orientation packet and at the top of the website as a quick link. Students are required to attend ALL learning sessions. Roll will be taken and will be reflected in your grade. Please review the appropriate Case Conference reading materials prior to Case Conference. A password is required for each topic and can be found on your case conference schedule. Case conference and didactic schedules for Chattanooga and Knoxville sites vary. Please ask your local clerkship director for details.

Longitudinal Wellness Curriculum

In each of the third-year clerkships, medical students will be completing a wellness curriculum surrounding a difficult topic specific to that specialty. In the pediatrics rotation, child abuse as been chosen as a potentially difficult topic for health care providers. Students will attend a special lunch session at noon on the third Friday of the rotation in which specific cases surrounding the difficulties of child abuse in the clinical setting will be discussed individually and in groups. During this time, honest discussion is encouraged regarding the suffering and uncertainty encountered in these circumstances. Instructors and students will also be able to highlight specific strategies for resilience and optimal mental health in these difficult clinical situations.

Other Conferences (Memphis Location)

All conferences are mandatory for students on the inpatient rotation. Some conferences are mandatory for all students. See Monthly Inpatient Calendar.

• Patient Checkout and Morning Report: All inpatient students are expected to attend every Monday, Tuesday, Thursday, and Friday mornings from 7:00am – 8:00am, Wednesday morning 7:00-7:30am.
• Grand Rounds: Wednesday mornings 8:00am-9:00am, Auditorium. Mandatory attendance for ALL students (except students on nights or those with Wednesday morning Germantown clinic).
• Noon Conference: Daily 12:00pm-1:00pm, Education Classroom. All inpatient students are expected to attend every day. Outpatient students encouraged to attend when possible.
• Longitudinal Wellness Curriculum: Third Friday Noon-1PM. Lunch will be provided.
• Chief Resident Rounds: One Thursday afternoon, inpatient students only.
• PICU Rounds: One Thursday afternoon, inpatient students only.

Clinical Skills Assessments (Rubrics)

Students will complete clinical skills rubrics for the following pediatric skills: 1) otoscopic examination and 2) developmental assessment. Rubrics may be completed either during inpatient or outpatient. You must be directly observed by a faculty member or supervising resident for each skill. Students will have 2 attempts for each skills assessment and must achieve a rating of “able to perform independently” on at least 4 items per rubric in order to pass this assignment. This is a pass/fail assignment that must be completed and turned in to the clerkship coordinator by the end of the clerkship. It is the student’s responsibility to alert the attending or supervising resident to the need for this assessment, and to ensure that both skills assessments are completed prior to the end of the clerkship.

Prior to the skills assessments, students should review the supplemental materials listed below:

• Otoscopic examination – Aquifer
• Developmental assessment – Read the following chapter, which can be accessed via Clinical Key on the UTHSC Library website: Caplin, D., Cooper, M. “Child Development for Inpatient Medicine”, Comprehensive Pediatric Hospital Medicine. 2007: 1285-1292.
• Students will also be provided with a copy of the “Kube card” of developmental milestones, which may be used during the skills assessment. *For Memphis location, these are in your Pediatrics Clerkship handbook.

Observed History and Physical

You are required to have a resident or attending observe your history taking and physical exam skills and sign the appropriate card. If you do not perform the skill adequately, you and the resident/attending should discuss ways to improve then they should observe you again for competence. This observed H&P form should be turned into the clerkship coordinator by the end of the clerkship.

*For Memphis location, this is in your Pediatrics Clerkship handbook.

Case Logs and Time Logs

In order to ensure that you are seeing a breadth of patients, we require documentation of 15 competencies located on eMedley. You should be a participant in the patient’s care, not an observer. If you do not see a patient with a particular diagnosis, you should complete the appropriate Aquifer Pediatrics case to fulfill this requirement (How to use the Pediatric Patient Encounter Logs example). If you use an Aquifer Pediatrics case, please mark this as a “simulated patient.” Go to the iLogin page and log in.

Hours will be limited to 80 hours per week averaged over a four-week period, inclusive of all in-house call and patient care activities. Continuous on-site duty, including in-house call, will not exceed 30 consecutive hours. Students may remain on duty additional hours to participate in transferring care of patients, conducting outpatient clinics, maintaining continuity of medical and surgical care, and attending required didactic activities. Students will be provided with one day in seven free from all educational and clinical responsibilities, averaged over the rotation, inclusive of call. One day is defined as one continuous 24-hour period free from all clinical, didactic, and administrative activities. Students should be provided with a 10-hour period after in-house call during which they are free from all patient care activities.

Log your hours on eMedley. These will be checked multiple times throughout the clerkship by the coordinator and you will be emailed if you are behind. All hours must be logged by the end of the day on the last day of the rotation (shelf exam day).

White Clinic Cards/Clinic Log

More information about these will be given during the outpatient orientation, but students must have a white card for each clinic and each morning of newborn nursery/NICU they attend during the outpatient portion of the clerkship.

*For Memphis location, these are in your Pediatrics Clerkship handbook.

Parking

Students must either park in their university-assigned parking spot or in the lot at 850 Poplar Ave. You are only permitted to park in the Le Bonheur Garage when you are on nights.

Lounge Use

For periods of relaxation and study, M3 students may use the resident lounge located on the 6th floor of the Children's Foundation Research Tower. There are computers, lockers, and relaxation and study space in this lounge.

Security

• Le Bonheur Security
• UT Security and escort service

Students are encouraged to seek constant feedback with each patient interaction or learning exercise. This can be done by directly asking residents, attendings, or other medical team members for feedback regarding performance on any task.

Formative feedback will be provided midway through the inpatient rotation and will be given by the attending and/or upper-level resident. Students will have their attending complete the mid-point evaluation and turn it in to Angie once it is completed. Formative feedback will not be added to your inpatient evaluation or MSPE. It is just for learning purposes. Mid-point formative feedback form

Students will also receive formative feedback regarding their performance on nights with their supervising residents. This form should also be returned to Angie when it is completed. Night Float evaluation form

Final, or summative feedback, will be given to the student at the end of their inpatient rotation and will be reflected in their final evaluation on emedley.

Students will be given a QR code to be kept on their ID badge in which any resident may complete an evaluation regarding their performance during the entirety of their pediatric clerkship. The QR code will take the evaluator to a student evaluation form to be completed by the resident. At the end of the rotation, the completed evaluations will be sent to the student’s inpatient attending to be incorporated into the attendings final evaluation. These comments will also be added to the attendings summative evaluation and will be incorporated into the MSPE. Any resident evaluations received after the end of the rotation will not be accepted into the final evaluation. QR codes are also posted in each of the inpatient team rooms for easy accessibility.