Objectives

Guidelines for Clinical Activities of Medical Students

Medical students rotate in clinical settings to learn all aspects of patient care, including obtaining patient histories, performing thorough physical examinations, formulating differential diagnoses, learning to make decisions based on appropriate laboratory and radiological studies and procedures, interpreting results of special studies and treatment, communicating with patients on all aspects of disease and prognosis and communicating with members of the health care team.

To this end, the medical student may participate in the following activities:

1. Access patients to obtain a medical history, perform a physical exam, and
   follow the inpatient and/or outpatient course.
2. Access the patient's entire medical record, including laboratory reports, x-ray reports, etc.
3. Perform appropriately supervised procedures as authorized by the patient's attending physician.
4. Perform basic lab studies such as urinalysis, under appropriate supervision and review.
5. When the student is clinically prepared, write orders for specific patients. All of the orders written by a medical student must be reviewed and countersigned by the responsible resident or attending physician before forwarding to the nursing service.
6. Write progress notes that the responsible resident or attending physician will review and countersign.

Students CANNOT:

1. Write orders independently, without review and counter-signature by the responsible faculty member or resident.
   
2. Be the primary line of communication in the critical value reporting process.
3. Have sole responsibility for communicating vital patient related information to the patient or family members.

LEARNING OBJECTIVES OF THE COMSEP CURRICULUM (2002-2003)

 

PROFESSIONAL CONDUCT AND ATTITUDES

1. Describe ways that development from infancy through adolescence affects the interaction between the physician, the patient and the family.
2. Discuss the way that communication skills affect the interactions with the growing and developing child or adolescent and his/her family.
3. Describe ways that respect for modesty, privacy, and confidentiality affect clinical interactions.
4. Discuss the general influences of cultural, ethnic, and socioeconomic factors on personal and familial traits, beliefs and behaviors.
5. Discuss the practical applications of the major ethical principles (Respect for autonomy, beneficence, non-malfeasance, justice), and demonstrate an understanding of the ways that these principles contribute to the physician’s responsibility to promote the best interest of all patients and families.
6. Identify key members of the healthcare team and discuss their roles.
7. Realistically self-appraise and explore personal strengths, weaknesses, and goals.
8. Recognize the impact of stress, fatigue, and personality differences on learning and performance.

SKILLS

1. INTERVIEWING SKILLS
   1. Compare and contrast the components of the history that should be obtained for different types of visits (e.g., first visit, acute care, health supervision).
   2. Determine when it is appropriate to obtain a complete medical history, or a focused or interval history.
   3. Describe how to modify the interview depending on the age of the child, with particular attention given to the following age groups: toddler/preschooler, school-aged child, adolescent, including when to address questions to child versus parent.
   4. Describe social, language and cultural factors that affect the interaction with the patient and family.
   5. Be able to obtain the following information in an appropriate manner from child and or the accompanying adult: past history, family history, social history, environmental and personal safety assessment.
2. PHYSICAL EXAMINATION
   1. Explain how the age of the child influences the physical examination, including the approach to the patient, the sequence of the examination, and the specific components of the examination.
   2. Explain how age-appropriate behaviors, such as stranger anxiety, affect the ability of the examiner to perform the examination, and describe strategies to perform a successful examination.
   3. Recognize the value of observation as an important assessment tool.
   4. Determine when it is appropriate to perform a complete vs. a focused physical examination.
   5. Explain how physical exam findings have different clinical significance depending on the child’s age.
   6. Be able to perform and interpret the following components of the physical examination: appearance, vital signs, growth, development, HEENT, neck, chest, heart, abdomen, genitalia, extremities, back, neurologic exam and skin.
3. CLINICAL PROBLEM SOLVING
   1. Interpret history and physical exam findings based on the age of the child.
      
   2. Develop a complete problem list and prioritize problems, taking into account the age of the child. Combine problems where appropriate to develop a specific differential diagnosis for the patient’s combination of symptoms.
      
   3. Create a sufficiently broad initial differential diagnosis for each problem (or combined problems). Ensure that the differential diagnosis is appropriate for the age of the child.
      
   4. Choose appropriate laboratory and diagnostic tests, and be able to justify those decisions taking into account a test’s sensitivity, specificity, and predictive value, as well as its invasiveness, risks, benefits, limitations, and costs.
   5. Interpret the results of diagnostic tests, recognizing the age-appropriate values for commonly used laboratory tests, such as the CBC, urinalysis, and serum electrolytes.
   6. Describe the most common treatments for the final diagnosis.
   7. Formulate a clinical question relative to a patient’s problem. Conduct an effective search of the medical literature. Critically read the pediatric literature and apply the information in developing a differential diagnosis, diagnostic plan, or management plan.
4. COMMUNICATION SKILLS
• Verbal Communication
1. Organize a case presentation to reflect accurately the reason for the evaluation, the chronology of the history, the details of physical findings, the differential diagnosis, and the suggested initial evaluation.
2. Include age-specific information.
3. Use precise descriptions of physical findings, and avoid vague term, such as "clear" and "normal."
4. Explain the thought process that led to the diagnostic and therapeutic plan.
5. Communicate effectively with other health care workers.
• Written Communication
1. Use precise descriptions of physical findings and avoid vague terms, such as "clear" and "normal."
   
2. Use appropriate formats for documenting history and physical examination depending on the purpose of the written document: inpatient admission and progress notes, office or clinic visits for acute illness, health supervision visits, and interval care visits.
3. Write admission orders for a hospitalized patient and write a prescription (see Therapeutics section).
5. Communication with the patient and/or family
   1. Use communication techniques that enable development of a therapeutic alliance with the patient and family, being sensitive to the unique social condition and cultural background of the family.
   2. Identify the primary concerns of the patient and/or family.
   3. Describe the relationship between physician, patient and parent and its effect on communication.
   4. Discuss medical information in terms understandable to patients and families.
   5. Avoid overuse of medical jargon and be able to explain medical terminology.
   6. Recognize the important role of patient education in treatment of acute and chronic illness, and prevention of disease.
   7. Describe the process of “breaking bad news” to patients and families, demonstrating knowledge about an individual’s reaction to such information, and ability to use basic skills of communication.

HEALTH SUPERVISION

1. List the most common preventable morbidities in childhood and describe strategies for prevention.
2. Describe the components of health supervision visits at various ages (newborn, infant, preschool, school age, adolescent).
3. Discuss the appropriate use, interpretation, and limitations of:
   1. Neonatal screening
   2. Developmental screening
   3. Hearing and vision screening
   4. Lead screening e. Anemia screening f. Tuberculosis screening
4. Understand the importance of immunizations in health supervision (see Prevention).
5. Define anticipatory guidance and recognize how it changes, based on the age of the child.
6. Recognize how injury prevention strategies change as an individual grows (see Prevention).

GROWTH AND DEVELOPMENT

1. GROWTH
   1. Explain the importance of monitoring the growth of a child.
   2. Explain the use and interpretation of growth charts in the longitudinal evaluation of height, weight, head circumference, and body-mass index.
   3. Recognize variants of growth in healthy children, (e.g. familial short stature and constitutional delay).
   4. Recognize abnormalities of growth that warrant further evaluation and discuss their basic causes (e.g. crossing lines on a growth chart, discrepancies among height, weight and head circumference, short stature, failure to thrive, obesity, microcephaly and macrocephaly, and growth abnormalities related to specific physical findings).
2. 1. DEVELOPMENT
   1. Describe age-related developmental changes in children and explain why they are important.
   • Infant –Disappearance of primitive reflexes; changes in tone and posture;
     cephalocaudal progression of motor milestones during the first year; stranger anxiety.
   • Toddler/child - Separation and autonomy in two to three-year olds; sequence of
     language development; concept of school readiness.
   • Adolescent - Sequence of physical maturation and sexual maturity rating (Tanner staging); stages of psychosocial and emotional development.
     
   2. Explain the importance of monitoring the development of a child.
   3. Discuss tools that can be used to assess developmental progress (e.g. Denver Developmental Screening Test 2 (DDST2). Be able to: 1) Describe the appropriate use of the test at various ages, 2) Describe how to perform the screening test, 3) Determine whether the results of a test are consistent with expected patterns of development.

BEHAVIOR

1. Identify behavioral and psychosocial problems using the medical history and physical exam.
2. Describe the typical presentation of common behavioral problems and issues in different age groups such as:
   1. infants: sleep problems
   2. toddler: temper tantrums, toilet training, eating
   3. school age: enuresis, encopresis, attention deficit
   4. adolescence: conduct disorders, eating disorders, risk-taking behavior.
3. Recognize that somatic complaints may represent psychosocial problems (e.g. recurrent abdominal pain, headache, fatigue, and neurologic complaints).
4. Recognize that alterations in school performance or social structures may reflect emotional or medical conditions.
5. Understand the types of situations where pathology in the family contributes to childhood behavior problems (e.g. alcoholism, domestic violence, depression).

NUTRITION

1. State the components of a routine diet history for infants, children and adolescents.
2. State the calories/kg/day needed to support growth in infants.
3. Identify the major differences between human milk and commonly available formulas.
4. Describe the advantages of breastfeeding and recognize common difficulties experienced by breastfeeding mothers.
5. Describe a diet that promotes health in children and adolescents.
6. List the consequences of common vitamin deficiencies and excesses and indicate which vitamins and minerals may require supplementation in infants, children and adolescents.
7. Recognize nutritional factors that contribute to the development of childhood obesity and to failure to thrive.
8. Describe the endocrine, cardiovascular, and orthopedic consequences of childhood obesity.
9. Identify individual and family risk factors for cardiovascular disease and diabetes that can be addressed with nutritional modification.
10. Recognize that chronically ill children may have special nutritional needs often requiring the assistance of a nutritionist.

PREVENTION

1. Describe how risk of illness and injury change during growth and development. Give examples of the age-and development-related spectrum of illness and injury.
2. List the immunizations currently recommended from birth through adolescence. Discuss the benefits, limitations, adverse side effects, and contraindications of each immunization.
3. Provide examples of anticipatory guidance aimed at prevention for different ages for the following: motor vehicle safety, infant sleeping position, falls, burns, poisoning, fire safety, choking, water safety, firearms and weapons.
4. Outline the physician’s role in the prevention of sports injuries, including the pre-participation sports physical.
5. Provide examples of risk factors that can be assessed for violence prevention counseling.

ISSUES UNIQUE TO ADOLESCENCE

1. Recognize unique features of the physician-patient relationship during adolescence, including confidentiality and consent.
2. List the components of health supervision for an adolescent, including personal habits, pubertal development, immunizations, acne, scoliosis, sports pre-participation evaluation, and indications for pelvic exam.
3. Describe an approach to the psychosocial interview of an adolescent, e.g. HEADSS method.
4. Discuss the characteristics of early, mid and late adolescence in the terms of cognitive and psychosocial development.
5. Discuss the sequence of the physical changes of puberty.
6. Describe the sexual maturity rating scale (Tanner Stages), and understand its use in measuring physical maturity.
7. Recognize common risk-taking behaviors of adolescents, such as alcohol and other drug use, sexual activity and violence.
8. Understand the contributions of unintentional injuries, homicide, suicide and HIV/AIDS to the morbidity and mortality of adolescents.
9. Recognize the features of common mental health problems in adolescence, including school failure, attention deficit, eating disorders, depression and suicide.
10. Discuss an approach to preventive counseling for risk behaviors of adolescents, including: sexuality/sexual activity (sexual orientation, contraception and sexually transmitted diseases), substance abuse, and personal safety (firearms, motor vehicles and violence, including sexual abuse/coercion, and date rape.)
11. List the components of a pre-participation sport physical and discuss its role in prevention of injury.
    
12. Recognize the unique difficulties encountered by adolescents with chronic diseases, including compliance and issues of autonomy vs. dependence.

ISSUES UNIQUE TO THE NEWBORN

1. List the information from the history of pregnancy, labor, and delivery that have implications for the health of the newborn.
2. List the key components of the physical examination of the newborn.
3. Discuss how gestational age can be assessed with an instrument such as the Ballard scale, identify key indications of gestational maturity, and discuss the effects of gestational age on the newborn infant.
4. Discuss the transition from the intrauterine to the extrauterine environment, including temperature regulation, cardiovascular/respiratory adjustment, metabolic fluctuations, state control, initiation of feeding, and managing the stress of the birth process.
5. Understand the transition of the parents into a family, taking into account the parents’ life stage. Discuss factors that affect the family’s transition to home, and the transition to the community medical provider.
6. Understand the appropriate care of the newborn and anticipatory guidance in feeding:
   • the basics of breast-feeding and formula feeding,
   • its benefits of breast-feeding for the newborn and mother,
   • the management of common problems (spitting, not interested),
   • Newborn screening; metabolic and hearing screening,
   • Safety: car seats, back to sleep recommendation,
   • Elimination patterns,
   • Sleep,
   • Skin care,
     Immunizations,
   • Medications, and
   • Circumcision controversy
7. Describe the presentation of the following common problems that may occur in the newborn:
   • The infant at risk for sepsis,
   • Jaundice,
   • Respiratory distress,
   • State abnormalities: temperament vs. pathology,
   • Feeding problems,
   • Large and small for gestation infants, and
   • The near-term infant

MEDICAL GENETICS AND DYSMORPHOLOGY

1. List common prenatal diagnostic assessments (e.g. maternal serum screening, amniocentesis, and ultrasonography) and understand their use.
   
2. List common medical and metabolic disorders (e.g. hearing loss, hypothyroidism and PKU) detected through newborn screening.
   
3. Discuss the effects of maternal health and potentially teratogenic agents on the fetus and child, including maternal diabetes, tobacco, alcohol, illicit drug use, and prescribed medications such as phenytoin, valproate, and retinoic acid.
   
4. Explain the use of the family history to construct a pedigree in the evaluation of a genetic disorder.
   
5. Describe the approach to the evaluation of a patient with a possible genetic disorder, such as developmental delay, mental retardation or short stature.
   
6. List the indications for obtaining chromosome studies.
   
7. Discuss the role of genetics in common multifactorial conditions (e.g. inflammatory bowel disease, pyloric stenosis, congenital heart disease, congenital hip dysplasia, diabetes and cancer) and describe how recurrence risk is estimated.
8. Recognize the role of careful history-taking and physical examination in the evaluation of a patient with structural or developmental abnormalities (e.g. facial features, palmar crease, measurements, symmetry).

COMMON ACUTE PEDIATRIC ILLNESSES

1. For these presenting complaints (cough and/or wheeze, fever, sore throat, ear pain, runny nose, abdominal pain, diarrhea, vomiting, rash, joint and limb problem and CNS problems), physical findings (excess bruises or petechiae, pallor, heart murmur, lymphadenopathy, splenomegaly, hepatomegaly, abdominal mass, impaired vision, white papillary reflex or delayed language development) or diagnostic test results (anemia, hematuria, proteinuria, positive PPD), list common conditions that could cause the finding.
2. For each complaint, physical finding or test result, describe the 1) etiology and/or pathophysiology, 2) natural history of the disease, 3) presenting signs and symptoms and 4) initial laboratory test and/or imaging studies indicated for diagnosis.
3. List indications that determine whether an illness should be managed in the hospital or outpatient setting.

COMMON CHRONIC ILLNESSES AND DISABILITIES

1. List the clinical signs and symptoms of the most prevalent chronic disorders of childhood including:
   Allergies Asthma Sensory impairment Cerebral palsy Malignancy
   Cystic fibrosis Sickle cell disease Seizure disorder Diabetes mellitus HIV/AIDS
2. Discuss how chronic illness can influence a child’s growth and development, educational achievement, and psychosocial functioning.
3. Discuss the impact that chronic illness has on the family emotional, economic and psychosocial functioning.
4. Recognize the impact of a patient’s culture on the understanding, reaction, and management of a chronic illness.
5. Define the unique contributions of each member of a multidisciplinary health care team in caring for children with a chronic illness
6. Identify the key components of delivering “Bad News” in relation to chronic illness.

THERAPEUTICS

1. Describe the ways that physical and physiologic growth changes the pharmacokinetics of commonly used medications in pediatrics. Specifically address drug absorption, distribution, metabolism and elimination.
2. Discuss the ways that pharmacokinetics affects the dosing of a medication.
3. List drugs that are contraindicated or must be used with extreme caution in specific pediatric populations.
4. Describe the appropriate use of the following common medications in the outpatient setting, including
   • When it is NOT appropriate to treat with a medication:
   • Analgesics / antipyretics Antibiotics Cough and cold preparations
   • Corticosteroids Bronchodilators Ophthalmic preparations
   • Otic preparations Vitamin / mineral supplements
5. List the components of a prescription.
6. Discuss how body size and weight or surface area are used to calculate medication doses.
7. Recognize the importance of patient education in ensuring adherence with treatment regimens.
8. Summarize the factors that affect drug excretion into breast milk.

FLUID AND ELECTROLYTE MANAGEMENT

1. List the daily water and electrolyte requirements for children of all ages.
2. List the factors that increase daily fluid requirements.
3. Define each of the following and discuss how it relates to the fluid management in health and illness: maintenance, deficit, ongoing losses.
4. List the key historical and physical exam information necessary to determine the hydration status of a child.
5. Recognize the causes of fluid imbalance leading to dehydration.
6. Describe the physical findings in hypovolemic shock and the approach to restoration of circulating fluid volume (i.e. “rescue” fluid infusion).
7. Discuss the water volume and electrolyte composition of maintenance fluids for children of all ages.
8. Know how to estimate the composition and volume of fluids for patients with fluid deficits.
9. Demonstrate an understanding of the electrolyte composition of standard and replacement oral and IV solutions.
10. Define hypernatremia, hyponatremia, hyperkalemia and acidosis. Describe a common clinical scenario in which each might develop.
11. Describe the effect of pH on serum potassium levels.
12. Know the conditions in which fluid administration may need to be restricted (such as the syndrome of inappropriate ADH secretion, congestive heart failure, or renal failure).

POISONING

1. Describe the developmental vulnerability for poisoning and accidental ingestions in
   infants, toddlers, children, and adolescents.
2. Discuss the ages at which prevalence of unintentional and intentional poisonings are highest.
3. Describe the clinical manifestations, toxicity, and basic management of important
   ingestions (iron, lead, acetaminophen, aspirin, caustic agents, narcotics, PCPs, cyclic antidepressants, hydrocarbons, strong alkali, alcohol, volatile hydrocarbons, and carbon monoxide).
4. Identify the environmental sources of lead and discuss the clinical and social importance of lead poisoning.
5. Know the passive and active interventions that decrease the incidence of childhood ingestions and injuries (i.e. locks or safety caps, pool fences, car restraints).
6. Describe the resources available to the physician for acute poisoning management, including poison information control centers and other resources (text and online).
7. Recognize that emotions of guilt and anxiety that may be present in the parent, caregiver or child at the time of ingestion.

PEDIATRIC EMERGENCIES

1. Describe the “ABCD” (the priorities of airway, breathing, circulation) assessment.
2. List the symptoms of and describe the initial emergency management of shock, status epilepticus, respiratory failure or insufficiency, head or cervical spine trauma, coma, apnea, proptosis, and suicidal ideation.
3. Describe the immediate emergency management of a child following trauma to the head, near drowning, or foreign body aspiration.

CHILD ABUSE

1. List characteristics of the history that should trigger concern for possible abuse.
   
2. List the physical and behavioral signs of physical, sexual, and psychological abuse and neglect.
3. Know the laws of your state for mandatory reporting of suspected child abuse and neglect.
4. Discuss the concurrence of domestic violence and child abuse and outline screening measures to identify family violence.
5. Understand the importance of a full, detailed, carefully documented history and physical examination in the evaluation of child abuse.
6. Discuss the unique communication skills required to work with families around
   issues of maltreatment.
7. Recognize the role of the physician in the reducing child maltreatment.

CHILD ADVOCACY

1. Describe barriers that prevent children from gaining access to health care,
   Including financial, cultural and geographic barriers.
2. Describe specific issues or situations where child advocacy by physicians has
   resulted in improvements in child health.
3. Describe the types of problems that benefit more from a community approach rather
   than an individual approach.

Competencies

Office of Medical Education
Giulia A. Bonaminio. PhD
Associate Dean for Medical Education and Director, Office of Medical Education
4959 Murphy
3901 Rainbow Blvd Kansas City, KS 66160-7831
Phone: (913) 588-8220

Contact Us

Department of Pediatrics
Mail Stop 4004
3901 Rainbow Boulevard
Kansas City, KS 66160
913-588-6301