Medical

Pediatrics In Review: A Look at Clerkship #2

Central to the skillset of every physician is the differential diagnosis; this is the process by which new patients are evaluated to establish the most likely diagnosis. Similarly, the first clinical year of medical school is like a differential for each student, except instead of a medical diagnosis, students are seeking to determine which specialty they will choose. This column explores this differential: experiences from each rotation by a current third year student.
In my first rotation, Women’s Health, I wrote about the humbling experience of helping with the birth of a child. This miracle of life is what attracts many people to the field of obstetrics, but working directly with the baby during the newborn period and throughout his/her childhood is, of course, the role of the pediatrician. As I’ve heard many times on this clerkship, “children are not simply small adults,” and understanding human development, the unique diseases of childhood, and the specific needs of young humans is often complex. For this reason, pediatrics is one of the oldest medical specialties, and remains the third largest by volume in the United States.[1]

Pediatrics is a primary care specialty, meaning pediatricians serve as the first and continuing point of contact between the patient and the health care system. A large component of clinical pediatric practices are “well child checks,” which are the regular check-ups for growth and development that many of us remember from our own childhood. These occur frequently in the first years of life and eventually space out to annual visits. The interesting thing about well child checks is that some pediatricians might actually see more healthy patients than sick patients on any given day! Many medical students are drawn to this aspect of pediatrics. Because of the primary care nature of pediatrics, these visits emphasize education, preventive medicine such as immunizations, addressing concerns before they become serious issues, and referring serious or complex issues on to specialists.
One component of this rotation that I’ve really enjoyed has been the opportunity to meet and learn from some amazing children. (And, as one of my attending physician likes to say, “In what other field would you get to play with babies all day?”) Through this, I’ve started to gather a sense of what children tend to be like at different ages (we call this “normal development”) and have loved beginning to understand how children see the world. Children grow rapidly, especially early in life, and it is amazing to see how quickly they change and learn and grow. This knowledge of normal development enables pediatricians to notice subtle changes or delays over time, which can make a major difference in the life of a child who needs any kind of specialty help.
One of the most compelling aspects of pediatrics is how pediatricians have a unique opportunity to make a difference in a child’s life. Along with teachers, they are influential voices of authority to whom children will often listen, even when they won’t listen to parents or family members – despite seeing their pediatrician only a few times a year.
For example, one of my professors (a pediatric psychiatrist) has often told the story of his own decision to pursue medicine. He points to his pediatrician, whom he saw for twenty minutes a year, but who acknowledged him, told a joke, and gave him a Spiderman sticker, and that interaction was meaningful enough to affect the trajectory of his life. Similarly, I watched one of the nurse practitioners with whom I worked speak briefly with a teenager with anxiety and depression. After his mother stepped out, the NP asked about his relationships, and then offered him some encouraging and supporting words. I feel sure that he knows how much she cares, and that he would come to her if he had any questions or needed help. I was struck by how such a short interaction could affect someone going through a difficult time.
There are other aspects of pediatrics that are fairly unique. For example, one of our teachers talks about the “therapeutic triad” of pediatrics, meaning the provider, the patient, and the patient’s owner (his term). This “owner” is often the parent but could be a grandparent, foster parent, guardian, sibling, etc. Who this person is, of course, makes a big difference in how the patient is approached, but regardless of who it is, it can be complicated to navigate this relationship. Pediatric patients can’t always speak for themselves, in even if they can talk, they can’t legally make most medical decisions. Physicians must work with difficult patients and difficult owners, sometimes; and even if no party is difficult, there is still complexity involved. This is why pediatrics is sometimes compared to veterinary medicine, and can frustrate some students (“Why can’t you just TELL ME what’s wrong!”)
There are two main wings of general pediatrics, inpatient and outpatient. I was fortunate to have both as components of my clerkship, which allowed just enough time to get accustomed to the flow of each before switching to something new. Outpatient refers to the treatment of patients not admitted to the hospital; this is typically a clinical setting in an office building. When most people think of going to see a pediatrician, this is usually what they are remembering. General pediatricians who work outpatient medicine enjoy continuity of care and seeing many healthy kids, or kids who are not deathly sick. By contrast, inpatient pediatrics deals with all children admitted to a hospital. This may be a standalone children’s hospital or simply a floor/ward of a general hospital. These children tend to be pretty sick, and the flow of the day is completely different than outpatient. Their role is that of a hospitalist – physicians go on rounds to see patients, coordinate consults, and administer therapies in the hope of discharging the patient home – but the patients still have the unique considerations and diseases of children.
Pediatrics as a specialty also enjoys a wide range of subspecialties. Nearly every medical specialty has a pediatric version, due to the special needs that children have compared to adults. Pediatrics is a 3-year specialty; there is also a 4-year combined specialty in Medicine and Pediatrics, which covers adults and children and provides experience in dealing with the critically ill of both. Most pediatric fellowships are an additional 3 years; these include Cardiac Critical Care, Cardiology, Critical Care, Emergency Medicine, Endocrinology, Gastroenterology, Hematology/Oncology, Infectious Diseases, Medical Toxicology, Nephrology, Pulmonology, Rheumatology, Sports Medicine, and Transplant Hepatology. The above list are medical specialties that are adapted for pediatrics; there are also pediatric-specific fellowships, which include Neonatal/Perinatal Medicine, Adolescent Medicine, Behavioral/Developmental Medicine, Child Abuse Medicine, and Allergy; Immunology Medicine. As if these choices weren’t enough, there are further opportunities to work with children in other specialties, e.g. Pediatric Surgery or Pediatric Psychiatry. Fellowships in these are pursued through their core specialty.[2]
Pediatrics has been a great experience, and a thorough look at many aspects of inpatient and outpatient medicine. I’m now transitioning to surgery, which I hope to highlight in an upcoming article. Stay tuned for next month’s post!
[1] AAMC, Physician Specialty Databook, 2014.
[2] See AAMC Careers in Medicine for more information.
About the Author
Brent Schnipke is a third year medical student at Wright State University Boonshoft School of Medicine in Beavercreek, OH. He is a graduate of Mount Vernon Nazarene University with a degree in Biology. His interests include medical education, writing, medical humanities, and bioethics. Brent is also active on social media and can be reached on Twitter @brentschnipke.

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Brent Schnipke, MD is a writer based in Dayton, OH. He graduated medical school in 2018 and is psychiatry resident at Wright State University Boonshof...