Internal Medicine Clerkship
The Internal Medicine Clerkship
The third year medicine clerkship is an awesome rotation that allows you to participate more actively and meaningfully in your patients’ care than any other third year rotation. This clerkship also provides a basic foundation of knowledge and clinical skills that will help you become a better clinician, regardless of what specialty you ultimately choose. At orientation, Dr. Vu will give you a thorough overview of the general expectations of the clerkship along with very helpful advice on how to succeed on this clerkship. Your team will also have more specific expectations, so you should definitely ask your attending and resident what their expectations are on the first day as a big part of your success on this rotation is related to how well you function as a part of the team. Your job, more than anything, is to know everything about your patients. This not only includes daily data and your exams when rounding, but also things such as what the consult teams are planning for your patients, evaluations made by ancillary staff (eg. speech pathology, physical therapy), and most importantly, the concerns of the patient and his/her family. If your team asks you something about your patient that you do not know, make sure you tell them you will find out and give them the information at a later time. Make sure to be observant during rounds! You can learn a lot about what information is important and how to polish your presentation skills by listening to the interns present their patients and paying attention to the types of questions your attending and resident ask them. Also, it is important to pay close attention to all your teammates’ presentation of their patients; you can learn a great deal from other people’s patients, and all members of the team are ‘fair game’ for your attending to direct his/her questions. So it pays to pay attention on rounds—you just never know when you’ll get called on!
Your daily schedule will vary depending on your team but a typical day on the inpatient service will require getting to the hospital around 7am. You will need to allow enough time before rounds to review your patients’ data from the last 24 hours (VS, I/O’s, labs, etc.), perform a brief physical exam on each of your patients, and beginning your notes (SOAP). It will be important for you to develop a method to keep this information organized so you can easily refer to it during rounds. It would be helpful to ask your resident or interns to show you how they keep everything organized. The entire team will gather at the appointed time for rounds and you will be expected to present your patients in a SOAP format and to have given some thought to the plan of care (they realize you are a student and will help you if you don’t have a clue). Your attending and resident will probably ask questions about differential diagnoses, pathophysiology, and treatment strategies as they pertain to your patients. If you have been reading about your patient’s condition, this is your chance to shine—so speak up and incorporate your reading into your presentations! Your team will be able to tell when you have been reading about your patients and will often comment about this in their evaluations of your clinical performance. At some point in the morning, you will need to enter your daily note in the electronic medical record. The remainder of your day will vary depending on which hospital you are at, but typically consists of attending morning report (most often an interesting case presented by one of the medicine teams), going to a lunch-hour lecture (bring your own lunch), following up on your patients’ test results, checking back in on your patients to explain any test results and what to expect next, and admitting new patients. The clinics you rotate through on an outpatient month will vary widely, but the general recommendations above will help you succeed in the outpatient setting as well.
Disclaimer: These are by no means the only topics you need to know about to succeed on the medicine clerkship, and the coverage of these topics is not intended to be comprehensive. What we have tried to do is hit the highlights of some of the more common things you might encounter on your rotation to help you get off to a good start.
The Shelf Exam
The test at the end of the clerkship is an NBME shelf exam: 100 questions in 150 minutes. The questions are long, so pace yourself to make sure you have an opportunity to answer every question on the exam. The best advice we can give is to read about your patients and read as much as possible. You will learn and remember the most when you can relate what you are reading to a patient you have seen. Question books are also very helpful. For a breakdown of the content of the exam and a few deceptively easy sample questions, see:
The EKG Lecture series
On the medicine rotation you will be taught an EKG lecture series, usually by the chief resident of the hospital. The lecture series is usually 4-5 lectures, and at the end there is a quiz. The most important thing for learning EKG's is to make a system for yourself and apply it, and do it on all of your patients EKG's. Really reading an EKG should take 1 minute initially, and you will slowly get better. It is really important to choose a book and finish it, lots of people use the following two books:
Good Luck and Enjoy Your Rotation! Best of Luck!!
Clinical Resources for the Medicine Clerkship
There are many great resources available, so feel free to seek out a format most suitable to your learning style. The following are a few of our favorites, listed in no particular order:
For your White Coat pocket
- The Massachusetts General Hospital Handbook of Internal Medicine - This book is about $50, but well worth it. It fits nicely in your pocket and is useful for medicine, family medicine, surgery, and emergency medicine
- Maxwell Quick Medical Reference
- Tarascon Pocket Pharmacopoeia
- PDA Smartphone App alternate: Epocrates Rx – We highly recommend this: it’s free, updated weekly, and saves room in your pockets.
- The Sanford Guide to Antimicrobial Therapy / Smartphone App alternate: Johns Hopkins Antibiotic Guide
For the Book Bag
- Internal Medicine Essentials for Clerkship Students – From the ACP and the Clerkship Directors in Internal Medicine
- Online Supplement http://www.acponline.org/essentials
- Step-up to Medicine – often considered the essential review book in studying for the shelf exam
- Rapid Interpretation of EKG’s by Dubin
- Case Files: Internal Medicine
- USMLEWorld Step 2 CK QBANK - Questions are ALWAYS going to help you score higher on the NBME
For the Bookshelf
- Harrison’s Principles of Internal Medicine – Available online through the library website
- Cecil Essentials of Medicine – great intermediate between full text books and IM review books
- Current Medical Diagnosis and Treatment - Available online through IUSM Library
- Swartz Textbook of Physical Diagnosis: History and Examination
- Question Books
- MKSAP 4 or 5 for Students – From the ACP Medical Knowledge Self-Assessment Program. Highly recommended. This consists of roughly 400 questions that will cover a great variety of topics. Furthermore, the entire contents of the book are available on the accompanying CD or online, if you purchased the 5th edition (online access code included in the book). If you are comfortable with this the electronic format (recommended, it’s faster without having to flip pages for answers), obtaining the CD (4th edition only) for a quick install is all that’s needed if you can find a friend willing to loan it to you.
- Medicine: PreTest Self-Assessment & Review
- First Aid or Kaplan USMLE Step 2 CK question books
- PDA Resources (also see section in Angel)
- Epocrates (http://www.epocrates.com/)
- Merck Manual (http://www.merckmedicus.com/pp/us/hcp/hcp_home.jsp)
- Diagnosaurus (http://books.mcgraw-hill.com/medical/diagnosaurus/index.html)
- Archimedes (http://www.skyscape.com/EStore/ProductDetail.aspx?ProductID=227)
- Skyscape – several free pocket guides available for your pda (http://www.skyscape.com/estore/ProductOverview.aspx)
- UpToDate: may purchase at student price available for free through IUSM library, with your IUPUI account.
- DynaMed: the current another IU Health online resource. Available for free with your IUPUI account.
- emedicine.com: Not as exhaustive, but a relatively comprehensive and free alternative to UpToDate. Need to register but allows access from home
Other Helpful Resources
Dr. Vu has put together several other helpful learning resources on Oncourse. These are located in the “Additional Learning Resources” folder and “Educational Resource Web Links” subfolder. Some of these websites provide helpful tutorials on heart and lung sounds to sharpen your auscultation skills—which you will need for the wards, clinics, and for USMLE Step 2 CK (and eventually Step 3). You will also find information that will help you improve your presentation skills.