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InternalMedicineDosandDonts
Whether you are planning to pursue a residency in medicine or another specialty, the internal medicine clerkship is one of the most important third year rotations. Not only will you strengthen your analytic, diagnostic, and physical exam skills; you will learn important principles of inpatient and outpatient medical management that will translate to other rotations and will help improve your scores on your shelf and USMLE examinations.

As a second year resident in internal medicine, I have encountered all types of medical students on my services and have had the chance to figure out what makes a successful student on this rotation. Here, I’ll talk about the do’s and don’ts of your internal medicine clerkship based on my own personal experience. 

 

Do Take Initiative.

You’ve heard it before, but your rotation is what you make of it.  Whether it’s your preferred specialty or not, the more effort you put in, the greater the educational experience will be.  Offer to see new admissions in the ED, actively participate in daily rounds, search out relevant literature to educate your team, and seek out opportunities to observe or assist in procedures.  Furthermore, this is a great rotation to improve your physical exam skills. Whether on the wards or in clinic, you will encounter both common and rare physical exam findings at the supervision of residents and attendings that have performed thousands of physical exams. Been struggling to hear a heart murmur? Now's your chance to really improve that skill.
 

Don't Lie About Your Interests. 

It’s okay: Not every student on a medicine clerkship has to be planning for a career in internal medicine. Nobody will judge you for planning to go in to a different specialty. Being up front allows us to tailor the rotation to your interests and to patients that you will likely encounter in your future career. For example: I make sure my students who are interested in surgical fields see perioperative consults or patients with surgical conditions. Likewise, I make sure that my students interested in radiology get plenty of practice reading chest films. Even expressing your interest in a medicine subspecialty such as cardiology allows me to tailor my teaching to benefit your interests.
 

Do Perform a Detailed History. 

As a medical student, you will have infinitely more time to spend with your patients than I will as a resident. While I may only be able to spend 10 minutes interviewing a new admit, you’ll have far more time to spend with them. The more detailed of a history you take, the more you will benefit the team when you can provide extra collateral information on your patient. Not only that, but you will strengthen the relationship with your patient and really improve your own skills.

Don't Get Distracted

Medicine patients often have multiple medical issues driving their admission. While a surgical patient may be admitted for acute appendicitis, it is not uncommon to see our patients admitted with acute kidney injury in the setting of a CHF exacerbation complicated by difficult to manage hypertension and diabetes. Still, your success is dependent on being able to differentiate between relevant medical issues and background comorbidities. Far too often I’ve heard a medical student talk at length about a patient’s elevated TSH while failing to mention the worsening hypoxia, edema, and oliguria that brought them in. Being aware of all of your patient’s medical issues is important, but being able to prioritize amongst them is even more critical.

Do Go the Extra Mile. 

Ask your resident how you can help! It might not seem like much, but calling a consultant on one of your patients, talking with social work about discharge planning, or calling a pharmacy for collateral information can really make your resident's day easier. Plus, it helps you take ownership of your patients and keeps you involved in their care. Practicing these skills now will really translate to success as an intern.
 

Don't Be a Gunner.

There’s a fine line between maximizing your own experience and negatively impacting that of your peers.  Avoid correcting your fellow students on rounds, answering questions directed towards someone else, and putting other team members down. Patient care is optimized when everyone is working together; and your evaluations will reflect that you were enjoyable to work with (a big plus to any residency program reading a Dean’s Letter).

Do Create Your Own Plan. 

The most rewarding and educational aspect of internal medicine is analyzing multiple pieces of clinical information and applying them to create a differential diagnosis and treatment plan. While it may be easy to just ask your resident for his plan, it is far more rewarding, educational, and impressive when students create their own plan. Actively working through these clinical issues will further solidify your understanding of clinical medicine and help you take your education to the next level. And don’t worry about always being correct; your team will appreciate your effort and you can always learn from your mistakes.

Don't Sacrifice Your Clinical Education for Your Shelf Score. 

I’ve seen far too many students on the wards with their heads in a book, missing out on learning opportunities in front of them. There is no substitute for the practical experience you get caring for a real patient. Instead of reading case files while in the hospital or clinic, focus on resources like Up To Date and searching for information that can be applied to your patients. Clinical trials will rarely appear on your shelf examination, but reviewing relevant trials will help you better understand patient management and improve your own abilities in forming a diagnosis and plan. Finally, ask your residents to provide didactic teaching for important topics. This teaching can help integrate knowledge for the shelf with clinical practice.

Do Read

Even with a great clinical performance, a large part of your overall grade will come from your shelf score. Regardless of clinical responsibility, make time to study for the shelf throughout your rotation. Map out a study plan at the beginning of your rotation, taking into account busy call days or difficulty stretches in an ICU setting. Most importantly, use the right resources. Too many students turn to dense resources such as Harrison’s that are far too time consuming for a shelf exam. Instead, I recommend focusing on more concise texts such as Step up to Medicine and Case Files: Internal Medicine as well as question banks like MKSAP for students or USMLE World.

If you follow the above advice, you will surely have a more enjoyable time on your medicine clerkship and put yourself in the best position for success. Regardless of your interests, the rotation will surely strengthen your clinical abilities and prepare you for more active roles as a fourth year medical student and intern.

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Dr. Christopher Carrubba

Dr. Christopher Carrubba

USMLE Tutor & Senior Contributing Editor
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