Internal Medicine

Last Updated: March 2014. Unlike any other clerkship, you actually have time to study (this may be true depending on your team's attending and how long they like to round for). Studying in this clerkship will be somewhat different from other clerkships. You will generally have time during the day to read on your own. (See "Books" table for specific advice.) This is true while you are at the hospital and VA sites. For the last 2 weeks you are usually outpatient, so expect an 8-6 schedule with significantly less time for studying.

One suggestion that I wish I had followed: The virtual cases assigned: "Simple Cases" are good, and a fine way to get started and see what you're in for. One reviewer felt that if they had been smart, they would have done all of them within the first month, including the assigned and unassigned. The cases are supposed to go over all the things you are supposed to know for the shelf, and besides that, give you some good strategies for how to present a patient, work up a new patient, and come up with the plan.

''Especially if this is your first clerkship, these cases actually give you a good feeling for what a perfect targeted physical exam would be (in an ideal world). I think they are invaluable, (and wish I hadn't just waited to do them all at the end of the rotation).''

Locations
PROVENA:

 The atmosphere at Provena has the reputation of being friendlier to students. The doctors are friendlier, the staff is friendlier, the atmosphere is more relaxed, and no one gets mad if you go into the doctors' lounge and get coffee and a bagel. There are some very friendly and helpful specialists in the cardiology/pulmonology clinic. The Christie teaching attendings are pretty great. And the best part is you get to have Dr. Collins lecture to you (story-time!!) once a week and evaluate your write-ups. Recently, call schedule was switched so that at Provena you are on call with your intern until 7pm every 4 days, including some weekends (normal days end at 4). You should only have to do one Saturday call and one Sunday call. Provena has three teams that you can be assigned to: they are all hospitalist teams as of July 2013 (there is no longer a Christie team). Typically, one student is assigned to each team, just as there is one intern and one senior on each. Each team carries a caseload of up to ~10 patients (this may change). If you make good with both the seniors and the interns, you will basically get to carry a few of these patients entirely yourself; you should aim to carry 2-4 patients yourself. I carried just one for the first few weeks, but immersed myself entirely in following their care. You will pre-round on them in the morning (how early depends on the team) usually starting around 6am once I got in the groove, or 5:30 when I first started. After prerounding, the day starts with sign-out rounds (presentation of patients admitted overnight, with the residents and sometimes an attending) at 7:00, then discussion of patients with the intern and senior followed by rounds at 8:30 or 9; depending on the attending, rounds can be over by 11:00 or last until mid-afternoon. A good strategy is to talk to your senior resident after you preround and before you round so that you can suggest your assessment/plan, or if you don't have one, ask them for help making one. Next you will present your SOAP to the attending. Some attendings let you get just a few sentences, others want an organized full SOAP, others will indulge you if you present it as such. I'm not sure what you'd have to do to dazzle them, but I'm sure you could make a bad impression in that amount of time.

In the past (via the unofficial guide), students worked 80+ hours at Provena, sometimes over 90. This just isn't the case anymore, although no one would stop you if you tried it out for fun. There were a few days when I stayed through with night float until near midnight, just to see what the nightfloat was like. This was interesting, and it was fun to do it just because I wanted to.

A big difference at the moment between Provena and Carle is that at Carle you write notes into the computer system- although unlike at the VA, they do not become part of the official record unless the residents or attendings use them. At Provena, there is a general suggestion that you could write up a note by hand and put it into the patient's paper chart co-signed. This seems sort of futile, but if you want practice writing notes then try it out and get an attending or resident to co-sign it. In the future, they may require this, but currently, notes do not seem to be a large priority. Some students had the opportunity to dictate notes with the help of residents. However, the computer system may change. Instead, you spend your time following your patient and helping to admit new ones. You can also watch some procedures, all you have to do is be in the right place or ask the right person. When my patient suddenly had to go for cardiac catheterization while I was in the middle of interviewing him, I was encouraged to follow along and watch the show.

CARLE:

The Carle rotation is very similar to the Provena in terms of format. 6 weeks of "hospitalist" duties in which you are assigned to a specific team (on your first day) and generally a specific resident/intern. Become the "best friend" of your intern and resident. Try hard to make their life easier and to contribute to the medical team. This will get noticed and will favorably be reflected in your evaluations--the resident and intern both fill them out but only the resident's is actually a part of your final grade. The better you can integrate yourself into your team the more you will get to see and the more you will learn--both by passive and active means.

Your day starts at 7AM during Morning sign-out rounds and then rounds with your attending usually start around 9AM (depending on the attending). It is probably not necesary to round on your patients before Morning Sign out; however, if you are a slow processor or still uncertain in your physical exam skills then pre-rounding on your patients before sign-out rounds might be needed in order to refresh yourself on your patients and examine them before rounds start. Many students find that they can arrive at 7AM for sign out rounds and have more than enough time to complete their responsibilities before attending rounds. '''It is also adviseable to review your patients with your intern and then your senior resident before attending rounds. '''That way you can be abreast to the latest plans. The further advantages are that you can learn a ton from your residents, you can "show what you know" and you can get a chance to practice the presentation before you actually do it for your attending.

You are required to stay until 4 PM or 5 PM. There is plenty of downtime during the day in which you can study. There are plenty of quiet places to plant yourself with the request from your resident that they inform you of anything happening with the patients on your team. The 5th floor near the call rooms is a great place with computers that is usually quiet with a Carle phone accessible near every computer workstation. The area requires a badge to enter and there are a lot of cupboards where you could put your books during the day so it is relatively safe.

There are lunchtime meetings nearly everyday and there is lunch provided at most, if not all, of them. Do your best to speak up, ask questions and answer questions whenever possible. You have the potential to be evaluated during these lunch time meetings and this could provide the better part of the balance of your time spent with Dr. Holley and/or other evaluators.

You are requried to be "on-call" (Untill 7PM) whenever your intern is and you are required to be at the hospital for one Saturday and one Sunday during the 6-week period at Carle. This could be variable depending on what you work out with your intern. If you are a part of the team and showing your willingness to work, you will have more leeway in working with your team in regards to your schedule. When you are on call you are supposed to respond to all "Codes" announced over the PA system. Go to the room, be there, be as close as you can, and stay out of the way. You can learn a lot by observation in these situations and the time for asking questions is after the situation has stabilized.

Most of the time the senior residents do more teaching than the attendings. The attendings Dr.s Awari and Kumar do a lot of very good teaching. Be teachable in all situations and find what you can learn from everyone, because as a 3rd year Medical student everyone has more clinical knowledge and insight than you do.

The final part of Carle is the write-ups and meetings with Dr. Holley. Dr. Holley is an important person in your evaluation; take these meetings seriously and try to be, "the best medical student you can be." The write-ups are very straightforward. They require a pedantic amount of detail (like tutorials amount of detail). Be prepared for it. 'Understand that the differential diagnosis and treatment plan are ESSENTIAL in the formulation of the grade. Don't just put in what your team did to the patient, rather take the time and write out what SHOULD happen in an ideal world. And provide any "updates" to the patient after the initial H&P and know what actually occured. ' There is a bit of advice that has floated around from students that it is important to show improvement in your write-ups so you "sandbag" your first one and attempt to do slightly less than your best work to show improvement. THIS IS A FALLACY! '''Do not do this! ''' If anything your first write-ups will be a lens to look at your others. Do yourself a favor and do your BEST work at the beginning, and if your work slips some, it will not affects you as trying to overcome a negative first impression. It may seem like obvious advice but when advice to sandbag is given from someone who is designated to provide advice it seems tempting. Don't fall into this trap.

Selecting patients for write-ups. The Unofficial Guide's position on how to effectively select a patient to use for your write up is best illustrated in the following rules.

 Don't choose a patient with ANY kind of kidney problem. Dr. Holley is a nephrologist and is VERY picky about the way that the patient's management, disease state and medical information are described. 

 Choose a young patient with few comorbitities. It is difficult to keep track of many problems and especially in the beginning when you are getting used to the format it can be detrimental to your grade. Younger patients with only one or two problems are ideal.

VA (Danville): 

 Danville is, in many ways, the Wild, Wild East. You are asked to be at Morning Staff Meeting at 8:00 AM and rounds start right after. If you want to pre-round on your patients (which is strongly advised) you would need to get there before then to collect needed information. Interdisciplinary meeting is later in the morning with all of the medical team working together. You then should study in the Resident's room until you are summoned for an admission. The day usually ends at 4 PM, you should not expect to get dismissed, you should let the attending on admission know that you are leaving. Medical students are to report to Dr. Lim. It is not anyone else. Dr. Jokela is the head of the clerkship so take what she says first and foremost and then in terms of the VA Dr. Lim is the next best person to listen to. You get out of it what you put in.

There are lots of opportunities to DO things. One reviewer spent every morning after their notes were done or before interdisciplinary rounds going over to the Surgical check-in and starting IVs in the patients who were coming in for surgery that day. Make friends with the friendly surgical nurses, let them know that you want to get good at starting IV lines and they will let you do as many as you want. The best part of the VA is getting to write notes into the computer and having lots of one on one times with an attending. Depending on your overseeing attending, you may get lots of feedback and babying directly from your attending, who looks over your notes before you sign them and makes suggestions), or you may write tons of notes on your own and discuss plans with the attending as you go. You have the ability to write orders and as you suggest to your attending tests, whether on rounds or in your assessment and plan that make any amount of sense, then they usually let you order them with them acting as cosigner. You can dictate D/C summaries (they MUST be dictated); it is fun to try practicing the skill. Finally you function at the level of an intern at the VA. You are directly responsible for your patients to your attending instead of having a resident you answer to. This helps you learn so much more. Afternoon lectures are variable. Often you'll read an Up-to-date article to you that they had asked you to read prior to lecture to prepare. Often you feel like asking them to "just leave you alone" so you can study to get ready for the shelf. The ride to Danville can begin to wear on you, but some students found it helpful to carpool and to quiz each other with UWorld, PreTest, or MKSAP questions to help increase the productivity of the drive.