Medicine Clerkship

Hi folks,
Medicine clerkship is generally your longest and in some cases, your most important third-year clerkship. It is during this clerkship that you will learn most of the practical information that will help you practice in any specialty.

Your main job as a junior medical student is to lessen the load of the team to which you have been assigned. This may take on many aspects such as obtaining a good history and physical exam, doing phlebotomy, tracking down radiographs and studies, keeping track of laboratory results, getting daily progress notes written and doing simple bedside procedures such as arterial blood gas sampling, starting IV lines, placing NG tubes and generally participating as much as possible in the total care of the patients assigned to you. The more that you participate in the care of your patient, the more you will learn.

1. Read everything you can on your patient’s disease and its process. This will help you anticipate problems as they arise and will help you learn to manage cases more independently.
2. Read about every medication that you patient is on both in hospital and outside the hospital. This will help you keep current on clinical pharmacology. Are there other drugs that might be a better fit your patient?
3. Try to be present if you patient has studies and procedures by interventional radiology, cardiology or gastroenterology. Nothing is better than seeing the original pathology or procedure. Learn to write a procedure note.
4. Learn the anatomy and proper placement techniques for: Central lines in the internal jugular, subclavian and femoral veins; arterial lines and Swan-Ganz catheters. Know your landmarks and ask to assist on these procedures.
5. Review your patient’s radiographs with your intern, resident or the radiologist often. Learn how to systematically read a chest radiograph. Look at every chest film in the same order so that you do not forget anything.
6. Learn how to insert a Foley catheter using proper aseptic techniques.
7. Learn differential diagnoses for: abdominal pain, chest pain, back pain, shortness of breath, fever of unknown origin FUO, anemia, fatigue, weight loss and syncope.
8. Learn how to work up: chest pain, pulmonary edema, shortness of breath, fever of unknown origin, gastrointestinal bleeding, anemia, rectal bleeding and change in mental status.
9. Know how to write general admission’s orders for patients: ADCVANDIMLS A-Admit; D-Diagnosis; C-Condition; V-Vitals;A - Allergies;A-Activity;N-Nursing; D- Diet; I-IV fluids; M-Medications; L-Labs and S-Special stuff. Ask your intern or resident to let you write admission orders on every patient that you can.
10. Learn how to do a good patient presentation to your resident and attending. Get your intern to go over your presentation before you present to the attending.
11. Learn how to write a good ICU progress note that is systems based. Learn your ICU parameters and indices.
12. Find a method of organizing your data and stay with it. Palm pilots, note cards, papers on a clip board and other methods are good but you have to be able to get your hands on your material quickly.
13. Read at least one hour each day and review on weekends. Try to cover a major topic per week such as cardiology, endocrinology, gastorenterology, infectious diseases, nephrology, hematology, oncology and rheumatology. Do some questions and case studies.

Good pocket books that I have found useful:
The Washington Manual (available for Palm)
Pocket Pharmacopaea (available for Palm)
Epocrates on Palm
Ferri Manual of Patient Care
Pocket Doctor

For lengthy reading:
Harrison’s Internal Medicine (the gold standard)
Cecil’s Internal Medicine
Hurst’s The Heart
Textbook of Intensive Care

Read the case resports and review articles in the New England Journal of Medicine. This material is often pimped on Medicine clerkships. Read at least the abstracts for the other articles in NEJM and JAMA.

Finally, enjoy yourself. You probably won’t be asked to stay later than 10:30pm on call nights and 5pm on other nights. Try to be a good team player and pitch in when things are busy. Don’t whine! Even if you hate internal medicine, don’t whine! Your evaluation is very subjective and is largely based on how helpful you have been to the team. The team includes: Attending, Chief Resident, Senior Resident, Intern, Acting-Intern and other Medical students.
Have fun and learn!

(Edited by njbmd at 11:32 pm on Mar. 25, 2002)

Thanks so much for the helpful info.
Phillip MS III
OMM Teaching Fellow

Internal Medicine – w/o a doubt, the most demanding (intellectually) clerkship of your third-year! The only one that will be more physically taxing will be surgery – but surgery does not drain the brain like IM does.
Let me describe the mechanics of my IM clerkship:
– You arrive in time to pre-pre-round on all of your patients, usually 2~4, but depends on the sr resident and how much you have impressed them…the better you perform, the more they will allow you to carry, up to a limit >>>> that meant I rarely arrived in-house later than 0600. You wirte tomorrow’s lab orders and any other routine orders you expect to need.
– after you’ve rounded (examined & written your daily SOAP note), you met with your intern and round on his/her & your patients - the intern helps you refine those orders you wrote and why you should/should not have written them
– on to morning report, where the folks from overnight call present a couple of patients in front of attendings, residents & students – at least 1 student presented each morning & if there was not a student on call the night before, the Doc leading rounds randomly chose one - you had to be prepared to not only present your patient thoroughly & succinctly, but be able to intelligently field questions about their disease process & treatment paradigms.
– after report, attending rounds…all of the patients on your team (Jr student, Sr student, intern & Jr/Sr resident + the attending) > for each patient, the team member caring for the patient gives a bedside bullet-point presentation, offers their insight and treatment recommendations, which the team them discusses. all of those orders you wrote are scrutinized, refined and usually added to…you learn much from your omissons.
– this took until lunchtime – lunchtime = lecture time (with the residents) while you eat
– after lunch, you chase the results from all of the tests & orders you wrote during the morning rounds…and you write additional orders in response to those labs – all of which must be co-signed by one of the interns, residents or attendings…lots of chasing folks down! One day/week, you’re in an outpatient clinic w/ your intern. This always makes you stay LATE, cause you have to chase those labs/orders AFTER the afternoon lecture.
15~1700 – another lecture, this time only with other students.
after 1700, IF all of your responsibilities are completed, and they will not be, you can leave…if they are not complete, you stay until they are done, which is usually 1800~1900.
Call Shifts
These are FUN!! Every 4 days, after the end of the day, as described above, your team goes ‘on call’. That means you handle all of the IM services admissions, follow ALL of the IM service’s patient who are in-house and handle many of the community Internists admissions and in-house needs until 0800 the next morning. SCHI’s IM service has 5 IM attendings, each with a team of students & residents, whose patients you are helping cover.
The first half of call is filled with admissions. Usually, you had an hour to hour & 1/2 to eat, pee and watch the news befor ethe fieworks started. At about 2000, the admissions faerie hit the ER and away you went! As a student, I averaged 3 or 4, sometimes as many as 5 admissions/night. I also would assist my intern with their admissions after I was capped. I chose to do more than I was required - there is a component to learning that simply requires volume & repetition.
Sleep? Yeah…right! On a great night, maybe 4 or 5 hours – VERY VERY RARE!!! The usual call night – 2 or 3 hours…and those nights from hell – ZERO sleep.
Oh…when you’re on call…you still have to round on your patients, write notes & orders BEFORE it’s time to meet your intern and pre-round. And, there was no go home after call. You simply started with pre-pre-rounding and went through the whole day again! It was not unusual to be up for 36+ hours w/o zero to 3 hours sleep.
Generally, our attendings are all young and easy to get along with…they had high expectations, but did not ever pimp you maliciously, unless you were lazy or a shithead >> then they’d nail your butt to the wall! After the little sleep, you said stupid stuff, got toungue tied and found things far more numorous than they actually were – our attendings never grieved us over this. They were too close to those days to be asses about it.
IM Docs tend to be creatures of minute details. They LOVE…no, they EXIST for decision tress and treatment algorithms…it is what makes them tick! They are some of the most knowledgable physicians I have worked with. They can cite studies from journals you did not know existed, apply them or choose not to apply them to the patient at hand. I was continually amazed at how they could take a case presentation and off the cuff work it into a 30 minute lecture complete with massive lists of differentials, empiric and specific treatments for each and how to norrow your focus – of course, in the most cost effective method possible. IM docs tend to be ‘thinkers’ and less ‘do-ers’. Where I am, there is a high-% of residents who went to school in the classic-British system in the Indian medical schools. Each of them is like a walking textbook of Internal Medicine!! I learned a TON from those guys.
All in all, very intense physically & emotionally – but a top-notch learning experience. It was during these 2 mos that I truly began to feel “doctor-like”. After IM, the work & expectations of the rest of my clerkships was not a problem & those included Surger, OB/Gyn, PICU, ER & Critical Care. Personality-wise, I could not ever be an IM doc. However, I have utmost respect for them and they knowledge they tote around in the knoggins. Under their fire was where I truly started transitioning from an old snot-jockey (resp terrorist) into a physician.