A Guide to Your First Clerkship: Internal Medicine
Stephanie Fosback & Harlan Gallinger
Before the First Day . . .
One of the most important things you can do to prepare for this clerkship is to come in well-rested, so take a few days before the clerkship begins to do something you really enjoy doing because the 12-week clerkship gets to be long. Pre-reading for this clerkship would probably not be of much value because you will have just taken USMLE step 1, and ICM II has spent the past year preparing you to succeed on the medicine clerkship! However, it would probably be helpful to purchase Doug Paauw's book before day one so you have something to read during the down time, and also a pocketbook of your choice for inpatient medicine management to help you with the differential diagnoses and plans when admitting your patients.
The schedules for the Seattle ward sites are e-mailed out before the clerkship begins and the first-half of the day is spent with the chief resident who orients students to the wards. It would probably be helpful before you begin to figure out how you are going to get to the site-walk, bus, bike, drive-on most days because if you are going to purchase a parking pass at Harborview you can do that the first day (for UWMC parking load up money on your Husky card and the VA is free). Learning the site's electronic medical record will usually be part of day one.
Having a pager for inpatient medicine is essential because you need to have a way for people on your team as well as nurses, social work, and others to reach you when they need to. Get a pager activated before starting your inpatient medicine clerkship. It seems that Cook Paging and Metro Call are the two options in Seattle. The previous classes had mentioned that Cook Paging does not work well at Harborview or UWMC, but most students in our class were happy with Cook Paging at both locations. Cook Paging works well at the VA and Children's as well. Metro Call pagers supposedly work better but were more expensive, a headache to obtain, and customer service was lacking.
Recommended Resources/Texts
For inpatient medicine: Pocket Medicine: The Massachusetts General Hospital Handbook to Internal Medicine by Marc S. Sabatine is probably the most used by the interns and recommended by fourth year students, but really just use what you are familiar with; also UpToDate and Guide to Internal Medicine by Douglas S. Paauw
For outpatient medicine: Doug Paauw's book, UpTo Date
For the exam: Doug Paauw's book, the outpatient cases on the website and imbedded within the lectures on the website
Other things that might be useful to carry: stethoscope, penlight, reflex hammer
Typical Schedule
Your typical day will be very site-specific, but at Harborview rounds started at 8 am and most students arrived between 7-7:30 am to pre-round on their patients. Pre-rounding usually consists of checking in with your patients to ask how they are doing/feeling, performing a focused physical exam, looking up their recent labs, and reading notes in CIS left by nursing, OT, PT, speech, and others as well as looking in the chart or ORCA for consult recommendation if any were requested. At the VA the electronic medical record "CPRS" is much better than Harborview or UWMC as everything is in one program rather than having patient information spread across three systems. (CIS-vitals, labs, medications administered, nursing, OT, PT, speech notes, social work notes; ORCA-inpatient notes, some outpatient clinic notes; Mindscape-radiology, future visits scheduled already, primary care physician, everything else.)
If you don't obtain your schedule before day one, then it might be wise to take things to spend the night because you might be on-call your first day. For inpatient medicine, you can wear scrubs the days you are on-call, otherwise you are expected to dress professionally on all other days. If you have questions just check-in with the senior resident who runs the team. Call is Q4 at UWMC and the VA and Q5 at Harborview. On non-call days, you are usually done with your ward work around 1-2 pm, but most days there are afternoon medical student didactics that are usually required. In addition there are morning resident report and lunch conferences that students are strongly encouraged to attend. Your schedule while on inpatient medicine is what your team's schedule is, meaning that if your team is on-call or post-call on a weekend day or holiday then you should plan to work, otherwise you are off. Plan for about 4-5 days off per month while on inpatient medicine and then most weekends off while outpatient. Your schedule and typical day for outpatient medicine are extremely site-specific and variable. In general outpatient medicine in Seattle is very slow and in WWAMI-land very busy.
Refer to the Absence/Time Off policy on the website for detailed information, but if you have to miss time for any reason, make sure that you have contacted your senior resident. If you know you have a wedding or family event that you must attend during your medicine clerkship, make arrangements with Kellie Engle in the student program office at UWMC. You can contact her at kaengle@u.washington.edu.
The Role of the Medical Student
Ah the most difficult task of the medical student...to find her/his role on the team. I think that you will find medicine is a clerkship that has a built in system to include every medical student. Your team will be made up of one to two interns (first year residents), a senior resident (either a second or third year resident), and an attending.
Ways to be especially helpful include teaching your team by reading up on your patient, answering questions that come up on rounds, and bringing in new articles that are pertinent to patients on your team etc. Remember that you can teach your team members new things, and you have the most time to spend learning. Other things that you as a medical student can do for your team include spending time with patients (you have more time than anyone), and managing what is happening with your patient (call consults, keep up to date on labs, get old records, call for an interpreter if necessary, and update sign out lists). Remember that you are a very valuable resource for your team...they want and need you there to help with patient care.
Assignments
On Medicine, the medical student is responsible for writing up every patient she/he admits to the team. The write-ups are comprehensive and should include everything you have learned in ICM (ID/CC, HPI, review of systems, PMH, family and social history, physical exam, and assessment/plan with discussion). Your attending will review your write-ups, (and so will other members of your team). Remember that every attending will want you to do things a little differently, and try to smile and adjust accordingly (even if the previous attending told you to do it differently). One thing that can be helpful with the write-ups is to have your senior resident (or intern) read it and go over the assessment/plan with you. It will give you insight into your plan, a wider differential, and will help you to make needed improvements before your attending reads it.
Finally, work on your differential and make it interesting. Try to put the most likely diagnosis first, and the least likely last. Use what you know about your patient already to defend why you think that one is more likely than another, and explain why your plan is going to help you determine or narrow the diagnosis. One key to creating a wider differential is to look things up. I like Up To Date for Medicine, because it is great for that specialty, but you can use whatever you like. First, try to come up with the things you have off the top of your head, but don't be too proud to look things up. And remember...get some sleep, you have to present tomorrow.
The Exam
The exam for Medicine is comprised of two parts, a written exam and three patient cases on the computer. Don't worry! It is a difficult but very fair test. The best study aid is the Internal Medicine Clerkship Guide. This is really all you need to do very well in Medicine. Try to read throughout the clerkship from the book and read more in depth (via articles or the web), about your patients. There are also some notes that were created by students in my class that are a shorter version of the guide and are great for studying. I will send these notes to your class this year, and the previous third years have them as well.
Evaluations/Feedback/Grading
Remember not to get too fixated on the grade. The goal is to learn...I mean it! Dr. Paauw and the medicine website go over the grading system for this clerkship, which is rather complicated. Evaluations, and both parts of the exam are included in your overall grade. What I recommend in order to do well is to ask for feedback early on, and use it to improve. Ask someone who you trust to give you constructive feedback, things you are good at and can improve upon. Do not fall into the trap of only asking the attending, because other members of your team can be very helpful! Overall, always show interest, work hard, and everything will work itself out.