Belly of the Beast: A Guide to Honoring the Internal Medicine Clerkship

Jul 09, 2020

Every year medical students around the country go through the Internal Medicine clerkship as part of their medical school’s required third year curriculum. Some students view it as a necessary evil, while others eagerly look forward to learning the essence of medicine. Regardless of where you fall on this spectrum, it is essential to excel in this clerkship as it provides the basic foundation for the rest of the third-year coursework. It also is often one of the longest clerkships of your third year. Your performance on this rotation is also often looked at by residency program directors regardless of what specialty you are applying for. Yes, this applies to the Ortho Bros out there as well.

Now that we have established why it’s important to do well, let’s get into the meat and potatoes. So, how do you actually get good evaluations, ace the shelf exam, and honor the clerkship? Well, thought you would never ask. LEGGO!

First and foremost, let's cover the overall mindset. Having the appropriate mindset is essential to planning, executing, and achieving results. You must desire to do well and try your best. I can’t stress how important this is. It follows the Law of Attraction. If you want to do well and believe in yourself, then you will do well! On the other hand, if you just go through the motions with the mindset of just trying to survive, you will attract the same subpar results. Another key component of the mindset is not getting discouraged when facing criticism or adversity. It’s a long rotation and at some point even the best students will encounter some type of hardship. Do not be discouraged; treat it like a mission. Get in. Get what you need. And Get Out.

Alright now that we have the frame of mind covered. Let’s begin with the actual execution. I’m going to break this down according to how most med schools give out final grades:

 There are two parts:

  1. Acing the shelf exam
  2. Getting Stellar Evaluations

The first part is more standardized - so I will begin with that and start in chronological order.

Before the rotation even starts, I recommend you read through the syllabus to get a sense of how you will be graded and a feel for the structure of the clerkship. If you don’t know where the net is, you can’t score.

Next it’s time to obtain the materials you will need to study and have them ready to go.

Resources

Subscription for UWorld STEP 2: this is going to form the backbone of your studying. There is a considerable amount of questions to get through (~2,000).

Step Up to Medicine (Book): this will basically be the First Aid reference guide for Internal Medicine. One can often find this for free laying around your medical school library collecting dust, left behind by your fellow fallen soldiers.

Medical Knowledge Self-Assessment Program (MKSAP): A smaller, but solid question bank made for the internal medicine clerkship. These questions are great if you are looking for additional questions or a warm-up to UWorld.

Do not use too many resources because you have limited time to study on the Medicine clerkship. You want to make sure you know the highest yield material inside-and-out. The trick is not how many resources you used, but how well do you know/can apply the material from the resources you did use. Just getting through the sheer amount of information from these resources alone will likely take up the entire amount of studying time you will have.

As per actually using these resources, I recommend using the Step Up to Medicine book just as you would have used First Aid for Step 1 Studying. It is your bible. Read it religiously. Read it when you have any down time. Several passes are ideal, but may be optimistic depending on the subspecialties you are assigned to. Understand the material first. Use Google and UWorld to supplement anything you don’t understand in this book. Learn the management algorithms for all the cardiac and respiratory conditions cold. This alone is essential. Finally, use the study techniques that work best for you. Two years into this game, trust yourself. Whether that means using Anki, highlighting, writing notes, or walking around the library talking out loud. (The librarian probably thought some of my classmates had sub-clinical schizotypal disorder at some point during STEP 1 dedicated month).

UWorld STEP 2 (Internal Medicine component) - It’s a question bank. You know the drill.

Now comes the more subjective and often frustrating part. How do you possibly get great evaluations from faculty and residents?

Let’s start with the factors in your control.

  1. Appearances: “Look good, feel good, get good evals” - is that how the saying goes? Well anyways, this is essential to making a good first impression whether you like it or not. Looking nice never hurt anybody. On the other hand, that stethoscope you haven’t cleaned in ages probably gave some poor guy in the ICU pneumonia.

  2. Interactions: Prim and Proper. That’s the motto. Countless sweet talkers have gotten burned by not following this rule. Be respectful of the power dynamics that are well established. Do not try to be buddy-buddy with faculty or residents, unless that relationship was already present before you joined their service. Instead treat everyone with the respect and the appropriate distance they deserve in relation to where you fit in as a medical student. There is nuance involved with this, think The Godfather movie. It is only normal to have a closer relationship with the resident than with the attending. Understand this and use it to your advantage. However, do not ever let your guard down. Always be professional and play your role as the medical student. Believe it or not, the one time you do let your guard down is when the resident will take notice. Everyone talks, so be nice to everyone - this includes but is not limited to: coordinators, nurses, PAs, and patients. Something about being confined in a highly stressful environment makes everyone gossip. Lastly, there have been countless times where I earned a good reputation by spending more time than usual chatting with a patient while pre-rounding in the morning. Later in the day, when the entire team would be rounding and walk into that patient’s room, that patient would tell the attending how nice I was to them.

  3. Performing: Do your job and do it well. Your job is being the medical student on the service.

On inpatient services:

  • Ask the resident the night before which patients you need to see for the next morning
  • Pre-round on all your patients
  • Have the newest labs ready for each patient as well as the labs that are being followed (CBC, BMP, cultures, troponin, CK, etc.)
  • Be organized (have the labs written or printed, take notes for each patient)
  • Perform a real History and Physical every time you see a patient (You know what I’m talking about). Listen to heart and lungs and do a basic abdominal exam on everyone (unless, the patient has a GI pathology, then do a more detailed exam) in addition to any other relevant exam (e.g., neuro, MSK, etc.)
  • Establish rapport with the patient (since you will most likely be seeing them multiple times)
  • Before it's time to round, make sure you know what diagnosis(es) is being treated and what the next steps in workup/management are. This is crucial. Always ask the resident just to make sure.
  • Practice your presentations in your head. Do a mental run through. Know the order of the information you will be presenting to the attending/resident. Perform the same presentation for the resident as you do for the attending.
  • Answer Pimp questions with humility: (Do not act like a know-it-all).
  • If you don’t know the answer. Admit that you don’t know the answer. So many students fail to do this and end up looking even worse.
  1. Do not compete with other medical students and do not try to make others look bad. This is just bad teamwork and very unprofessional.

  2. Before the rotation starts, introduce yourself to your team via email and find out when/where you have to show up. When the rotation is over, thank everyone you worked with in person. Tell them how much you enjoyed working with them and how much you learned. Send thank you emails if you cannot do this in-person.

On outpatient services: the same principles apply except your presentations will be shorter and less thorough. Do not break the flow of the clinic.

I hope this sheds some light on the Internal Medicine rotation. It is definitely one of the tougher ones to get through, but using these tips will definitely make it easier and allow you to perform your best.

About the author of this blog: Ronit Shah, M.D. is an Orthopaedic Surgery Resident at Temple University in Philadelphia, PA. Dr. Shah is also a co-author of the Principles of Clinical Biochemistry Textbook from DaVinci Academy.

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