For most third year medical students, the internal medicine clerkship is make-or-break — it’s where we get to flex our diagnostic muscles and probably where we get our first real taste of autonomy in patient care. Our performance here will be scrutinized by residency directors as they evaluate our fitness for their program.
The clerkship being as important as it is, it’s capable of manifesting a considerable amount of stress. The tips that follow are my best advice for reaching your full potential during this rotation.
Student, Know Thy Attending. This tip tops the list because at the end of the day, it’s the evaluations that matter, and you’ll be spending much less time with your attendings than you will with your residents. Pinpoint your attendings’ favorite topics, but also what I like to call their “blind spots” – you can’t possibly be proficient in everything, so get in the habit of prioritizing topics based on your current team. For example, one of my attendings loved to discuss antibiotic choices based on local resistance patterns, another expected me to know every medication each of my patients was on, and another was quite frankly obsessed with evidence-based medicine.
Be a Shot-Caller. As I mentioned, this may be the first rotation that truly affords you any sort of autonomy with regards to patient care. Your level of autonomy will be team-dependent, but even if you’re not consulted first when a plan is formulated, you should speak up and offer your own assessment and plan. When asked by the nursing staff if you’d like to hold Mr. Jones’ blood pressure medicine because he’s been running low, don’t shrug your shoulders and let the nurse call your resident, call them yourself and return with an answer. Being confident and proactive will help you stand out amongst your peers, and even senior students, but don’t overstep your role on the team, and never circumvent the chain of command.
Know Your Patients. Your residents will be carrying many more patients than you, and your attending is responsible for more still. That means they have less time to focus on (or recall) details about these patients. You should be the leading expert on all of your patients, such that your team calls you for clarifications or updates throughout the day. Know when their labs are drawn, be the first person to find the results so you can report them, and follow-up (or be present for) any important tests or procedures, if possible. If you’re checking on a patient and a consultant happens to be visiting, give them a quick run-down of the patient’s history and why your team placed the consult – they really appreciate it, and I can’t tell you the number of times I’ve had to re-consult a specialty because the reason for the consult was not effectively communicated.
Impact Patient Care. Making a true impact on the care of a patient will not only earn you a good evaluation, but is incredibly rewarding as the low man on the totem pole. As I implied earlier, don’t passively accept your team’s initial plan of care – they’re often hastily prepared, especially on busier services. Do your own research and look for ways to improve the care your team is providing – if what you propose is reasonable, your residents will be more than happy to help you by placing orders. Your ideas will be shot down more often than not, but when you nail this one, you’ll feel it.
Go the Extra Mile (at work). Whether it’s offering to run to the other side of the hospital to see if GI wrote that consult note or promising your resident you’ll figure out the difference between Rovsing’s sign and the psoas sign after you screw it up in front of them, act like you want to be there. Don’t shy away from responsibility, and always offer to do as much as you’re comfortable with (biting off more than you can chew won’t actually make you look like a hard worker).
Go the Extra Mile (at home). If you really want to find success in this clerkship, your job doesn’t end when you leave the hospital. You must, for your sanity, carve out time for yourself, but you should also be making time to study and read medical news & scientific literature. Your team will notice, and it will boost their confidence in you – plus, it helps prevent panic mode before the shelf exam.
Network. Please, don’t be one of those snobby medical students who treats floor staff like garbage because you’re going to outrank them someday (or think you already do). I’m fairly introverted, but at the end of my 8 weeks, I knew the consultants in most specialties, docs in the ED, respiratory techs, nurses, administrators, and janitors. I can’t overemphasize how important it is for you know who to ask for help, and if those people actually want to help you, your life will be made easier by a factor of ten. You don’t have to take anyone out to dinner, just say “Hi!” and thank them – you’d be surprised how miserably many students (and doctors) fail in this regard – and you will be rewarded for your effort to stand apart from them.
Final Advice. I was assumed to be the team’s fourth year medical student by several attendings throughout my clerkship — I don’t say this to flatter myself, but to share what I think is an excellent goal to have: don’t perform at your expected level, perform above it. You won’t always impress everyone – in fact, it’s more likely you’ll embarrass yourself most of the time (but that’s okay).
To summarize, your goals for this clerkship should be: 1) be confused for an MS4, 2) impact the care of your patients, 3) make your team(s) miss you. Of course, these tips are generalizable to your other clerkships, and I hope they provide guidance to anyone who’s feeling lost.
Internal Medicine Case Files – Get this book. Do a case or two a day, or a few each weekend, with the goal of completing it before your shelf exam. It’s not comprehensive, but is a great set of cases to have under your belt.
USMLEWorld – Go ahead and renew your subscription, it’s totally worth it. It’s unlikely you’ll actually be able to complete all of the internal medicine questions UWorld offers, but do a few each night and review them. It will not only help you better diagnose and care for your own patients, but will make your shelf exam less painful.
SDN Forums – I don’t use it much anymore, but the Student Doctor Network is a great resource to fall back on when you’re clueless about something – chances are, you aren’t the first person with that particular question, so search the forums before posting.