Primer to the Internal Medicine Clerkship A GUIDE PRODUCED BY THE CLERKSHIP DIRECTORS IN INTERNAL MEDICINE JOEL L. APPEL, DO Wayne State University School of Medicine THOMAS M. DE FER, MD Washington University School of Medicine D. MICHAEL ELNICKI, MD University of Pittsburgh School of Medicine MARK J. FAGAN, MD Brown University School of Medicine SHIPHRA GINSBURG, MD University of Toronto Faculty of Medicine PAUL A. HEMMER, MD Uniformed Services University of the Health Sciences F. Edward Hébert School of Medicine WARREN HERSHMAN, MD Boston University School of Medicine WALTER N. KERNAN, MD Yale University School of Medicine TAYLOE LOFTUS, MD State University of New York Upstate Medical University PHILIP A. MASTERS, MD Pennsylvania State University College of Medicine K. PATRICK OBER, MD Wake Forest University School of Medicine SHALINI REDDY, MD University of Chicago Pritzker School of Medicine DEBBIE J. STEVENS Pennsylvania State University College of Medicine RAJIV SWAMY, MD University of Chicago Affiliated Hospitals Editor and Co-Author: ERIC J. ALPER, MD University of Massachusetts Medical School Co-Authors: December 2004
Transcript
Primer to the InternalMedicine Clerkship
A GUIDE PRODUCED BY THE CLERKSHIPDIRECTORS IN INTERNAL MEDICINE
JOEL L. APPEL, DOWayne State University
School of Medicine
THOMAS M. DE FER, MDWashington University
School of Medicine
D. MICHAEL ELNICKI, MDUniversity of Pittsburgh
School of Medicine
MARK J. FAGAN, MDBrown University
School of Medicine
SHIPHRA GINSBURG, MDUniversity of Toronto Faculty of Medicine
PAUL A. HEMMER, MDUniformed Services University
of the Health Sciences F. Edward Hébert
School of Medicine
WARREN HERSHMAN, MDBoston University
School of Medicine
WALTER N. KERNAN, MDYale University
School of Medicine
TAYLOE LOFTUS, MDState University of New York Upstate Medical University
PHILIP A. MASTERS, MDPennsylvania State University
College of Medicine
K. PATRICK OBER, MDWake Forest University
School of Medicine
SHALINI REDDY, MDUniversity of Chicago
Pritzker School of Medicine
DEBBIE J. STEVENSPennsylvania State University
College of Medicine
RAJIV SWAMY, MDUniversity of Chicago
Affiliated Hospitals
Editor and Co-Author:ERIC J. ALPER, MD
University of Massachusetts Medical School
Co-Authors:
December 2004
1. Find out what your preceptors expect of you. Meet and try toexceed their expectations.
2. Go the extra mile for your patients. You will benefit as much as they will.
3. Go the extra mile for your team. Additional learning will follow.
4. Read consistently and deeply. Raise what you learn in your discussions with your team and in your notes.
5. Follow through on every assigned task.
6. Ask good questions.
7. Educate your team members about what you learn wheneverpossible.
8. Speak up—share your thoughts in teaching sessions, share youropinions about your patients’ care, constructively discuss obser-vations about how to improve the education you are receivingand the systems around you.
9. Actively reflect on your experiences.
10. The more you put in, the more you will gain.
Be caring and conscientious and strive to deliver outstanding quality toyour patients as you learn as much as you can from every experience.
2
Top 10 Ways to Excel on the InternalMedicine Clerkship
Welcome to your internal medicine clerk-ship. We are genuinely delighted to haveyou join us for this short period. On the
clerkship, you will likely only get a small glimpse intothe world of internal medicine. Nevertheless, throughthis experience, we expect that you will acquire fun-damental skills, reinforce and expand your knowl-edge, and develop personally and professionally. Wehope that this experience drives you to want to learnmore and experience more of what internal medicinehas to offer. We wish you the most exciting, stimulat-ing, rewarding, and transforming experience possibleover the upcoming weeks.
The information in this booklet has been produced bythe collaboration and consensus of internal medicineclerkship directors across the country, most of whomhave spent many years teaching, evaluating, and advis-ing students. Additionally, a substantial component ofthis book has come from insights of students whorecently completed their clerkship. We try to pro-vide the most generic, common, reliable, “tried andtrue” approaches to the clerkship. We hope that thisguide will provide you with knowledge and perspec-tive that will last you well beyond your internalmedicine clerkship experience.
It is important to note that information provided byyour clerkship director should take precedence overthe suggestions that you find here.
TABLE OF CONTENTSGoals for the Clerkship 4
How to Learn Most Effectively on the Internal Medicine Clerkship 5
Suggestions for Success in the Inpatient Setting 7
Suggestions for Success in the Ambulatory Setting 14
Professionalism 17
Conclusion 19
Appendix 1: If you are Thinking about Internal Medicine 20
Appendix 2: Basic Clinical Definitions 23
Appendix 3: The People with Whom You Will Work, Interact, and Learn during Your Internal Medicine Clerkship 25
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Introduction
Disclaimer—Any reference to a product in this book does not imply any endorsement of the product by CDIM or the editor andauthors. Product references are only included to provide examples of resources and are not meant to be exhaustive lists of available material.
The primary focus of the clerkship is toincrease your capacity to function as a car-ing, increasingly independent but super-
vised clinician on an interdisciplinary team.
For the specific goals of your internal medicineclerkship, consult the material your clerkship direc-tor has provided. Many clerkship directors use the
national Clerkship Directors in InternalMedicine/Society of General Internal MedicineCore Medicine Clerkship Curriculum for the clerk-ship. You can access this guide at www.im.org.
In seeking to achieve the goals of the clerkship, webelieve it is important for you to understand whatinternal medicine is and the ideal internist. Internalmedicine is, in the broadest sense, medicine for adults.It is the largest specialty by far. It is a major part of theoverall landscape of medicine. It spans adolescence tothe ever growing elderly population. Practitionersinclude primary care general internists, who see adultswho may present with any problem at all. All infor-mation goes back to and through them. Internal med-icine also include subspecialists such as cardiologists,nephrologists, oncologists, critical care physicians, andmany others who focus on care of patients with specif-
ic disease types or single diseases (see Appendix 1 foradditional details). Many subspecialties of internalmedicine are heavily procedure based.
An internist’s practice may be mostly office-based orhospital-based. The internist coordinates the care ofthe whole patient, working in concert with col-leagues, values a strong patient-doctor relationship,and applies the best scientific evidence. Theinternist is the clinical problem-solver who is able tointegrate pathophysiologic, psychosocial, epidemio-logic, and “bedside” information to address urgentproblems, manage chronic illness, and promotehealth. Internists frequently participate in research;many teach students and residents.
BASIC PROFESSIONALEXPECTATIONS➾ Attend all clerkship activities on time. If you
must be absent, get permission in advance.
➾ Dress professionally. The way you dress makes astatement about your school, hospital, and themedical profession; it may influence the way thatyou are perceived by your patients. If you haveany question about what constitutes professionaldress, consult with your clerkship director.
➾ Treat every member of the health care team, theclerkship team, and every patient with respect.
➾ Answer your pager and email in a reasonabletime frame.
➾ Make sure your handwriting is legible and ensureevery note includes your name, role, and pager.
➾ Preserve confidentiality—do not discuss patientsin public places and destroy all papers withpatient specific information that are not part ofthe medical record. Do not look in the chart(paper or electronic) of any patient for whomyou are not caring.
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Goals for the Clerkship
“An internist is a physician
who can embrace complexity
yet act with simplicity.” Louis Pangaro, MD, Vice Chair for
Educational Programs, Department of
Medicine, Uniformed Services University
of the Health Sciences.
Most learning will take place outside ofthe classroom, through experiences withpatients and interactions with your
team. While you may be offered a series of lectures,the bulk of your learning needs to be self-directed.It is essential that you read regularly to answer thequestions you encounter each day. Take responsibili-ty for your own education. Make sure that throughyour reading, experiences, and didactics, you meetthe goals of the clerkship.
➾ Understand and clarify, if necessary, the expecta-tions your residents, attendings, and coursedirectors have of you.
➾ Keep a list of questions that arise during yourday and seek the answers.
➾ Be an active participant in your patients’ care.Be the “go to” person for all your patients. Eachproblem or question that arises is an opportuni-ty to learn.
➾ Be a “team player”—be available to help allother team members, including other students.Be around—do not expect your team to findyou when something important is happening.Although you may not always recognize it, youare an integral member of the team. Do notunderestimate your importance. Knowing whereyou fit in and acting the part is very important.As a junior member of the team, it is generallybest to be malleable and “go with the flow” ofyour team. However, if you have an importantquestion or concern, it is equally important that
you (and every other member of your team) askthe question or express the concern. Your state-ments will often result in a valuable contribu-tion to the education and work of the team andto patient care.
➾ Try to be observed and solicit feedback on a reg-ular basis, both positive and constructive.Constructive feedback is essential to yourgrowth in your third year, as it is for all of us.
➾ Learning moments may come when you leastexpect it. Pay attention at all times, even whenthe focus is not on you or your patient.
➾ Strive to practice evidence-based medicine. It isour responsibility to bring the best scientific evi-dence to every clinical decision that we make.Use evidence-based clinical practice guidelinesand standard order sets whenever possible andlearn from them.
➾ Demonstrate that you are a self-directed learner;read during the medicine clerkship. Your educa-tion will depend on it.
➾ Learn from your patients whenever possible.Read about all of your patients in depth. Thegoal is to integrate your basic science knowledgeand its application to your patient.
It is important for you to gain broad knowledgeabout the spectrum of medical illnesses as it may beimpossible for you to see patients with all condi-tions about which you need to learn during yourclerkship. Follow a structured reading program. It ishelpful to have an overview textbook of medicine,
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How to Learn MostEffectively on the InternalMedicine Clerkship
one which you can read in depth, ideally from coverto cover, over the course of the clerkship (examplesinclude Cecil Essentials of Medicine, Pauuw’s InternalMedicine Clerkship Guide). A textbook of medicineis recommended for most patient-related reading(Harrison’s Principles of Internal Medicine or CecilTextbook of Medicine). Your clerkship director canprovide specific recommendations about whichbooks and resources are preferred locally.
Students also need additional resources to read ingreater depth; review articles from the literature orelectronic resources are good resources to access. Youwill also want to have access to small texts for rapidreference (on bedside rounds or in the emergencydepartment, for example). The Washington Manualof Medical Therapeutics is invaluable for formulatingtreatment plans and writing orders. Ferri’s Care ofthe Medical Patient and The 5 Minute ClinicalConsult also serve this function. These books can bepurchased for PDAs for slightly more than the printcounterparts (www.skyscape.com has many titles).However, they will not be adequate for helping youunderstand differential diagnosis, pathophysiology,etc. When it comes time to prepare for the clerkshipfinal examination, many students use MKSAP forStudents, an excellent resource produced by theAmerican College of Physicians and the ClerkshipDirectors in Internal Medicine, consisting of ques-tions with detailed explanations.
UpToDate is an excellent electronic resource for spe-cific clinical questions. However, it will be less valu-able for overview reading of larger clinical topics (anoverview of congestive heart failure, for instance).Additionally, the Internet provides access to anenormous library of medical information as a rapidreference. It is always a good idea to start at yourschool’s library website.
Students should be self-directed learners and sharewhat they have learned with their colleagues. Thispractice of continuous, ongoing learning will benecessary throughout your career. When you read,consider preparing a single-page summary; be pre-
pared to present this synopsis to your team. Youshould do at least one topical presentation per four-week rotation. If your attending or resident does notassign you a topic, pick a clinical subject that inter-ests you and is relevant to at least one of the patientson your current team. If you are having troublechoosing a topic, ask for help from your attendingor resident. If you have been given a specific topicto research, do not be afraid to ask for guidance. Aconcise summative handout is a nice touch.
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Your job in the inpatient setting is to caremeticulously for the limited number ofpatients you are assigned, while at the same
time learning as much as you possibly can. At times,service and learning may be at odds but generallyspeaking they coexist quite well. It is useful to recog-nize that the faculty and house officers you work withare attempting to balance competing demands as well.
➾ Actively and enthusiastically participate inrounds. (See appendix for definition.)
➾ Demonstrate effective organizational skills.
You will learn more, have more fun, contributemore to patient care, and be less stressed if you keepyourself, your schedule, and your patient informa-tion organized. It will come as no surprise to youthat being a doctor is a very hectic business. There isa lot to remember. Start training yourself to beorganized now!
➾ Carry a calendar and mark all conferences andcall days right away.
➾ Develop a system for keeping patient data andtasks at your fingertips (note cards, fill-in-theblank templates, PDA).
➾ Have information about your patients immedi-ately available (e.g. vital signs, laboratory data,diagnostic studies, medications).
PERFORMING INPATIENT HISTORYAND PHYSICALSYou will usually have new patients assigned to youon call days. Your initial interaction with them willgenerally consist of performing a complete historyand physical examination (H&P). Yours should be
the most thorough assessment of the patient.Thorough does not automatically imply long! Beingconcise without sacrificing thoroughness is animportant skill. It is not at all unusual for the med-ical student to be the only one who obtains a crucialpiece of information that substantively changes themanagement of the patient.
➾ Perform as many H&Ps on your own as possible.
➾ The H&P should be thorough yet focused. Thedifferential diagnosis for the patient’s problemsshould drive what you ask and what you perform.
➾ Begin with open-ended questions first then nar-row down to more specific questions as necessary.
➾ Gather a complete social history and review ofsystems.
➾ While examining your patient, strive to proceedin a logical sequence that maximizes time effi-ciency and minimizes patient discomfort. Theold-fashioned head-to-toe method still workswell for the large majority of patients.
➾ A focused exam is rarely a single system. Forexample, for a patient with shortness of breath,one needs to examine the neck for jugularvenous distention, the extremities for edema,tenderness (DVT?), and clubbing, the abdomenfor splinting or masses…in addition to thelungs and heart.
➾ Perform examinations like funduscopic exams,rectal examinations, male and female GU exam-inations (chaperoned) whenever possible toimprove your comfort and to learn to distin-guish normal from abnormal.
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Suggestions for Successin the Inpatient Setting
THE WRITTEN HISTORY AND PHYSICALOne of the major goals of the internal medicineclerkship is for you to learn how to communicatemedical information and your assessment via thor-ough, well-developed medical documentation.Writing H&Ps is an important skill and learningtool. Think of writing your H&P as a means for inte-grating all of the information you gather with whatyou know and what you read to form a coherent,informed argument of what you think is happeningwith the patient, why, and what you want to do.
There are many different ways of doing preparingan H&P, and you should be open to suggestions. Besure to carefully review any specific guidelines forwritten H&P provided by the clerkship. Eventuallyyou will develop your own style, but, for now, stickto the stated expectations.
➾ Use a clear and concise writing style. Words thatare not completely necessary are often left outJust the facts.
➾ Write your history of present illness (HPI) totell the story chronologically and with all rele-vant details. When reading your HPI, the readershould be able to determine the diagnostic pos-sibilities that you are considering and what ismost likely.
➾ Write in a way to identify information you for-got to gather. Go back and get the informationyou need.
➾ Document a thorough past medical history andcomplete medication list. This step is essentialto providing safe, high quality care, even thoughyou may not always recognize why.
➾ Document general appearance and vital signs.Vital signs are vital.
➾ Use only standard and widely accepted abbrevia-tions; creative abbreviations confuse and slowthe reader.
➾ Never use dangerous abbreviations in the med-ication section (e.g., qd instead of “daily,” _ginstead of mcg, U instead of units, etc.). Acomplete list of abbreviations prohibited by thehospital at which you rotate should be availableto you.
➾ Include laboratory data and results of diagnos-tic studies after the exam. Do a complete ECGreading and document specific findings (orlack thereof ) from radiologic studies (e.g.,“CXR-no infiltrate or edema” is better than“CXR negative”).
➾ Write neatly. If no one can read what you havewritten, what good is it?
The assessment and plan (A/P) is always the mostchallenging and important section. You may want todiscuss your thoughts with your resident beforebeginning to write. It is important to develop acomplete, well-considered problem list for yourpatient. List all active problems in order of descend-ing importance. Each problem should be consideredas you write your assessment and plan. For eachproblem, what will ideally follow as your assessmentis a differential diagnosis for the problem (whenappropriate), a statement demonstrating under-standing of underlying pathophysiology, and a diag-nostic and management plan.
Do not use systems (e.g., respiratory, cardiac) as theheaders for discussion in your A/P, regardless ofwhat your resident may tell you. The “risks” ofusing this approach are that one problem mayinvolve multiple systems (e.g., chest pain), andpatients may have multiple problems with a singlesystem (e.g., COPD, pneumonia, lung nodule). Aproblem-based approach is generally much moreeffective and appropriate.
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In some cases, the problem will be a symptom(abdominal pain); in other cases, when a diagnosis isestablished by the data you have already collected, itwill be a diagnosis (pancreatitis). For example, theheaders for your discussion in the A/P would be:
Correct Incorrect
Chest pain Cardiac
Pneumonia Infectious Diseases
Lung Nodule Oncologic
BUILDING DIFFERENTIAL DIAGNOSESBelow are some common strategies utilized in gener-ating a differential diagnosis. You will find that aparticular strategy is more logically applied to someproblems than others. You may also find that yourway of learning is better suited to a particular strate-gy. You are encouraged to try the strategies listedbelow. Watch how your resident, attending, andother teachers utilize these strategies in approachingdifferent clinical problems.
The Simple ListThis consists of a short, memorized list of the possi-bilities. When the list is short and there is no otherlogical way to categorize the list, it is probably themost effective strategy. How short is short? Five orshorter for most of us.
EXAMPLE: What ingested substances cause ananion gap acidosis?
Aspirin, methanol, ethylene glycol, paraldehyde.
The Mnemonic DeviceThis is a device used to remember a somewhatlonger list which does not lend itself to a more logi-cal sub-categorization. If you can utilize a strategythat is based on pathophysiology or anatomy, it willserve you better than a mnemonic in the long run.
EXAMPLE: What is the differential diagnosis for ananion gap acidosis?
The Systems ApproachThe list is based on the underlying mechanisms ofthe disease process in question. A complete listingwill include all of the following systems:
Degenerative: Ankylosing spondylitis (achronic degenerative disease ofthe spine that is occasionallyassociated with fever)
Endocrine: Thyrotoxicosis, pheochromo-cytoma
?? Psychogenic: Factitious fever
Of note, many diseases can be placed in multiplecategories.
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The Diagnostic TemplateA diagnostic template is essentially an outline of aclinical problem structured according to medicalconcepts. In short, it is a way to think like a doctor.You can think of it as setting up a branching tree.Each branch can be considered (or ignored) basedon a readily ascertainable clinical fact. There arethree major advantages to the diagnostic template:
1. You are thinking medically, not just relying onyour memory banks. Therefore, you can go back tothe first principles and rebuild the template in yourhead if simple memory fails you (and it will at somepoint).
2. Once you have constructed a diagnostic templatein your mind for a particular clinical problem, youcan recall and recreate it any time that the problemarises in other patients.
3. Because it is based in medical thinking, it notonly helps generate the differential diagnosis, butorganizes your diagnostic approach as well.
EXAMPLE:
Pattern RecognitionDiseases and syndromes are distinctive patterns ofclinical findings. Pattern or cluster recognition con-sists of choosing the chief points in a clinical sce-nario, connecting them, and associating them with aknown disease or syndrome. Pattern recognition is avaluable skill. This tends to be the approach takenby experts. It does have important limitations:
1. If you do not pick out the “correct” cluster offindings, you may miss the diagnosis or makean incorrect diagnosis.
2. Patients may have many problems, and the keypoints may be buried.
3. Knowledge base and clinical experience limitpattern recognition. If you do not know thepattern, you cannot recognize it.
Trying several different clusters in a given patientcan minimize all three limitations. Make sure youhave a detailed history for each problem and thinkabout each problem independently.
EXAMPLE: A 58-year-old woman presents withpleuritic chest pain, shortness of breath, cough,fever, and right lower leg swelling and redness. Howcan these symptoms be clustered?
Pleuritic chest painShortness of breath Pulmonary EmbolusUnilateral leg swellingPleuritic chest pain
Pleuritic chest painShortness of breathCough PneumoniaFever
At this point, you should return to the moredetailed data to see how well it fits with one ormore of these diagnoses.
In your discussion, a list of differential diagnosticpossibilities is not sufficient. Do not simply quote atextbook. You must articulate why you think thatpatient has specific diagnoses, citing data from thehistory, exam, and studies that support yourthought process.
THE ORAL PRESENTATIONYou will hopefully be doing presentations regularlyover the course of the clerkship. For example, youwill usually present your patient to your attendingand the rest of the team the morning after admission.This is an essential means of communicating infor-mation about patients. Presentations often make stu-dents anxious. Remember, “practice makes perfect.”
The degree of thoroughness, the length of the pres-entation, and the content that you include willdepend upon the audience to whom you are pre-senting. Generally, HPI makes up 30 to 50 percentof the total presentation and is chronological, atten-tive to detail, and inclusive of pertinent positivesand negatives. In the past medical history, majorongoing chronic medical problems should be sum-marized succinctly. Medications and allergies are
always presented. The social history, family history,and review of systems can usually be compressed. Ifthe information is key, it should probably be inHPI. Your exam should be orderly and include allthe pertinent positives and negatives. Labs should bepresented in an edited fashion (i.e., only abnormalvalues or normal values that are crucial to the diag-nosis or excluding diagnoses).
Your assessment should include a brief discussion ofthe major problem(s), differential diagnosis of thatproblem, which diagnosis is most likely and why(using the data you have just presented), and theinitial diagnostic and therapeutic strategy. If youhave done additional reading or research, presentthat information concisely afterwards.
➾ Ask your resident or attending if you are uncer-tain about how much information to give.
➾ Practice! You may want to rehearse your presen-tation in advance.
➾ “Tell the story” with minimal reference to notes.Do not read off a photocopy of your H&P.Have reference materials available if necessary.
➾ Strive for five minutes; most listeners will beunable to attend for more than 10 minutes.
➾ Answer questions to the best of your ability andpick up right where you left off. It is good ifpeople ask you questions. If no one asks ques-tions, you talked too long
➾ Do not improvise information if you are notsure. If you do not know the answer to some-thing that you are asked, it is OK to say you donot know.
➾ Remember that the listener is creating, prioritiz-ing, and re-prioritizing his/her own differentialdiagnosis based on what you say.
➾ Remember that style counts! Your presentationshould be tightly organized, smooth, persuasive,and confident.
Your attending may interrupt your presentation toprobe you or the team to consider additional infor-
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mation which might be relevant. Also, do not besurprised if your attending stops you after the diag-nostic studies to teach.
ADDITIONAL SUGGESTIONSCommunicate effectively with patients and theirfamilies.
➾ You have the ability to make an importantimpact on the care and experience of yourpatient. You will likely spend more time withyour patients than other members of the team.Your patients may see you as their primaryprovider, in effect, as “their doctor.”
➾ Spend additional time learning about who yourpatient is—understand their social, economic,personal background, and values. In otherwords, who is the person before me?
➾ After diagnostic and therapeutic plans have beenformulated with the assistance of your residentand attending, return to the bedside and discussthem with your patients.
➾ Feel free to have personal and emotional discus-sions with your patients. You will have the abilityto comfort your patients during times of anxietyand fear. You will likely benefit from these discus-sions as much as your patients. Some sensitivediscussions, like disclosing very bad news, shouldbe conducted by more senior members of theteam, but you can still be available to provideadditional information and support to the patientand family once this information has been pre-sented. Discuss with your team and attending.
Show competency with patient care responsibilities.
➾ Be fully prepared and on-time for work roundseveryday and have all pertinent data available.Have a daily plan for each of your patients.
➾ Take the lead in talking with your patients dur-ing work rounds.
➾ Try to be the first one to get the important
pieces of information about your patients.
➾ Have all notes and orders promptly co-signed.You may want to carry order sheets with you onrounds—discuss this strategy with your team.
➾ With the guidance of your resident, contact andcommunicate with all consultants.
➾ Participate (including just watching) in as manyprocedures as possible, even if you are not fol-lowing the patient.
➾ Try to accompany your patient to any diagnos-tic evaluations that occur during the hospitalstay.
➾ Write admission orders on all patients that youadmit. (Even if the intern has already completedthis task, it is a very instructive to write yourown.)
➾ Assist your interns with cross-coverage.
➾ Learn about the other patients on your team.You should have at least a basic understandingof what is going on with all the patients on theteam.
➾ Pitch in and be of assistance to your residentand intern when your other responsibilities aretaken care of. However, you should not do thisto a degree that interferes with your self-directedlearning.
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The role of the student in the ambulatorysetting is usually more hands-on than inthe inpatient setting. You will often be the
first person to acquire a history from the patientbefore they have been subjected to other interviews.The most important skills for success in the ambu-latory internal medicine setting are efficiency,organization, the ability to think on your feet, anda solid knowledge base. A successful ambulatoryexperience will help you acquire skills you will usethroughout your career.
Patients see physicians in general medicine or primarycare clinics to get a “general check up” or for specificcomplaints. You may see new patients who present toestablish themselves with a primary care physician (i.e.no chief complaint), patients with an acute complaint,or patients with chronic medical problems requiringclose and frequent follow-up. You may be workingwith one general internist in one-on-one sessions.
SUGGESTIONS FOR WORKINGWITH YOUR PRECEPTORWhen you first meet with your preceptor (thephysician you will be working under), it is impor-tant to establish several things:
Logistics➾ General information about how the clinic is set up.
➾ What time clinic starts and when you should arrive.
➾ How do you know when a patient is ready foryou to see?
➾ Will the attending pick specific patients for you?
➾ Where should you document your note? Howdetailed should it be?
Degree of independence ➾ Will you be shadowing the preceptor? If so,
does the attending want you to ask any ques-tions or just observe?
➾ Will you be seeing and examining the patiententirely on your own and then presenting to thepreceptor? Sometimes the attending will ask youto collect the history and then conduct the exami-nation together. (It is recommended that thethird-year clerkship ambulatory experience shouldnot be completely shadowing; students shouldindependently interview, examine, and assesspatients a substantial proportion of the time, priorto seeing the patient with the preceptor.)
Organization of a patient’s visit➾ How detailed should the physical examination be?
➾ How much of the exam do they want to dotogether?
➾ How much time is allotted for you to take the his-tory, conduct the exam, and present the case?
➾ How are test results communicated to thepatient? How should you follow-up on testresults?
In the outpatient setting, timing and efficiency areespecially important. Because patients are scheduledfor specific times, there is less flexible time than in
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Suggestions forSuccess in theAmbulatory Setting
the inpatient setting. When a patient requires, forexample, 20 minutes more than allotted, thatmeans the preceptor is 20 minutes behind for allpatients that follow, unless time is made up withother patients. Some preceptors have a greaterpropensity and a greater tolerance for runningbehind, and this may vary with the day (if yourpreceptor needs to attend a meeting or pick up achild at daycare). Office-based preceptors generallyrecognize that having a student in the office usuallyadds some time to their day. Nevertheless, studentsshould be sensitive to their preceptors’ efficiencyand time demands, so that you will be able to helpyour preceptor meet personal and professional obli-gations as you meet yours.
SUGGESTIONS FOR THEOUTPATIENT VISIT
New patients/annual “check-ups”The structure of the new patient visit will vary ingeneral and subspecialty clinics. Overall, youshould collect an HPI if the patient has a chiefcomplaint. If not, collect a past medical/surgical/gynecological and psychiatric history asappropriate; inquire about medications, drug aller-gies, family history, and preventive health. The lat-ter is of particular importance in the primary careclinic. You should ask about vaccination status,screening, vitamins, and alternative therapies.
Follow-up clinic visitsOutpatients frequently do not have a chief com-plaint—they frequently have multiple complaints.As follow-up clinic visits are generally brief, onemay not be able to cover all the patient’s concerns inone visit. Your job is to set an agenda with thepatient that covers their most significant concerns aswell as yours.
What follows is a suggested structure for the outpa-tient interview:
1. Prepare: Find out what the patient’s medicalproblems are by reviewing their chart or dis-cussing their history with their physician.
2. Negotiate an agenda: a. Ask the patient what their concerns are.
b. Prioritize concerns by the problems that aremost concerning to you and to the patient.
c. Tell the patient your agenda; most frequentlythis will involve establishing the status ofchronic medical problems. “Dr. Smith tellsme you have high blood pressure and dia-betes. How are doing with your blood pres-sure and blood sugars?”
d. When the patient has more concerns thancan be covered, let the patient know that youwould like to hear more about those con-cerns during their next visit. “Let’s talk somemore about your chest pain and hyperten-sion. I’d like to hear more about your kneepain. Since we have a brief visit scheduledtoday, can we cover that in more detail whenI see you next?”
3. Gather the data: a. Conduct a focused history with targeted
review of systems. For example, in a patientwith diabetes, you may want to ask aboutpolyuria and polydipsia.
b. Perform a targeted yet appropriately thorough physical exam.
4. Collect your thoughts:a. What are the major issues?
b. What are the most likely differential diagnoses?
c. Do you have time to quickly read up on yourpatient’s complaint?
d. What is your plan?
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5. Present the case:a. Identify the patient: “Mr. Smith is a 50-year-
old man with hypertension and diabetes who presents for a routine three month follow-up.”
b. Review the agenda: “In addition to reviewinghis chronic medical problems, the patientalso wanted to discuss left knee pain.”
c. Present the problem list:
i. Knee pain: “The patient has had kneepain for 6 months. It is worsened by …”
ii. Diabetes: home blood sugars average, low-est reading was, highest reading…last eyeexam was…foot care, etc.
iii. Hypertension.
iv. Health maintenance
d. Present the physical examination.
e. Present your assessment: “ Overall, Mr.Smith is doing well. His diabetes and hyper-tension are adequately controlled. The differ-ential diagnosis for his knee pain isosteoarthritis, gout, and pseudogout. I thinkit is most likely…”
f. Present your plan:
i. For his knee pain, X-rays will help to con-firm the diagnosis of OA. He can tryTylenol for the pain. We should avoidNSAIDS in diabetic patients if possible.
ii. For his diabetes, check hemoglobinA1c…etc.
iii.For his hypertension…
iv. For his health maintenance…
g. Discuss follow-up appointments and referrals.
6. Follow through: check test results and commu-nicate these with the patient as arranged withyour preceptor.
Another “learner-centered approach” to the presen-tation would be to use the SNAPPS model:
Summarize briefly the history and findings.
Narrow the differential to two or three relevant pos-sibilities.
Analyze the differential by comparing and contrast-ing the possibilities.
Probe the preceptor with questions about uncer-tainties, difficulties, or alternative approaches.
Plan management for the patient’s medical issues.
Select a case-related issue for self-directed learning.
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The development of professionalism is anexplicit and important goal of your clerk-ship. In 2002, the American Board of
Internal Medicine Foundation, American College ofPhysicians Foundation, and the EuropeanFederation for Internal Medicine wrote a charter onprofessionalism that has gained widespread support(see the charter at www.abimfoundation.org). Itstarts by stating that “professionalism is the basis ofmedicine’s contract with society.”
The fundamental principles of professionalism are asfollows:Principle of primacy of patient welfare.
Principle of patient autonomy.
Principle of social justice.
Its set of professional responsibilities are as follows:Commitment to professional competence.
Commitment to honesty with patients.
Commitment to patient confidentiality.
Commitment to maintaining appropriate relations withpatients.
Commitment to improving quality of care.
Commitment to improving access to care.
Commitment to a just distribution of finite resources.
Commitment to scientific knowledge.
Commitment to maintaining trust by managing conflictsof interest.
Commitment to professional responsibilities.
It is important to note that some of these principlesare occasionally at odds with one another, and inthese situations it is important to be able to recognizeand effectively negotiate these conflicts when theyarise. There are a number of ways to grow your levelof professionalism over the course of the clerkship.
➾ Do your best to get to know your patients well.Understand who they are and why they have theproblems that they have. Treat every patient asyou would hope your family member would betreated. As you invest in your patient, they willinvest in you, and this will allow you to experi-ence something that may not have before—atrue therapeutic relationship.
➾ Follow your patients over time; call them afterthey have left the hospital to find out what hap-pened to them.
➾ Be an advocate for your patient whenever neces-sary. Discover for yourself what Francis W.Peabody, MD, articulated: “The secret to caringfor the patient is caring for the patient.”
➾ Reflect actively on your actions and experiences,on a regular basis. After each interaction, espe-cially those in which you find you are havingstrong emotions, spend some time consideringand analyzing what you have experienced. Writeit down. Discuss your thoughts with your peersand advisors.
➾ Be honest to yourself and others. It is honorableto say “I don’t know.”
➾ Be aware of the “hidden curriculum.” Thisrefers to that which is taught outside the class-room and which may not be the best examples.Think critically about everything that you aretaught, no matter the source.
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Professionalism
➾ Work to improve the quality of the system inwhich you work. Every medical system hasweaknesses, gaps, inefficiencies, and processesthat allow errors to occur. Be a part of the solu-tion. Consider ways that the system might beimproved and pass them along.
➾ Learn from your mistakes. You will make mis-takes. We are human, and we can expect no lessof ourselves. And, as a learner, you do not yethave all the knowledge and skills to practiceindependently. Strive to never make the samemistake twice. Share your experiences with yourpeers, so they avoid repeating mistakes. Learn asmuch as you can about ways to prevent makingimportant errors (and there is a growing litera-ture on how to do this), and be willing to adaptyour practice to provide the highest quality andsafest patient care.
➾ If any problems occur during your clerkship, letyour clerkship director know as early as possible.
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The internal medicine clerkship is one of themost important experiences of medicalschool. Regardless of what specialty training
you ultimately pursue, you will unquestionablyadvance your knowledge and skills on this clerkship.
Ultimately, we will view this as a successful clerkshipexperience if it makes you a better caregiver,improves your skills, improves your confidence inyourself, helps you to become more professional,and helps you to become more aware of your careerpreferences. You will be one step further to whereyou ultimately will be—a skilled, caring, knowl-edgeable physician in the area of your choice.
You will only have one internal medicine clerkship.As much as we may try to make experiences consis-tent, no two medicine clerkships are ever the same—from school to school or from student to student.Your patients, your team, your preceptors andattendings, your hospital and clinics, and you willultimately determine the outcome of this experience.This clerkship will shape you, even if in small ways.You will carry your experiences from these weekswith you for the rest of your professional career. Weencourage you to do everything that you can tomake the very most of this experience. We hope thatthis handbook has served as a guide of how to doexactly that. We wish you the very best clerkshipexperience possible. Your clerkship director feels gen-uinely privileged to accompany and guide you.
Conclusion
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Not every student who comes through theinternal medicine clerkship will ultimatelychoose to specialize in internal medicine.
However, a substantial number of students will ulti-mately choose to pursue internal medicine—it is byfar the most frequently chosen residency, and thereare more residency positions in internal medicinethan in any other specialty. Additionally, internalmedicine residency training is frequently combinedwith other specialty training, including pediatricsand psychiatry. Given the wide variety of optionsthe internist has upon completion of training—including practicing primary care, subspecializing,entering procedurally based fields, practicing hospi-tal medicine, working with specialized populations,teaching medical students and residents, conductingquality improvement work, entering industry—theflexibility that internal medicine offers will likelycontinue to make it a frequently chosen career pathfor medical school graduates.
While the ultimate function of the clerkship is notto entice you into entering internal medicine prac-tice, we hope that you are interested in learningmore about what a residency and career in internalmedicine offers.
Why do most people choose internalmedicine?There are many reasons frequently cited for pursu-ing internal medicine as a career. Obviously, caringfor adult patients is a cornerstone of the discipline.Most internists also state a love for the diagnostic
process, the detective work that comes with tryingto analyze a patient’s problems. Many physicians ininternal medicine express a desire to be activelyinvolved in the care of inpatients and outpatients.Some clearly want to follow patients over time, toexperience continuity, and to make a lasting impacton their patients.
Students who choose internal medicine express anaffinity for the training, which tends to be intellec-tually and educationally rigorous, where colleaguesare collegial, professional, and respected. Medicalstudents also pursue internal medicine to enter aspecific subspecialty or to learn specific procedures.Many students may consider lifestyle issues whenconsidering internal medicine; the lifestyle of aninternist tends to be very manageable, although thisobviously varies widely across physicians and areasof the practice.
What about lifestyle? How hard dointernists work?There is a tremendous range of lifestyles in internalmedicine, which reflects the wide variety of practicetypes and styles within internal medicine. There aremany fields that have essentially a 9:00 a.m. to 5:00p.m. schedule. There are some fields within medicinein which one may expect to work longer hours andhave more overnight call. For example, if one choos-es to become an interventional cardiologist, oneknows that patients may occasionally need an coro-nary intervention in the early hours of the morning.Many internal medicine careers do have some degree
Appendix 1: If you Are Thinking aboutInternal Medicine
of overnight call, but the extent and nature of callmay vary tremendously depending on the number ofpatients and physicians in the practice/coveragegroup, the specific needs of patients, etc. Many hos-pitalist groups work shifts. Additionally, there tendsto be substantial flexibility to practice on a part-timebasis. All internists recognize the desire to build afamily and to preserve personal time. Many peoplewithin internal medicine achieve the desired level ofbalance between professional and personal life.
How well are internists and subspecialistsof internal medicine reimbursed?We ultimately hope that our future physicians will
choose a career based on enjoyment and satisfactionthat the field produces, as this will likely producelonger term fulfillment. However, compensation isan important variable most students consider. Dataon compensation of various specialties are widelyavailable; we have not included them here due tospace limitations. A review of these data demon-strate: (1) internists earn compensation to support avery comfortable life; (2) some subspecialties earnmore than others, particularly in the private sector;(3) compensation for internal medicine and its sub-specialties is on par with other major specialties.
What does an internal medicine residencyconsist of?Internal medicine is a three-year residency program.There are two main types of internal medicine resi-dencies, “categorical” or traditional, and primarycare. There may be additional tracks of residencies(women’s health and hospital medicine) that youwill find, but these are the most common.Generally, categorical residencies are heavily hospi-tal-based. Residents spend most of their time onhospital medical wards, in intensive care units, insubspecialty services, in the outpatient setting, inthe emergency department, etc. All internal medi-cine residents have a continuity clinic in which theyfollow their own patients (with supervision) overtime. Continuity clinics are required to happen at
least one session (approximately four hours) perweek, regardless of the rotation. In primary caretracks, medical residents spend a higher percentageof their time in the outpatient setting, especiallyafter internship. Regardless of the track chosen, resi-dents can still choose a variety of career options atthe end of training, including an outpatient or hos-pitalist practice or further training in a subspecialty.
In the majority of internal medicine programs, theinternship year is the most intense year of trainingwith the most months of direct patient care and leastmonths of electives. Call schedules vary from pro-gram to program, but they tend to range from everyfourth to sixth day on call. In the second and thirdyears of an internal medicine residency, residentshave progressively more time for elective rotations,during which residents can determine their schedulesfor some months during the year. Some residentschoose to do research, some choose clinical electiveson site, and some travel elsewhere. There tends to bea fair amount of flexibility to the training.
How difficult is it to get into an internalmedicine residency program? In general, internal medicine is not currently verycompetitive as there more internal medicine residen-cy positions than positions for any other specialty.However, top internal medicine programs remainextremely competitive. Students who match at topinternal medicine programs often have sustainedsuperior clinical performance on their clerkships andfourth-year rotations, obtained AOA status, scoredwell on the United States Medical LicensingExamination Step I and Step II, and secured strongletters of recommendation. However, for the majori-ty of applicants and the majority of programs, itremains a buyer’s market—students who performwell can typically enter a program of their choice.Internal medicine residencies are typically offer acomprehensive teaching program and extensivesupervision by skilled physicians. One does not needto attend the very top programs to become very wellprepared in internal medicine.
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What combined internal medicine pro-grams are there?It is possible to complete a combined residency withinternal medicine and other areas such as pediatrics,emergency medicine, family practice, preventativemedicine, and psychiatry. These combined programsoffer dual board certification eligibility with feweryears of residency than internal medicine (threeyears) and the corresponding specialty put together(e.g., pediatrics is three years; however, most medi-cine/pediatrics residency programs last four years).There are some benefits and some disadvantages ofpursuing a combined program. Some physicians feelstudents should pick one specialty and focus on it.The idea behind these combined programs was thatstudents could build practices based on where theseprograms overlapped. An example of this would behow some medicine/pediatrics residents are interest-ed in pursuing a career in adolescent medicine,while others plan to subspecialize and see patients ofall ages in that subspecialty in the future. Forinstance, a medicine/pediatrics specialist could fur-ther subspecialize in cardiology and focus on con-genital heart disease or endocrinology and followtype I diabetics throughout their lifetime. Manyinternal medicine/emergency medicine residentschoose this route because they are interested in hav-ing a private clinic in addition to working shifts inan emergency department.
I’m still interested. What should I do? Keep your mind open during this and every otherclerkship. Actively consider what it is that you enjoyand that you can envision doing for the rest of yourprofessional career.
Work hard. Express enthusiasm for your work. Readactively and frequently. Embrace opportunities forpatient care, learning, and presenting. Getting your-self positively recognized will probably help you,although this is not critical at this early point.
Learn more about internal medicine. The AmericanCollege of Physicians (ACP) has prepared a numberof resources for students who are considering enter-ing internal medicine. See the ACP website atwww.acponline.org.
Finally, identify an internal medicine advisor whocan give you guidance about how to proceed as youplan your fourth year, applications, and interviews.
If you remain unsure at the end of your clerkshiplike very many people do, do not get anxious. Yourfourth year should allow you substantial opportuni-ties to experience different aspects of internal medi-cine and other fields, and for most students, theseadditional rotations are helpful in determining careerchoice. Use an advisor to help you find direction.
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The following is a series of basic definitions ofterms and types of people that you are likelyto encounter over the upcoming weeks.
Inpatient: Refers to care of patients who are hospitalized
Outpatient/Ambulatory: Refers to care of patientswho are not in the hospital. Ambulatory,meaning “able to walk,” is applied to describethe care of patients in clinics/offices.
Internal medicine: Adult medicine. Internists, prac-titioners of internal medicine, see patientsfrom late adolescence through the geriatricyears. Many people who train in internal med-icine practice as adult primary care physicians,based primarily in the office while also caringfor patients in the hospital. Some internistsrestrict their practice to the office only, andsome restrict their practice to the hospital(hospitalists). About 60 percent of internistssubspecialize in one of the subspecialties ofinternal medicine (see below). Many of thesepeople ultimately practice only their subspe-cialty, but many also practice general internalmedicine as well.
Resident: Residents have completed their medicalschool training, have their doctoral (MD orDO) degree, but are not yet eligible forautonomous practice. All trainees must com-plete a “residency” in the area of their choice;residency in internal medicine is traditionallythree years in duration. Residents are typicallydescribed by the year of their training; forexample, a junior resident is a resident in theirsecond post-graduate year (PGY-2). A seniorresident is typically PGY-3.
Interns: Residents in their first year of residencytraining (PGY-1). Internship is typically themost intense year of residency during whichmany basic skills are acquired. Do not confusewith internist, a physician who practices inter-nal medicine.
Subintern or acting intern: A fourth year medicalstudent in preparation for internship, workingas independently as possible but with residentsupervision to provide direct patient care.
Chief resident: Usually has completed his/her train-ing in internal medicine and selected to spendan additional year coordinating operations ofthe residency with the program director.Activities usually include patient care, educa-tion, and administrative oversight of residents.
Fellows: Trainees who have completed residency intheir specialty (e.g., internal medicine) butwho has elected to perform additional subspe-cialty training (e.g., cardiology). Fellows workclosely with subspecialty attending staff andfrequently coordinate and are first contacts forsubspecialty consultations.
Attending physician: A physician who assumes ulti-mate responsibility for a patient’s care. Thephysician who is ultimately responsible for allactions of patient care for any given patient isthe “attending of record.”
Consultant: A physician who is invited by theattending physician to provide recommenda-tions for the care of the patient.
Subspecialists: Internists who practice a subspecialty.A number of subspecialties exist within inter-
Appendix 2: BasicClinical Definitions
nal medicine, including allergy and immunol-ogy, cardiology, endocrinology, infectious dis-eases, hematology, gastroenterology, geriatricmedicine, nephrology, oncology, pulmonaryand critical care medicine, and rheumatology.Many of these subspecialties have additionalpaths of specialization, for example, invasivecardiology or hepatology.
Hospitalist: A physician, most commonly trained ininternal medicine, whose primary professionalfocus is the care of hospitalized patients. Thisis a relatively new and rapidly growing areawithin medicine.
“Rounds:” There are several different types ofrounds. “Rounds” most typically refers tomorning walk rounds, or work rounds, duringwhich the team will see all the patients on theservice. Rounds typically include reviewing thepatient’s brief history, the status of active prob-lems, the medications that the patient is taking,and the vital signs/intake and output for theprevious 24 hours; these reviews are followedby patient interviews and examinations. Ideally,the plan for the day will be determined. “Pre-rounds” is typically an individual activity wherethe student will see all of his/her patients andgather information prior to the entire teamvisit. This is a means for the student to be evenmore prepared for work rounds. “Attendingrounds” is a teaching session in which the teamwill discuss cases and learn from their patientswith the team’s attending.
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You will work with many people during yourclerkship. All of these people are part of alarge multidisciplinary team that participates
in the care of patients. There is an interdependencyof all members to do their jobs well in order to takemost effective care of patients; therefore, it is impor-tant to be able to work well with all of them.
Nurses are responsible for safely and promptly exe-cuting the plan of care for patients and addressingthe patients’ emotional needs while hospitalized.They administer almost all medications, coordinatetransportation, educate, and discharge. If somethingneeds to get done rapidly for the patient, it is bestto discuss this directly with the patient’s nurse.
Nurse’s aides or patient care aides are assistants tonurses who may have a variety of responsibilities—lifting or moving patients, measuring and recordingvital signs or blood sugars, phlebotomy, bathing,toileting, and feeding patients.
Unit secretaries are stationed at the front of theward. They are responsible for answering phones,answering patient calls, and perhaps most impor-tantly, taking of orders. In most hospitals (those thatdo not have computerized provider order entry), thesecretary will transcribe orders into a computer sys-tem or onto paper medication administrationrecords. They will likely know if blood has beendrawn, if a patient has left the floor, and if a test hasbeen ordered.
Case managers are typically nurses whose primaryresponsibility is to assist the provider team withachieving timely and appropriate discharge ofpatients. They are invaluable in securing outsideservices, assisting to arrange follow-up, and gettingpatients screened for placement in rehabilitation ornursing homes.
Appendix 3: ThePeople with WhomYou Will Work,Interact, and Learnduring Your InternalMedicine Clerkship
Ancillary staff include the many additional non-physician providers who may interact with yourpatients:
➾ Physical therapists evaluate strength and balanceto determine if patients are safe to return homeand prescribe exercises.
➾ Occupational therapists evaluate patients’ finemotor and cognitive skills to determine theirabilities to care effectively for themselves.
➾ Speech therapists evaluate patients’ abilities toswallow in event of neurologic injury or muscu-lar weakness of the oropharynx.
➾ Phlebotomists draw blood.
➾ IV therapists place saline locks and sometimeslonger lines which may be more durable, etc.
It is very important to understand the role of eachmember of the team and effectively communicatewith all, so that the patient can receive the mosteffective care.
Finally, you will be working with patients. It bearsnoting that your patients will come from all walksof life and may have very different abilities or stylesof communication. Some will not speak the samelanguage. Some may be angry or offensive. Somemay be entitled and demanding. Some may beunable to communicate at all or severely disabled. Itmay be tempting at times to pass judgment on thosewe treat. Strive at all times to follow Maimonides’recommendation: “May I never see in the patientanything but a fellow creature of pain.”
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CLERKSHIP DIRECTORS IN INTERNAL MEDICINE2501 M Street, NWSuite 550Washington, DC 20037-1325Telephone: (202) 861-8600Fax: (202) 861-9731Email: [email protected]: www.im.org/cdim
Copyright 2004 Clerkship Directors in Internal Medicine
CDIM thanks the Shadyside Hospital Foundation of
Pittsburgh, PA, for its support of the reproduction and
distribution of this primer.Electronic versions of the primer inAdobe Acrobat (forreproduction) andMicrosoft Word (fortailoring by clerk-ship directors) areavailable on theCDIM website.
CDIM thanks the Shadyside Hospital Foundation of
Pittsburgh, PA, for its support of the reproduction and
distribution of this primer.Electronic versions of the primer inAdobe Acrobat (forreproduction) andMicrosoft Word (fortailoring by clerk-ship directors) areavailable on theCDIM website.
