How to do well on Internal Medicine
Internal medicine physicians know medicine—they understand the pathophysiology of diseases and know how to manipulate these relationships to heal. Within medicine, there's a large variety of subspecialties that run the gamut of pure, consult-based advisory services (such as infectious diseases) to procedure-based practices (such as gastroenterology and interventional cardiology). It goes without saying that Internal Medicine is fundamental to the house of medicine as a whole. As a medical student, Internal Medicine is where you will learn to comprehensively present patients, hone your physical examination skills, and learn to carry through a detailed and thorough history.
Tips on doing well on your Internal Medicine rotation/clerkship
Tell a story
Tacking onto the first point, when relaying an HPI, tell it as a story. After seeing a new admission in the ED or in the clinic, take a deep breath and, after your patient identifier information and chief complaint, paint a story of how the patient ended up at the hospital. We are all natural storytellers; creating the narrative will help your attending and team easily understand the underlying issues.
Learn how to give a good oral presentation
As a medical student on internal medicine, your evaluations will be mostly be based on the quality of your presentations. As such, it makes it imperative to learn the correct sequence of oral presentations. There is a well defined, step by step approach that goes into presenting patients and deviating from this pattern can often mean missing details and can make your presentation look sloppy. If you really want to hammer it out, this article (https://meded.ucsd.edu/clinicalmed/oral.htm) goes into detail regarding the different presentations based on whether or not they are new or known patients in the clinic or hospital setting. Briefly, the proper inpatient morning rounds presentation is as follows
Identifier: "47 year old male who presented with…" If you want to be real snazzy, you can add a "this is hospital day..." and the reason for why they are still admitted "...still admitted for management of his acute congestive heart failure."
Overnight and interval events: "Yesterday, he had an echo which showed an EF of 30%…" "This morning, he endorses improved chest pain and dizziness. He was able to ambulate with PT and tolerated the clear liquid diet we started yesterday"
Vitals: Feel out if your attending wants the complete vitals or just wants an assessment of the vitals
Ins and outs: "Total ins and outs were 1550 in and 1800 out of which he took in 800 PO…urine output has been adequate at .5 ml/kg/hr."
Exam: Again, see if your attending wants directed exam findings or the whole exam
Labs: Present relevant labs. Take into consideration any trends. Remember, it's only a trend if it's 3 or more values.
Imaging: Any new imaging that was done in the last 24 hours
Micro: Any update on any cultures
Pathology: If relevant
Assessment: While you can start your assessment as "So, again, this is a 47 year old male…" but remember that your assessment is your overall gestalt or feel of the patient. Are they improving? Is their current management helping them get better? What is causing this disease process? What elements of the clinical puzzle are missing?
Plan: While this isn't the ICU, get in the habit of thinking of problems in the context of systems; that is, from top down, neurological, HEENT (head, eyes, ears, nose, throat), cardiac, pulmonary, abdominal, hematological, genitourinary, or musculoskeletal issues. Create a plan/rehash what the team is doing for each active problem a patient is dealing with in the hospital.
Drop the mic: Because you've just given a thorough oral presentation. Good work soldier.
Learn how to pre-round
Pre-rounding is an art in and of itself. The point is to gather all of the information necessary to present effectively. A generic schedule is the following:
Look first at the vitals, ins and outs, and labs for the patient. Write these down and circle any deviations from normal. Quickly note relevant trends (such as in the hemoglobin or WBC).
Read all the notes written on the patient in the last 24 hours.
Quickly refresh yourself on the last assessment and plan for the patient and think about what needs to be done today to get the patient better and out of the hospital
Go see the patient, asking questions that pertain to the principle reason the patient is still in the hospital and doing a directed physical exam. Some generic questions that are relevant to every patient, because they often are things that the patient need to demonstrate for them to be reliably discharged, are whether they are tolerating PO intake, ambulating safely (either by themselves or with PT), and if their pain is well controlled.
Start typing your note, come up with your overall assessment of the patient (if their active medical problems are getting better, staying the same, or getting worse), think up of any new modes of intervention that are needed to get the patient better, and confer with the resident taking care of the patient on the overall plan for that day.
Wear comfortable shoes
You'll be standing for a while during rounds. Shoes with good support make all the difference.
Read up on your patients
The patients and diseases that you will encounter on your internal medicine block will be more representative of the shelf, and Step 2 CK, than, say, neurology, where you will likely not see in person a great deal of the pathology that is tested. With any patient that you have, read up on its disease process and management. It'll help with pimping during presentations as well as help tie in the information for exams.
Study concurrently
The internal medicine shelf covers the clinical applications from essentially the entire second year of medical school. Keep up with UWorld Step 2CK questions; if possible, try to run through all of the internal medicine questions once and your missed questions another time. Having a text is helpful to refresh pathology as well. However, as you have likely seen most of the material in internal medicine at least once or twice before (while during your MS2 classes or while studying for Step 1), you should aim to mainly test and solidify your knowledge using questions.