Internal medicine clerkship

What is internal medicine?

• Internal medicine is a broad field with a general focus on preventing, diagnosing, and treating a wide array of diseases in adult patients.
• Diseases treated by internists commonly involve multiple organ systems, which is why taking a thorough patient history and physical examination are often considered the most important diagnostic tools for providing a complete assessment.
• Decision-making relies on evidence-based medicine, clinical reasoning, and the quality of the patient-physician relationship.
• Training
  • Training involves a 3-year residency training program, at the end of which residents are eligible for board certification in internal medicine.
  • After completing the residency program, internists can continue training in a wide variety of subspecialty fields, including:
    • Cardiology
    • Gastroenterology
    • Hematology/oncology
    • Pulmonology and critical care
    • Rheumatology
    • Infectious diseases
    • Nephrology

A strong foundation in internal medicine is usually considered essential for all physicians, regardless of their specialty!

What does an internist do?

• Internists provide a wide range of care for their patients, from managing acute conditions to chronic illnesses.
• Internists rely heavily on clinical skills, such as:
  • Detailed history taking
  • Comprehensive physical examination, including techniques such as observation, auscultation, percussion, and palpation
  • Using various tests to confirm diagnoses, including:
    • Laboratory tests
    • Ultrasound
    • ECG
    • Echocardiography
    • Pulmonary function tests
    • Biopsies
  • Managing patients with treatments such as medications, physical therapy, and minor interventional procedures (e.g., catheter-based procedures)
• Subspecialty-trained internists may also have to perform more extensive procedures, including coronary angiographies, central venous catheter insertions, or endoscopies (e.g., ERCP, bronchoscopy).
• Careers in internal medicine may also vary drastically depending on the practice setting.
  • Inpatient setting
    • Academic setting: An internal-medicine attending works at a teaching hospital and spends a considerable amount of time teaching medical students, training residents, supervising research, and fulfilling other administrative duties.
    • Internal medicine wards at the hospital: A hospitalist acts as the primary responsible physician for admitted patients and consults other specialties as needed with the goal of stabilizing patients before discharge.
  • Outpatient setting: Internists usually function as primary care providers for a certain patient population, ideally over the long term.
  • Some physicians engage in both settings and might offer follow-up appointments in their own outpatient clinic to some patients after discharging them from the hospital.
• The variety and severity of diseases seen by an internist may vary with the specific location of the health care facility.
  • Urban areas: Patients usually have easy access to an emergency department at a hospital.
  • Rural areas: Physicians might act as first responders more frequently than in urban areas because they are often the only health care providers available.
• When deciding on a career path, all of these factors should be considered. When in doubt, seek out mentors in internal medicine, who are usually happy to discuss their career path!

Clerkship structure

• The length of the clerkship varies between 8–12 weeks, depending on the medical institution.
• Rotations can comprise the following settings:
  • Inpatient portion: internal medicine wards
  • Outpatient portion: primary care clinic
  • Community health portion, e.g., internal medicine wards at a community hospital
  • Additional subspecialty rotations, such as:
    • Medical intensive care unit (MICU)
    • Specialized wards (e.g., cardiology, gastroenterology, nephrology)

Clinical skills

• History taking
• Physical examination
• Patient presentations
• Supplementary diagnostic methods
• Minor procedures

Daily schedule

Specific schedules may vary depending on the institution, preferences of the attending, or the weekday. Examples of the inpatient and outpatient settings are provided below.

Inpatient schedule sample

• Arrive early for pre-rounding.
• Morning report with the whole team
• Start rounds with attending, residents, and students.
• Finish patient notes and other tasks (e.g., orders).
• Attend daily teaching and lunch conferences (e.g., resident noon conference, morbidity and mortality conferences (M&M), or grand rounds).
• See consults in the afternoon.
• Lectures and seminars (e.g., case-based teaching sessions, case presentations) and self-directed learning time

Outpatient schedule sample

• Review patient charts with upcoming appointments (either the night before or arrive early).
• Morning appointments
• Lunch/teaching rounds (e.g., case presentations, resident teaching session)
• Afternoon appointments
• Finish patient notes and other tasks (e.g., orders).

Evaluation and grading

• Varies among institutions but usually is pass/fail, and (typically) also high pass and honors. It consists of:
  • Clinical grade
  • Examination (usually shelf exam)
  • Possibly other assignments.

AMBOSS Study plans

• AMBOSS has created study plans with recommended articles and questions for all clerkships, including:
  • Internal medicine: https://go.amboss.com/medicine ^[1]
  • Cardiology and angiology: https://go.amboss.com/cardiology-angiology ^[2]
  • Pulmonology: https://go.amboss.com/pulmonology ^[3]
  • Gastroenterology: https://go.amboss.com/gastroenterology ^[4]
  • Hematology and oncology: https://go.amboss.com/hematology-oncology ^[5]
  • Nephrology: https://go.amboss.com/nephrology ^[6]
  • Endocrinology and metabolism: https://go.amboss.com/endocrinology ^[7]
  • Rheumatology and immunology: https://go.amboss.com/rheumatology ^[8]
  • Infectious diseases: https://go.amboss.com/infectious-diseases ^[9]
  • Dermatology: https://go.amboss.com/dermatology ^[10]

Objectives

• Following the internal medicine clerkship, students should be able to:
  • Obtain a full patient history and physical examination for patients with acute and chronic diseases.
  • Present cases of newly admitted patients as well as summaries and updates on the progress of previously introduced patients.
  • Interpret laboratory values and other test results (e.g., ECG, imaging) in the context of common pathologies.
  • Formulate differential diagnoses and plan further diagnostic steps.
  • Formulate and discuss treatment options and present a treatment plan to patients and potentially their family members.
  • Summarize a patient case and obtain all required documentation for discharge.
• Furthermore, students should have:
  • Scientific and clinical knowledge of common acute and chronic diseases in internal medicine as well as preventive measures
  • Communication skills to engage professionally in conversations with patients and their families as well as colleagues and other house staff
  • Cultural sensitivity and ethical behavior to address patients appropriately in life-changing situations (e.g., before procedures or regarding end-of-life decisions)
  • Strategies for self-assessments and self-directed learning to ensure knowledge gaps are recognized and reliable resources are consulted

Internal medicine wards are the main inpatient setting for internal medicine physicians at the hospital. However, some members of the team see patients in other services as part of an internal medicine consult. Usually, patients in other services have been admitted to the hospital for a chief concern outside of the scope of internal medicine, but their primary responsible physician sees the need for advice from an internist.

Pre-rounding

• Preparing for rounds
  • Always be prepared for rounds with pertinent overnight updates, any new laboratory and/or imaging findings, consult team recommendations, and an assessment and plan for the patients you are following.
  • You can use AMBOSS to read up on each disease so that you are aware of the pathophysiology, symptoms, and treatment options for every patient cared for by your team.
• See “Pre-rounding” in the “Clerkship guide” article for more information.

Rounding

• Structure
  • Rounds are a vital part of internal medicine: They are where most of the learning takes place.
  • The whole team will typically be present (attending, resident, nurse, students, etc.).
• The student's role during rounds
  • Be attentive during interactions with all patients (not just your own).
  • Listen to how the residents present patients and to the types of questions asked by the attending in order to prepare for your own patient presentations.
  • Ask questions to show interest.
  • Volunteer to help where possible (e.g., calling consult services).
  • Never interrupt another student when they are giving their presentation.
• See “Rounding” in the “Clerkship guide” article for more information.

Notes

• See “Writing patient notes” in the “Clerkship guide” article for more information.

Presenting patients

• Compared to some other specialties, patient presentations in internal medicine are usually comprehensive and detailed, and they should include your reasoning as well as any questions or discussion points.
• While patients are often admitted to the hospital for one particular issue, always list all current issues that have to be addressed for a patient.
• Rather than reading from your notes, aim to make your presentation sound as natural as possible, which shows whether you have understood the case.
• See “Presenting patients” in the “Clerkship guide” article for more information.

Placing tentative orders

• See “Placing tentative orders” in the “Clerkship guide” article for more information.

Call duty

• See “Call duty” in the “Clerkship guide” article for more information.

Attending meetings and conferences

• Include daily teaching rounds (e.g., resident noon conference, case presentations), seminars and lectures on specific clinical topics (e.g., case-based teaching sessions), and grand rounds and/or morbidity and mortality conferences
• You may be asked to present a topic depending on your rotation requirements.
• See “Attending meetings and conferences” in the “Clerkship guide” article for more information.

Outpatient clinics can be located at a hospital or a special outpatient facility. In contrast to hospitalized patients, those in the outpatient setting are only present at the health care facility during their visit, meaning that all essential information has to be gathered in a short amount of time. Structuring a clinic visit, beginning with reviewing the patient's chart and ending with your presentation to the attending, will help you to be efficient and organized, and will help to impress your attending.

General considerations

• Know the workflow: Knowing how things are run at your clinic will help you plan your day efficiently and contribute better to the team. At the beginning of every day, you should ask yourself:
  • Will I be seeing the patients before the attending?
  • Will I be taking turns seeing patients with fellow students?
• Keep organized
  • If you know which patients you will see during the day:
    • Spend time on reviewing all the patients' charts in the morning of the clinic or on the day before.
    • Write down a few important points about each patient.
  • If you do not know the clinic workflow, try to spend at least a few minutes reviewing the charts of the patients you will see in the clinic.
  • Use AMBOSS articles to review symptoms and diseases that you are likely to see.

Preparing for a patient visit

• Review the chart or electronic health record of the patient you are going to see.
• Look at the patient’s most recent clinic note to ensure you have their most recent medical history (e.g., the reason for their last visit, treatments provided by the attending or resident).
• In addition, check for:
  • The most recent lab work
  • Current medications and other treatments
  • Other clinics visited by the patient
• Try to get an overview of the patient's past medical history and current health concerns.
• If you are required to write a note for each patient, start drafting the note before seeing the patient.
  • Example: “This is a 55-year-old man with a history of coronary artery disease and congestive heart failure last seen 3 months ago. The patient was referred to a cardiologist because of abnormal echocardiographic findings. He has since been seen by a cardiologist and received a diagnostic angiogram. Today, he is here for a scheduled 3-month follow-up visit and to repeat lab work including CBC and BMP.”

Seeing clinic patients

• Ask your attending how much time you should take to see each patient.
• Ask your patients if they mind you taking notes while talking to them.
  • If they say this is okay, pull up your note and add to it while you are interviewing the patient.
  • It is important to maintain frequent eye contact with your patient and engage in the conversation while you are taking notes.
• Organize your patient's visit by prioritizing current concerns.
  • Decide which concerns you will address during this clinic visit.
  • Move through each one systematically.
  • Obtain a detailed history of each concern (see medical history for more information).
• Develop a differential diagnosis.
• Move on to the patient's next concerns and repeat the steps above.
• Then, perform a physical examination focusing on the chief concern (see the physical examination article for more information).
• Reevaluate your differential diagnoses.
• Consider additional testing (e.g., ECG, lab work, imaging).
• Counseling and treatment plan
  • As a new third-year medical student, it is okay not to address the assessment and plan during your visit.
  • Tell your patient that you will discuss the findings with your attending and that you will both come back to address further management.

Presenting patients in the outpatient setting

• Use your note: You will already have a brief summary documenting the patient’s last clinic visit, their progress since the last visit, and why they are here to see you today.
• Structure
  • Start your presentation with a chief concern followed by your summary.
  • Go through each concern systematically.
  • Describe the patient's physical examination, starting with vitals followed by the relevant positive and negative findings.
• Conclude your presentation
  • Provide a brief assessment and plan regarding today’s encounter.
  • An assessment and plan based on a list of concerns is a commonly used structure.
• Example: If a patient has abdominal pain and a history of coronary artery disease and congestive heart failure, start with subjective symptoms, history, and review of systems. Continue with the objective findings, including physical examination, imaging, and lab results. Present your assessment and plan by starting with your differential diagnosis regarding abdominal pain and what treatment you would provide before moving on to chronic issues such as coronary artery disease. Discuss any medication the patient is already on, any new treatments since the last visit, and any changes you would propose.

• Medical history
  • Essential tool for forming a differential diagnosis
  • Students should practice taking a thorough and complete patient history.
  • See medical history for more information.
• Physical examination
  • Useful for ruling in or ruling out various differential diagnoses
  • Students should learn how to carry out a full physical examination as well as practice thorough but targeted examinations for specific questions.
  • Students should know normal physical examination findings, common pathological findings, as well as the use and significance of specific physical examinations.
  • Physical examination findings should always be interpreted in the context of the medical history and other supplementary findings.
  • See physical examination for more information.
  • Specific examinations
    • Mental status examination
    • Head and neck examination
    • Cardiovascular examination
    • Pulmonary examination
    • Abdominal examination
• Presenting patients
  • Students should learn how to efficiently communicate patient information to attendings and senior residents.
  • For more details, see ”Presenting patients” under “Inpatient setting” above and refer to the “Clerkship guide” article.
• Interpreting supplementary diagnostic methods
  • Chest x-rays
  • ABGs
  • ECGs
  • Point of care ultrasound
    • Ultrasound is becoming an important and more widely used tool in internal medicine.
    • Medical students can expect some exposure to ultrasound examinations during their internal medicine rotation.
• Interventional procedures
  • Students in internal medicine rotations sometimes have the opportunity to perform certain procedures under supervision.
  • Some subspecialty rotations, such as ICU, might offer more opportunities than rotations on regular medicine wards.
  • Examples of procedures in internal medicine: central venous lines, arterial lines, thoracentesis, and paracentesis

1. Diabetes mellitus
2. Acute coronary syndrome
3. Congestive heart failure
4. ECG
5. Hypertension
6. Anemia
7. Pneumonia
8. Chronic obstructive pulmonary disease
9. Asthma
10. Overview of antibiotic therapy

• Grading among institutions varies but is usually pass or fail (typically further categorized as high pass and honors) and consists of the following components:
  • Clinical grade, which includes:
    • Evaluation of clinical performance by preceptors (attendings, residents, and interns)
    • Observed H&P
    • Patient presentations
    • Patient notes
    • Admission orders
    • Clinical logs
  • Examination: consists of shelf exam (NBME® for MDs, or NBOME® COMAT for DOs) and/or sometimes in-house exams
• See “Evaluation and grading” in the “Clerkship guide” article for more information.

• Many attendings will test your knowledge with questions during rounds or when discussing specific topics. This is a great chance for you to impress your attending, as well as assess which topics you need to study or review (see “Clinical evaluation: how to impress your preceptors” in the “Clerkship guide” article for more information).
• Some typical question topics in internal medicine may include:
  • Pulmonology
    • Pulmonary embolism (PE)
      • Common ECG findings
      • Causes
      • Diagnosis
  • Cardiology
    • Chronic heart failure: treatments for CHF associated with a higher survival rate
    • Mitral stenosis: most common cause
    • Pericarditis: diagnosis and treatment
    • Aortic stenosis: most common cause of senile aortic stenosis
    • Pericardial effusion and cardiac tamponade: diagnosis and treatment
    • ECG
      • Which rhythms can be defibrillated?
      • Synchronized cardioversion vs chemical cardioversion for arrhythmias
  • Gastroenterology
    • Pancreatitis: diagnosis and treatment
    • Bowel obstruction: common causes
    • Peptic ulcer disease and gastritis: most common causes
    • Gall bladder
      • Differences between cholecystitis, choledocholithiasis, and cholangitis
      • The Charcot triad
    • Ascites
      • Differential for low versus high SAAG
      • Light criteria
  • Endocrinology
    • Diabetes mellitus (DM): diabetes management (screening tests and their cutoff values for diagnosing DM)
  • Nephrology
    • Hyperkalemia: management
    • Edema: pathophysiologic difference between pitting edema and nonpitting edema
    • Hypercalcemia
      • Differential diagnosis for hypercalcemia
      • Workup for hypercalcemia
    • Acute kidney injury
      • Definition
      • Differential diagnosis for acute kidney injury
  • Oncology
    • Malignancies: recommended cancer screenings
  • Infectious disease
    • Antibiotic treatment
      • Antibiotics effective against pseudomonas and MRSA
      • Treatment of C. difficile infection
    • Sepsis: diagnosis (SIRS and qSOFA)

• Shelf exam content ^[11]
  • Cardiology and pulmonology (10–15% each)
  • Nephrology and gastroenterology (8–12% each)
  • Hematology, neurology, dermatology, the musculoskeletal system, and endocrinology (5–10% each)
  • The male and female reproductive systems, immunology, biostatistics, principles of medical law and ethics, general principles (1–5% each)
• Timing of the shelf exam
  • The internal medicine shelf exam will typically be taken at the end of your internal medicine rotations.
  • If you schedule your internal medicine clerkship in the middle or towards the end of your third year, you will have the broadest knowledge base from other rotations before taking the shelf exam.
  • Scheduling your clerkship early might mean you have to study more content, but you will then have a solid foundation for the rest of your third year.
• Preparation for the shelf exam
  • To help ensure solid preparation for your shelf exam during your clerkship experience, try to schedule all your rotations in general internal medicine.
  • The patients that you see and the knowledge that you gain on a general internal medicine ward will provide you with a good foundation for your internal medicine shelf exam.
  • If you are interested in a subspecialty, such as cardiology or hematology, you will still have time to explore these fields during your career exploration electives in your third year or during electives in your fourth year.
  • Choosing a subspecialty rotation during the third year might create a situation where a lot of the knowledge you are gaining on the wards is very specific (e.g., chemotherapy treatments in oncology) and might not be directly applicable to your shelf exam.
  • AMBOSS
    • Besides its comprehensive library with over 400 medicine-specific AMBOSS articles, you will also have access to more than 1,300 questions that will help you prepare for your internal medicine shelf exam.
    • We also have curated study plans for internal medicine and subspecialties. See “AMBOSS study plans” below.
• Study strategies for the shelf exam
  • Your study plan should include all relevant topics.
    • Make sure you include less intuitive fields covered in the internal medicine shelf exam; for example, you might encounter dermatology questions (see “Shelf exam content” above).
    • You might find it helpful to organize your study schedule by going through all the subspecialties and organ systems.
    • Split up the time for each of the subspecialties, keeping in mind their importance in the internal medicine shelf exam and your existing knowledge.
    • You can go through each of the subspecialties in the AMBOSS library and follow up with questions in the AMBOSS Qbank.
• For more information: See the “Clerkship guide” article.

• AMBOSS has created study plans with recommended articles and questions for all clerkships, including:
  • Internal medicine: https://go.amboss.com/medicine ^[1]
  • Cardiology and angiology: https://go.amboss.com/cardiology-angiology ^[2]
  • Pulmonology: https://go.amboss.com/pulmonology ^[3]
  • Gastroenterology: https://go.amboss.com/gastroenterology ^[4]
  • Hematology and oncology: https://go.amboss.com/hematology-oncology ^[5]
  • Nephrology: https://go.amboss.com/nephrology ^[6]
  • Endocrinology and metabolism: https://go.amboss.com/endocrinology ^[7]
  • Rheumatology and immunology: https://go.amboss.com/rheumatology ^[8]
  • Infectious diseases: https://go.amboss.com/infectious-diseases ^[9]
  • Dermatology: https://go.amboss.com/dermatology ^[10]

• AMBOSS: You can use AMBOSS both as a clinical companion on the wards and a reliable study guide for your internal medicine shelf exam.
  • Access more than 400 medicine-specific AMBOSS articles in the knowledge library when you're with patients or rounding with your team.
  • Practice for the shelf exam with more than 1,300 questions in the Qbank.
• IM Essentials Questions by ACP: a question book with over 500 multiple-choice questions for students ^[12]
• Harrison’s Principles of Internal Medicine ^[13]
• Case Files® Internal Medicine ^[14]
• Rapid Interpretation of EKGs by Dubin ^[15]
• American College of Physicians: Membership includes access to Annals of Internal Medicine and DynaMed. ^[16][17]
• See “Resources” in the “Clerkship guide” article for more information.

General tips

• Internal medicine is an incredibly diverse field with immense opportunities to specialize/subspecialize (or not).
• If you think you are interested in internal medicine, talk to residents and attendings about their career paths and experiences.
• See the “Residency applications“ article for more information.

Research opportunities

• As a broad specialty with many subspecialties, internal medicine offers a wide variety of research opportunities. Depending on your personal interests and career goals, you can find projects in different areas ranging from basic sciences to clinical sciences to medical education and more.
• Many research projects in internal medicine do not encompass the whole field but are focused on specific questions regarding particular organs. If you have specific interests in one of the internal medicine subspecialties, research is a great way to gain more insight and get in touch with attendings in the field.
• Before choosing the type of research that you want to pursue, inform yourself of all the available options: Research in the field of internal medicine is often more than simple laboratory bench work.
• See “If you want to specialize in the field” and “Research” in the “Clerkship guide” article for more information.