How to Look Like a Rockstar on Your 3rd Year Internal Medicine Clerkship

So you are finishing your second year. You take your boards. You relax for a little while. Now it’s time to hit the wards. Let’s say you are interested in internal medicine, or you have it as your first rotation. Here is a set of guidelines on how to do well, and what topics/diseases you should really focus on.

Now this is information on how to look good on the wards. This isn’t how to do well on your shelf exam. That’s a whole different topic and will test on things you will probably not see in your month of internal medicine.

  1. Show up on time and stay until someone tells you to go:  Pretty self-explanatory, but get there early, see your patients, and practice presenting to your residents before you present to your attending. There are lots of resources out there on how to present, so I won’t go into that. Act interested (even if you are not) with your interns/residents/attendings.
  2. Read up on your patients every night: This will help with pimp questions, looking like you are well-informed on your patients, etc. If you have access to the New England Journal of Medicine, try to find a review article on your patient’s main hospital problem. They are great reviews.
  3. Ask to interview new patients with your resident/intern there:  In my experience, as a 3rd year, with new patients, you will go in the room with your inter/resident for the initial history while they do the entire H&P. Do this at first so you can learn what your intern/resident does. But then ask to start doing it yourself so you get to practice. This will be really beneficial and you will get good feedback from it.
  4. Develop an approach to your differential: There are lots of ways to develop a differential. You can do it by anatomy of the surrounding areas chief complaint, systems, etc. Develop an approach, talk with your residents about their approach, and use this approach for every patient.
  5. Try to understand why labs/imaging are being ordered: Don’t just try to memorize what labs you order for chest pain, what imaging you get for shortness of breath, etc. Understand why these are being ordered (or how they are helping narrow down your differential), as this will help you in the long run.
    Ask questions – there is going to be a lot of information you have no idea about. Don’t be afraid to ask something that you think will make you look stupid. If you already knew everything, then you wouldn’t need to be there.
  6. Learn the social issues in the hospital: For example, learn about who goes to an SNF after their stay, who goes home, who goes to a nursing home, etc. Learn how all the social work pertains to your patient. You will have to do some of this stuff when you are a resident, so best to start learning this process now.

There are many more things you will need to do other than those, but those are some big things. I want to get into the list of topics/diseases you should really know. These are the most common issues you will encounter on the IM wards.

When I give this list, you should try to know everything about these diseases. For example, know what to ask in the history, what to look for in the physical exam, differential you should have, labs to order, images to order, admission criteria, prognostic criteria, common complications, treatment, etiology, risk factors, pathogenesis, and admission orders.

Here is the list of the most common diseases you will see in internal medicine:

  • Pneumonia
  • COPD exacerbation
  • Asthma exacerbation
  • Pleural effusion
  • Venous thromboembolism (DVT/PE)
  • Acute coronary syndrome
  • Heart failure
  • Atrial fibrillation
  • Syncope
  • Upper/lower GI bleed
  • Chronic liver disease and its complications
  • Acute pancreatitis
  • Acute kidney injury
  • Chronic kidney disease
  • Anemia
  • Thrombocytopenia

Seems like a big list, but it is nothing compared to everything you will be tested on for your shelf exam. It is a lot to know, but if you can have a good game plan for these diseases, you will look like a rockstar (if you knew all of these well as a beginning intern, you will look like a rockstar also).

You also should have an idea of an approach to certain symptoms/complaints. For example, it’s nice to know everything there is to know about pneumonia, but you won’t have a patient come in with a chief complaint of “I have pneumonia”. Instead, they can say they feel short of breath.

So I put together a list of common workups you will need to know as well. If you are at night and you get paged that a patient has acute shortness of breath, you need to know what to do. Develop a differential, do a quick H&P, initiate a workup, and start managing them. Know these for this list here:

  • Chest pain
  • Shortness of breath
  • Abdominal pain
  • Headache
  • Hypotension
  • Hypertension
  • Common arrhythmias
  • Fever
  • GI bleeding
  • Diarrhea
  • Constipation
  • Insomnia

Yes, this is a lot to know. But if you want to look really good, you should have a good idea of all this by the end of your rotation.