Thomas Jefferson UniversitySidney Kimmel Medical College

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Internal Medicine

Medicine is a very important rotation where you will learn to manage sick patients.  Students spend a total of twelve weeks on IM.  The time is divided into three 4-week blocks during the rotation. Two blocks are spent at an affiliate hospital and one at Jefferson.  During the course of the rotation, students will be exposed to a wide variety of diseases. Most patient encounters deal with cardiac, GI, renal, hematology/oncology, pulmonary, endocrine, infectious disease and rheumatologic disorders.

The four weeks at Jefferson tend to be the most demanding part of the rotation. Each student is assigned to a specific team made up of an intern, a second or third year resident and one attending supervising the team. Sometimes, you may even have a fourth year sub-intern.

Unfortunately, students may not have much time with the attending physicians while at Jefferson. Interns and residents, for the most part, will be able to answer any questions or address any concerns. Students are expected to see each of their patients (usually three or four) first thing in the morning before rounds and to write a complete SOAP note. The SOAP note includes a thorough assessment and plan for each of the patient's concerns.  Taking the time to write a thoughtful plan can score big points.  As a third year, it is important to know your patient through and through. If you "own your patient" and know them as if you are the only one caring for them, it will be difficult for you not to get noticed.  Some people find it easier to keep track of their patients by using a patient record form where they record vitals, medications and lab values throughout the patient’s stay.  Alternatively, some students find it helpful to photocopy their SOAP notes and carry them around during the day for presentations and jotting down new developments.

Some teams will expect the students to renew any medications on the charts and to write for any new medications or electrolyte replacements needed.  Someone must co-sign all orders and nurses make it a priority to contact them regarding your orders.  During rounds with the team, students will present the patients they are following.  Students are also expected to attend lecture series on various topics given by various attending physicians and chief residents.

At the affiliates, students tend to have more autonomy, responsibility, and greater attending contact. Students also attend daily lectures throughout their rotation at the affiliate. Some affiliates offer excellent radiology sessions to the students that go over reading chest x-rays. On the whole, the affiliate experience can be quite gratifying and instructive.  The Jefferson month is typically weighed more heavily than the affiliate months with regard to your final clerkship grade.

Call

Call is every fourth night at Jefferson and is often every fourth to fifth night at the affiliates.  You will be asked to help with admissions and check on patients during the night. Students usually are given one to two admissions while on call. At Jefferson and most of the affiliates, call involves staying until 9 or 10 PM (if a night float system is present). Sites that do not have a night float system may require overnight call. You may wear scrubs the day of call.

References

Bold titles are highly recommended.

Text Books

  • Harrison's Principles of Internal Medicine is the gold standard reference text. Excellent for reading up on specific illnesses with which your patients present. Too long to use as the primary text to prepare for the exam. Available online via JEFFLINE.
  • Current Medical Diagnosis and Treatment (Lange) is a great text that comes out every year in the fall.  Very complete and worthwhile reading during the rotation.  Of particular interest is the “further reading” segment at the end of every section that references up-to-date journal articles and review on the topic.  Available online via JEFFLINE as part of the AccessMedicine service.
  • Cecil Essentials of Medicine is an abbreviated version (~900 pages) of the complete Cecil’s.  It is a concise and reasonably complete reference. Some students can read this in twelve weeks if a couple hours are devoted every night.  This is the recommended text for the clerkship.
  • Mayo Internal Medicine Board Review is an excellent text that is very complete and to the point. Text is written for residents preparing to take their Internal Medicine boards. At the end of every disorder, there is a summary of the main points you need to know in bullets. There are also board-like questions at the end of each chapter with well-explained answers that follow.
  • Rapid Interpretation of EKGs (Dubin) is the most readable EKG text written. Many helpful pointers written throughout the text make it very understandable.
  • Blueprints for Internal Medicine and First Aid for Internal Medicine are from the two series that become a staple of most third year's libraries. Step Up To Medicine is another commonly used review text for this rotation.  Far from comprehensive, these books still provide the most common topics with enough information to sound competent on rounds and to perform adequately on the final examination. They are reader friendly, but don't count on preparing any presentations from these sources alone.
  • MKSAP for Students 3 is a great board-style question book that is a must-read before the final examination.  This book tests your knowledge of common topics in internal medicine and provides detailed explanations of the answer choices.

Pocket Books

  • The Maxwell Guide is the most important pocket guide for all rotations. Get it, love it.
  • Pocket Medicine is probably the best pocket book for internal medicine, and is the most popular choice for both medical students and medicine residents. Provides practical information for the floors, with treatment plans and references to the original articles.
  • Practical Care of the Medical Patient (Ferri) is another popular pocket reference. Very practical with complete differential diagnosis, commonly used meds, and various pertinent lab tests. Somewhat bulky and heavy.
  • The Washington Manual is a great pocket-sized reference. It includes a lot of management-related information as well as pathophysiology. It is one of the larger-sized "pocket" books, and is used far more by medicine residents than by medical students. Probably more detail than is necessary for the IM clerkship.
  • Pocket Guide to ECG Diagnosis (Chung) is a handy pocket guide that includes common electrocardiographic abnormalities and common arrhythmias that all medical students and house officers should be familiar with. Excellent quick guide, especially if you are on the cardiac service.
  • Pocket Harrison's is a fairly complete handbook that describes most commonly encountered disorders, with some detail of the underlying pathophysiology. Unfortunately, not much is written concerning the management of each disorder. Overall, not a popular book choice.

Online Resources

Up-To-Date is an on-line reference that is continually updated. It contains the most current clinical thinking in an extremely useful format that includes data pooled from the original studies on which the management recommendations are based. It is available via JEFFLINE (but only on campus).  Many students find Up-To-Date to be the best resource for reading up on patients.

PDA Resources

The best pocket reference for internal medicine, and in fact, overall is the 5 Minute Clinical Consult, which is sold at the TJU bookstore for approximately $60 or available via JEFFLINE in Stat!Ref. If you enjoy interfacing with a PDA, 5MCC is truly a must-have. The second must-have resource is Epocrates, a pharmacopeia that may be downloaded free-of-charge at epocrates.com.

Formal History & Physical (H&P)

You must complete one formal H&P during your medicine clerkship. Dr. Diemer (clerkship director) does read each student's H&P, and a narrative grade for this manuscript will appear on your final medicine evaluation. It should be typed and as complete as possible. Following the example at the end of Bates' Physical Diagnosis is a good idea. This H & P tends to be quite long and should not be put off until the last minute.

Final Examination

Internal Medicine uses the NBME shelf examination.  The best reference (aside from reading on patients throughout the clerkship) is MKSAP for Students 3.  Go through the entire book a week before the examination.  One of the best questions books written for any clerkship!