Prepare for your internal medicine clinical rotation by learning what to expect, which topics to review, and how to build a strong support system during clinicals.
Freaking out about the jump from classroom to clinicals? Don't worry, we've been there too. That's why we made this go-to guide to help prepare for clinical rotations. Consider this your trusty sidekick, packed with top-notch rotation advice and real-life tips from med students who've been in your shoes and made it out on the other side.
The internal medicine service is responsible for taking care of all of the patients with medically managed issues admitted to the hospital. They are generalists, which means they are responsible for admitting and discharging medical patients but will consult other specialties (medical and surgical) when they need an expert opinion. This often puts internal medicine in a medical administrative role as they shoulder ultimate responsibility for their patients during their hospital course.
Internal medicine can be both inpatient and outpatient (many primary care providers are internal medicine boarded physicians). The only difference is that outpatient patients do not stay in the hospital and inpatient patients stay in the hospital.
Your IM rotation can vary depending on your school’s curriculum. I completed 6 weeks of inpatient IM and 3 weeks of outpatient IM as separate rotations with separate evaluations. However, I met other students in different programs who did 12 weeks of inpatient internal medicine as well. You are usually responsible for being at the hospital 6 days a week, with one day usually a half day after you are on-call.
A typical day on IM starts at 6-6:30 am with individual patient rounding and reviewing patients' records. Sign-out begins at 7 am, where you observe the night residents handing off patients. Afterward, you see your patients again, take good notes, and present in SOAP format. Rounds with the attending happen around 9-10:30 am, where you present patients either at the table or outside the patient’s room, depending on the attending's preference. Post-rounds, you continue patient care, write progress notes, discharge patients ready for lower acuity care, and possibly admit new patients from the ER. Throughout the day, you update patient statuses, respond to acute issues, and complete bedside procedures. Your residents sign out around 4-5 pm, and the on-call team covers until the night team arrives at 7 pm. On call days, you also handle emergency responses and admit patients, staying later and typically having a half-day the next day to recover.
Arrive 6-6:30am: Get to the hospital prior to sign-out (usually starts around 7 am) to do your individual rounding on a patient. Arriving about 30 minutes to an hour early should give you enough time to pre-round on your previous patients by yourself.
~7am: After you see your patients, you will go to sign-out where you will meet your resident team and will observe while the night residents sign out patients to their respective teams (both old and newly admitted patients).
~9-10:30am: When the attending arrives, you’ll start rounds.
After rounds have finished, you will continue to care for your patients and will work on discharging patients that are ready to go home or to short-term or long-term rehab/care facilities.
You may also admit new patients from the ER that are high enough acuity to need inpatient medical care. You will likely go down to the ER with your residents to see the patient and take an H&P with or without your attending present prior to them being moved up into a medicine bed.
This is also the time of day when discharge and H&P notes are written. Your team will check in with their patients periodically throughout the day, complete any bedside procedures that are needed, and respond to any acute medical events concerning them.
Your team will then “run the list” which entails going down your patient list and updating their status (maybe they are ready for discharge or they need to be transferred to the ICU). All the while your residents and AI will be writing orders for medications, procedures, and consult other medical/surgical services for your patient list.
~4-5pm: Your residents will sign out their patients around 4-5 pm (don’t rely on this time if the day is busy) and the on-call team will cover until the night team gets to the hospital around 7 pm. It is possible you will be dismissed before sign-out, but do not count on this especially if it is a busy day.
If you are the team on call for the day, you will also likely be the emergency medical response team. This means you will respond to all pages for acute medical issues in the hospital.
Your team will likely not have to pick up any new admits that morning but will start getting admits after a certain time during the day. You will stay later than normal that day before signing out to the night team around 7 pm but will usually have a half-day the next day to recover.
If you are on an outpatient IM rotation, your day will be very similar to your day on your primary care rotation, so I would suggest you check out the write up for that guide as well! However, not all medical schools will require an outpatient IM rotation and will just do 12 weeks of inpatient IM.
Residents will be giving a large amount of your clerkship rotation feedback and attendings and clerkship directors will go to them for feedback on your performance as well.
You don’t need to be your resident’s best friend (don’t be a suck up, they hate that), but ultimately it helps if residents like you and can rely on you for even small tasks. This may take time before they trust your ability not to make mistakes that can injure the patient, so try and be helpful with small tasks to start with, such as taking notes, vital signs, etc. Once they trust you, they will likely give you bigger tasks and allow you to get more involved with patient care. This isn’t necessary, but I do think that getting more involved in your rotations than the bare minimum does positively affect your evaluations and make you into a better student-physician!
Remember, residents also have the ability to affect your residency application to their program and can black ball you if they think you won’t be a good fit for the program or can advocate for you if they think you will be a good fit.
You will eventually be asking attendings for letters of recommendation, so it is a good idea to make sure they see you perform well on your clerkship and get to know you, so you aren’t a complete stranger when you need to ask during 4th year rotations.
IM rotations are special since all students will do a required 3rd year clerkship and a 4th year acting internship rotation in IM. That being said, it is not the end of the world to ask an attending for a LOR during your 4th year if you have never worked with them before, but it can help if you have met them before and worked with them during your 3rd year clerkship so they already have an idea of how you perform as a medical student on an IM rotation.
Many other specialties will also utilize IM letters so developing a relationship with IM attendings is super important even if you are applying to a specialty that is not IM.
You will be interacting with nurses every day on your rotation. One of the biggest mistakes I see medical students make is to discount nurses’ experience/knowledge and not utilize their expertise. I have even heard of medical students being rude to nurses. They will not forget that. Your interaction with them as a medical student is not as integral as your interactions with them as a resident will be (they are an important part of your care team in every specialty), but they can teach you a great deal due to their plethora of experience.
If you are looking to get more involved with patient care beyond just rounding with your residents/attendings and writing notes, they are your gateway to the patient as they have the most contact with them out of any one on the care team. Everyone loves a resident who can be helpful with their patient beyond just assessing them and writing orders. This gives you a chance to practice working with nurses and develop your own approach to this professional relationship you will have in a couple years. All of this is even more important when approaching your IM acting internship as a 4th year because you will be acting as a 1st year resident at this point.
Developing this relationship can take time before nurses trust you not to make mistakes, so my advice similar to residents is to approach this relationship with humility and recognize that even though you are clearly an awesome individual who was able to get into medical school, there are many things you don’t know yet, so asking how you can be helpful is a great first step as well as indicating you are interested in learning how improve your bedside patient care. Once they see they can trust you with smaller tasks, they are more likely to teach you more complex tasks. This is not something that is required on your rotation, but at the minimum, I think practicing how to have a good professional relationship with your patient’s nurses is something you should develop during your rotation.
Finally, nurses may not be grading you in an official capacity, but residents and attendings can go to nurses to gather feedback on you for their own evaluation, so developing a good relationship with them can be highly beneficial for you as well.
Similar to what I wrote above in the nurses section, you will eventually be a resident and will be expected to maintain a professional working relationship with your entire care team (i.e. Nurse Assistants/Surgical Techs/Patient Transport/Respiratory therapists). All of these players make important contributions to helping a hospital run and to everyday patient care. If you can develop yourself as a student doctor who is respectful and helpful, you will be an awesome resident someday.
Similar to nurses, residents and attendings can go to nurse assistants, techs, etc. to gather feedback on you for their own evaluation, so developing a good relationship with them can be highly beneficial for you as a student as well.
You never know - you may also find a mentor here!
Everything you need to complete a full patient history and physical examination. The ability to complete an in-depth patient assessment is a cornerstone of the IM clerkship as IM physicians take overarching responsibility for most medical patients (and eventually some post-surgical patients) and consult other specialties as needed.
However, IM is the specialty that organizes the overall care of medical patients in a hospital, so as a medical student on your IM rotation, your goal is to be able to replicate this the in-depth patient assessment needed to produce a history and physical on newly admitted patients, how to assess patients day-to-day progress and to ultimately discharge them when ready (though you may not be responsible for writing all these notes yourself). This is a good goal to have when approaching your IM rotation.
Materials needed for a physical examination that are not commonly in every patient room such as:
The rest of the equipment you’ll use (blood pressure cuff, pulse oximetry monitor, etc.) should already be in the patient's room. However you may need to source objects for a neuro exam to test sharp and soft sensation (cotton ball, broken tongue depressors, etc.).
The equipment you need to take a history on a patient as well as day-to-day notes includes scrap paper (blank printer paper or notebook) or if your residents show you how to print out a list of your patients you can use that as well.
As explained in the General Principles section, medical students on their IM rotation are primarily responsible for presenting patients to the care team during rounds and writing notes on their patients. How well students complete these assignments factors into their ultimate evaluation by the residents and attendings they worked with during their IM rotation.
Prepare patient presentations for their assigned patients for the day by independently seeing these patients and taking a history and physical prior to rounds.
Write notes on these patients which are then reviewed and edited by their residents. So expect to pre-round on patients/present them everyday and then write notes on patients.
H&Ps and discharge summaries are more involved than progress notes so it is possible students will not be asked to write these types of notes, but check with your medical school clerkship curriculum and your residents.
Write an H&P that only your course director or attending will read, so you can get feedback on writing this type of note without it going into a patient’s EMR.
You may be asked by your attending to prepare a short presentation on a subject you had trouble understanding or that they just want to assign to you to present to the care team (usually a short oral presentation during rounds), and your medical school clerkship curriculum might also have the requirement for you to prepare a more in-depth presentation on a topic during your rotation.
As I said above, evaluations are based on improvement and not how you do with these assignments initially as there is a steep learning curve involved in your IM rotation. So no matter where you start in your ability to complete patient presentations and write notes, just focus on improving every day of your rotation and your evaluation will be great! 😊
SOAP format to start:
Introductory statement and chief complaint (patient is a 67 year-old female with a past medical history of stable angina, hyperlipidemia, and hypertension who presented to the ER with 1 hour of radiating chest pain, nausea, and vomiting)
Every attending is different, so a good rule of thumb is to start with SOAP format, and then if they tell you they want you to present another way, be flexible, note the changes you need to make to your presentation format and present that way the next time you work with them.
This need to tailor presentations and patient care to your specific attending will not change when you are a resident, so it is best to develop your flexibility and ability to take criticism as a student doctor rather than as a resident when the stakes are much higher.
This advice also works for any criticism you get from residents or attendings during your presentation: have a thick skin, be flexible to changing how you are doing things, and remember that criticism is not necessarily negative, it is how you respond to the criticism that will define your professionalism and ability to work with all different kinds of people.
Often the attendings and residents you work with are tired and overworked and they also do this almost every day of their lives. No matter how they convey it to you, they have experience and knowledge that will be invaluable to your own development if you are able to distill it down into something useful.
There are too many to list unfortunately because IM is an incredibly broad specialty where providers are required to have a good understanding of a huge spectrum of pathologies, but not necessarily be experts in any of them. However, a good rule of thumb when preparing for questions during rounds is to think about pathologies in a SOAP format.
All this requires you to have a good understanding of physiology, microbiology, pharmacology, and pathology which is a staggering amount of information.
The good news is that you just spent 2 years on learning all of this during your preclinical years. The bad news is there is no good way to prepare to know everything prior to your 3rd year IM rotation because it is inherently such a broad field of medicine.
So what I would recommend is preparing for questions on a case-by-case basis. If you get one patient with COPD and another with an AKI, read about COPD and AKI prior to sign-out/rounds or one-on-one time with your attendings and organize your notes in a SOAP format for both of those pathologies.
This is where Sketchy Clinical can be very useful (they organize all their videos in SOAP format) as well as quick resources such as AMBOSS/other medical resource apps or Pocket medicine.
You may only have a few minutes to look something up before a potential questioning session but it is super useful to cram that information even if you don’t learn everything right at that time. You will develop your long-term retention via note writing (especially in the assessment and plan sections) and in your independent studying for the shelf.
The IM shelf is more difficult than any of the other shelves and therefore has a generous curve, but depending on your program your shelves may still be graded vs. pass/fail so your score may be the differences between honors and pass on your clerkship.
Even if your medical school is pass/fail, they may still rank you and your classmates internally. So check your school’s grading policies before determining whether you need to just pass the IM shelf or need to crush it (however learning the material as well as possible is always important because you will be tested on Step 2 during your 4th year).
Due to the difficulty of the exam, my classmates and I approached this exam as a Step 1.5.
Let’s be clear, just passing the IM shelf is difficult, never mind scoring in the high 70s-90s. You will have to put in serious amounts of studying no matter your goal on this exam and a percentage of students do fail the exam their first time and have to retake it.
Studying during clerkship year is difficult because you have to balance the responsibility of being at your clerkship during the day with also having to study for your clerkship exams and Step 2 eventually. Some students just focus on being at their clerkship during the day and then study at night. Others will try and study during downtime during the day if possible. The second approach has the advantage of reducing the amount of material you must study when you get home after clerkship. However, it can be hard to balance studying and working at the same time and you don’t want to be seen by residents as shirking your clerkship responsibilities.
Resources and timelines:
Studying in addition to working hard on your clerkship is not easy during your IM rotation, so be prepared to put in some serious work, but it will be worth it once you crush your shelf and get great evals back from your attendings/residents.
Approach this clerkship as a warm-up to your IM acting internship during 4th year. You will not have the same level of responsibility or expectations as you will during your AI, but you can attempt to hold yourself to a similar level of responsibility and residents and attendings will see this.
Work up to taking on several patients (maybe 3-5 patients) rather than just the minimum number required by your clerkship requirements.
Know all your patients in a high level of detail and stay updated with current developments in their healthcare plan rather than ignoring them after presenting them and writing their notes in the morning.
Work on being actively helpful to your residents by volunteering to contact patient’s families to update them or gather more information, gather medical records that are incomplete from other hospitals or clinics, and be actively involved in bedside patient care whenever possible (vital signs, help move the patient, watch/assist bedside procedures like NG tubes, chest tubes, etc.).
Work hard to develop the assessment and plan sections of your presentation (the hardest parts by far) and try to take an active role in suggesting first-line medical interventions and medications for all your patients rather than waiting to be asked. It’s ok to be wrong but ask questions and learn from the explanations you receive so you aren’t making the same mistakes twice.
You won’t need to ask for a LOR during your third year but do develop good relationships with attendings you might want to ask for a letter during your 4th year. That way they know you already and have worked with you will be more likely to be willing to write you a letter when you discuss this with them at the beginning of your AI in IM.
Consider asking your residents once you have gotten to know them if there are any case reports you can assist on. These look great on your resume and can help deepen your relationship with your residents.
xx
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