IM is the specialty where I want to go eventually. Given that I got "lucky" to get IM as a first rotation - I'm going to probably suck big time. Any tips to what major mistakes to avoid - so at least I won't act like a complete idiot? How hard is IM - meaning does it has steepest learning curve out of all rotations given the broad range of diseases it deals with? Really wanted to do it as a mid-year rotation after I gain some patient or history taking skills, but it is what it is.
IM as a first rotation - is it bad? How to survive? Thanks.
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You'll be fine. Take a deep breath. The luxury is that nobody expects you to actually know anything. So all you have to do is show up early, show initiative and pre-round on 1-2 patients and know everything about them. Then supplement your readings with the various pathology that you come across. Work on your physical exam skills.
Basic questions to always know the answers to:
- Are they on blood thinners? And if so, why?
- Pertinent past medical history?
- Are they on steroids for any given reason?
- What's their code status/living will?
I'm sure there's more but that's all I can muster at the moment.
It's not so much the rotation itself that is difficult but rather whether or not you get a good resident team to work with. Cheers.
Basic questions to always know the answers to:
- Are they on blood thinners? And if so, why?
- Pertinent past medical history?
- Are they on steroids for any given reason?
- What's their code status/living will?
I'm sure there's more but that's all I can muster at the moment.
It's not so much the rotation itself that is difficult but rather whether or not you get a good resident team to work with. Cheers.
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It wont make that much of a difference tbh. In addition, attendings and residents often have lower expectations when you first started out, they do expect you to improve over the course of your rotation tho so pay attention to each attendings' "style of presentation," attending A might want you to just give a succinct presentation whereas attending B wants you to read the full autobiography of such patient.
IM is pretty broad but about 90% of the time inpatient IM will be COPD, Afib, CHF, asthma exacerbation, a few DKAs here and there, PEs, Pneumonia, HTN emergency, ESRD, AKI, stroke, MI etc. These are the biggies, I bet you will see at least 1 or 2 of each of these during the first week of your rotation, pay attention to the management and the reasoning for such management during this first week, if you have nice residents and interns, they will prime you up for success. Read the notes especially the Plan and Assessment.
If anything with the Step 1 minutiae still fresh in your cranium, you will be able to recall and answer the more esoteric pimp questions.
You will be assigned a few patients to follow, own those patients, those are YOURS. Ask if you can go see the patients first and do the admission, write the n0tes, go home read on their conditions, pre-round on them the next day, talk to the nurse to get the updates from the night before.
Read the consultants' notes so you can mention it in your presentation of your plan, your attending will ask "so what do you want to do?" you can say "so I saw that Cardiology has dropped a note and this is their recommendation..." that way you can learn from these specialists and at the same time you can show that you pay attention to details and follow your patients closely. Also labs, studies, imaging results.
NEVER EVER LIE about something you didn't do, its ok to say "idk," "I forgot to do it" "I'll go look it up"
If you don't know something, it's ok to ask questions during round but if rounds are getting too long, learn to keep your mouth shut or your residents will hate you
The nice perk of having IM first is that it gives you a nice foundation for the rest of your 3rd rotations and shelf exams. I learned a **** ton after 12 weeks of IM
IM is pretty broad but about 90% of the time inpatient IM will be COPD, Afib, CHF, asthma exacerbation, a few DKAs here and there, PEs, Pneumonia, HTN emergency, ESRD, AKI, stroke, MI etc. These are the biggies, I bet you will see at least 1 or 2 of each of these during the first week of your rotation, pay attention to the management and the reasoning for such management during this first week, if you have nice residents and interns, they will prime you up for success. Read the notes especially the Plan and Assessment.
If anything with the Step 1 minutiae still fresh in your cranium, you will be able to recall and answer the more esoteric pimp questions.
You will be assigned a few patients to follow, own those patients, those are YOURS. Ask if you can go see the patients first and do the admission, write the n0tes, go home read on their conditions, pre-round on them the next day, talk to the nurse to get the updates from the night before.
Read the consultants' notes so you can mention it in your presentation of your plan, your attending will ask "so what do you want to do?" you can say "so I saw that Cardiology has dropped a note and this is their recommendation..." that way you can learn from these specialists and at the same time you can show that you pay attention to details and follow your patients closely. Also labs, studies, imaging results.
NEVER EVER LIE about something you didn't do, its ok to say "idk," "I forgot to do it" "I'll go look it up"
If you don't know something, it's ok to ask questions during round but if rounds are getting too long, learn to keep your mouth shut or your residents will hate you
The nice perk of having IM first is that it gives you a nice foundation for the rest of your 3rd rotations and shelf exams. I learned a **** ton after 12 weeks of IM
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Read about your patients.
Usually there's a progression of responsibility. Not much is expected of a third year - show up, be enthusiastic and take the initiative. Ask your intern or resident if there's anything you can help with, e.g. making/returning phone calls, that kind of thing. Ask for advice on how to present, how to write an H&P, how to write a progress note, and if you get good with those, ask if you can try writing orders, which can be cosigned. One important thing about presentations: there is variation from attending to attending and service to service. Ask early on how they prefer presentations and then stick to it as long as you're on that service with that attending.
Don't ever lie and say a finding was positive or negative if you didn't actually do it. Just be honest and say you didn't ask, didn't check, or you will go back to ask or check. Interns, and moreso residents and attendings, know their patients pretty well, believe it or not, and if you lie to them, you're hurting yourself in that you don't look like the kind of person they'd want to advocate for when it comes time to find a residency spot in their specialty.
Ask for feedback. It doesn't have to be formal, but reflection is an important part of clinical practice. Hopefully, you have some insight into your ability and knowledge and have an understanding of what you're doing well and what you can improve upon, but it's a good idea to ask for feedback from your interns, residents, and attendings. It shows maturity and that you're probably teachable.
Usually there's a progression of responsibility. Not much is expected of a third year - show up, be enthusiastic and take the initiative. Ask your intern or resident if there's anything you can help with, e.g. making/returning phone calls, that kind of thing. Ask for advice on how to present, how to write an H&P, how to write a progress note, and if you get good with those, ask if you can try writing orders, which can be cosigned. One important thing about presentations: there is variation from attending to attending and service to service. Ask early on how they prefer presentations and then stick to it as long as you're on that service with that attending.
Don't ever lie and say a finding was positive or negative if you didn't actually do it. Just be honest and say you didn't ask, didn't check, or you will go back to ask or check. Interns, and moreso residents and attendings, know their patients pretty well, believe it or not, and if you lie to them, you're hurting yourself in that you don't look like the kind of person they'd want to advocate for when it comes time to find a residency spot in their specialty.
Ask for feedback. It doesn't have to be formal, but reflection is an important part of clinical practice. Hopefully, you have some insight into your ability and knowledge and have an understanding of what you're doing well and what you can improve upon, but it's a good idea to ask for feedback from your interns, residents, and attendings. It shows maturity and that you're probably teachable.
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Show up and work hard.
As some of the others have said, do not lie about patient findings/exams.
You'll learn as you go. There's no sense in worrying about it right now and people won't expect much of you at all.
Keep everything systematic. Always get your history in a specific order just then do a focused exam then give a concise, orderly presentation. Many diagnoses can be made 80% time with just a good history-taking.
When the resident in charge of you tells you to go home, never ask, "Are you sure?" Just say, ok, leave the hospital, and enjoy your life.
As some of the others have said, do not lie about patient findings/exams.
You'll learn as you go. There's no sense in worrying about it right now and people won't expect much of you at all.
Keep everything systematic. Always get your history in a specific order just then do a focused exam then give a concise, orderly presentation. Many diagnoses can be made 80% time with just a good history-taking.
When the resident in charge of you tells you to go home, never ask, "Are you sure?" Just say, ok, leave the hospital, and enjoy your life.
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Use your patients' illnesses to serve as a guide of what to review on any given day.
Quick list of high yield topics:
-Chest Pain/ACS
-CHF
-Afib
-COPD exaccerbation
-Pneumonia
-Infections/Sepsis in general-> PNA, UTI, bacteremia
-Abdominal pain -> Cholecystitis, pancreatitis
-Alcohol withdrawal
-Tox/drug overdose
-DKA
-Renal insufficiency/AKI/acute renal failure
-Stroke/TIA
Have some sort of handbook/reference handy that you like. I've always liked the Washington Manual series and used that small Pocket Medicine handbook by Mass General.
Don't lie, ever. MUCH better to say you didn't ask or do something on an exam than make it up.
Don't be afraid to say you don't know. Conversely, if they ask you after presenting a patient what you'd like to do then certainly feel free to offer up a possible management plan even if it may be wrong. We also just don't want scribes who are just collecting data but not attempting to synthesize the information into some sort of plan and integrate what they've read.
Use this time to develop some sort of consistent approach to taking a history and performing an exam. Unfortunately I think with EMRs and at some places limited ability for med students to document the skill of putting together a coherent HPI is declining. When I first started on rotations as a student we didn't have an EMR system yet and we as med students would first do the H&P, write it up and then review it with the intern/resident though it would be used in the chart. And when you're doing history, ROS or exam try and be consistent. Obviously each situation will call for slightly different approaches and questions, though if you do it completely different each time then it's easy to miss things. If you develop a consistent approach (Same general approach to the HPI, same 2-3 questions for each system for your ROS, same order for your physical exam, etc...) then I've found it's less likely you'll skip over something.
Quick list of high yield topics:
-Chest Pain/ACS
-CHF
-Afib
-COPD exaccerbation
-Pneumonia
-Infections/Sepsis in general-> PNA, UTI, bacteremia
-Abdominal pain -> Cholecystitis, pancreatitis
-Alcohol withdrawal
-Tox/drug overdose
-DKA
-Renal insufficiency/AKI/acute renal failure
-Stroke/TIA
Have some sort of handbook/reference handy that you like. I've always liked the Washington Manual series and used that small Pocket Medicine handbook by Mass General.
Don't lie, ever. MUCH better to say you didn't ask or do something on an exam than make it up.
Don't be afraid to say you don't know. Conversely, if they ask you after presenting a patient what you'd like to do then certainly feel free to offer up a possible management plan even if it may be wrong. We also just don't want scribes who are just collecting data but not attempting to synthesize the information into some sort of plan and integrate what they've read.
Use this time to develop some sort of consistent approach to taking a history and performing an exam. Unfortunately I think with EMRs and at some places limited ability for med students to document the skill of putting together a coherent HPI is declining. When I first started on rotations as a student we didn't have an EMR system yet and we as med students would first do the H&P, write it up and then review it with the intern/resident though it would be used in the chart. And when you're doing history, ROS or exam try and be consistent. Obviously each situation will call for slightly different approaches and questions, though if you do it completely different each time then it's easy to miss things. If you develop a consistent approach (Same general approach to the HPI, same 2-3 questions for each system for your ROS, same order for your physical exam, etc...) then I've found it's less likely you'll skip over something.
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Every response in here has excellent advice. Take it to heart and you will do well.
IM is actually the best rotation to start out as a MS3. It gives you all the core fundamentals you will need to succeed during your entire 2 years of clerkships --- rigorous work schedule, teamwork with other students and residents, seeing how consultants work, meat & potatoes of every day hospital medicine (H&P, daily notes, treatment plans, discharge plans, etc), and the opportunity to learn/do procedures.
Plus like others have said, attendings and residents know you are a freshly minted MS3 so they will go easier on you versus an MS3 in January who is expected to know the ropes of routine clinical stuff by that point. If you wanna make a great impression --- project yourself as a VERY humble student who is not afraid to say "I dont know" and don't be afraid to ask anyone (nurse, X-ray tech, PT/RT) for advice. This is not the time to act like God's gift to the wards because if you do then you will be beaten down and humiliated quickly!
It's gonna be tough but also very educational, so enjoy the experience.
IM is actually the best rotation to start out as a MS3. It gives you all the core fundamentals you will need to succeed during your entire 2 years of clerkships --- rigorous work schedule, teamwork with other students and residents, seeing how consultants work, meat & potatoes of every day hospital medicine (H&P, daily notes, treatment plans, discharge plans, etc), and the opportunity to learn/do procedures.
Plus like others have said, attendings and residents know you are a freshly minted MS3 so they will go easier on you versus an MS3 in January who is expected to know the ropes of routine clinical stuff by that point. If you wanna make a great impression --- project yourself as a VERY humble student who is not afraid to say "I dont know" and don't be afraid to ask anyone (nurse, X-ray tech, PT/RT) for advice. This is not the time to act like God's gift to the wards because if you do then you will be beaten down and humiliated quickly!
It's gonna be tough but also very educational, so enjoy the experience.
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get there early, learn 1 or 2 patients really well
be nice and humble
do a lot of reading
gradually work your way to 3, maybe 4 patients by end of rotation.
But don't overextend yourself. It's better to go slow, and be very methodical.
Get to know your residents, ask them questions, be respectful of their time.
Never interrupt another student or resident during rounds.
If you have a theory or idea about a patient, bring it up. You'll get respect for at least trying.
be nice and humble
do a lot of reading
gradually work your way to 3, maybe 4 patients by end of rotation.
But don't overextend yourself. It's better to go slow, and be very methodical.
Get to know your residents, ask them questions, be respectful of their time.
Never interrupt another student or resident during rounds.
If you have a theory or idea about a patient, bring it up. You'll get respect for at least trying.
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Whether it is good or bad depends completely on the rotation. IM clerkship is not the same at every school.
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I am not in IM but what I tell every medical student that I work with is “I don’t expect you to know anything, but i expect you to want to learn and work hard.” If you can do that, you will be fine.
