Q/A on IM Clerkship

[HarryRosenMD]

.Hi….​

.First off… Windows Vista is a recurrent thorn on my side... as it was the reason I could not participate in the live chat arranged by SDN . However... we could try a thread..

.I'll try to answer the days questions all together late tonight..​

.I want everyone to feel at ease and comfortable with asking anything they want. .​

.I am a Hospitalist at West Hills Medical Center in Southern California… loving inpatient disease diagnosis and treatment. I figure that one good way to start off our chat is with a kind of primer to the typical morning on the Internal Medicine wards. .​

.Always show up on time! Always! You need to be a team player, as well as make your personal mark during the clerkship. One way to show that you are mature and serious about the responsibilities you will be given is to be there on time. The morning flows as follows:.

.6-7am:.. Arrive at the hospital to pre-round on your patients. .

.The term pre-rounding is used to denote the fact that formal rounding with your team and attending will occur afterwards. You will typically be responsible for following an average of 3 patients alongside the interns, who will usually be responsible for 8 to 12 patients each. The teams are typically comprised of 2 interns (sometimes 3), 1 resident (sometimes 2), 1 attending physician… along with perhaps a pharmacist, nutritionist, social worker, and 1-2 medical students. .

.Pre-rounding consists of you obtaining your patients' overnight information, current status, and to some extent… plan for the day. Prior to seeing each patient at bedside… get the information regarding:.

.Overnight vitals.

.Imaging results:.. CXR, CT, MRI, PET, Echocardiogram.​

.Invasive Procedures:.. Endoscopy, Surgery.

.Medications:.. Know the reasoning behind each medication being given.

.Nurses assessment:.. Always…. always… always befriend the nurses, and ask them to fill you in on their overall assessment of the patient. Nurses can be a great source of ‘insider' information – as they typically know the patient best..

.Then go and see the patient..… being armed with all the background information needed. Go over overnight events… ensuring to review possible issues about the chief admission complaint, pain, appetite, ambulation, bowel-bladder movements..

.Then meet with the intern(s)..… and exchange information. Just let them know the overall picture. Give them the short and sweet about what's going on with their patient(s). If something is concerning (ex. vitals, labs, imaging, etc..) LET THE INTERN KNOW so that they can assess the situation… after which they will report to the resident..

.Then meet with the team resident.., who will typically have a mini-rounds session of their own in order to get an idea of what's happening with the patients in general. .

.Then meet with the team attending.., who will then do formal rounds with the entire team… expecting:.

.- Full History and Physical presentations on new patients.
.- Full SOAP note presentations on old patients.

.Formal rounds may last several hours. Sometimes until lunch. Then you break off to do the days work… .​

.Now ask away!!!!!!!!!!!!!!!!!!!!.

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[Scaredshizzles]

Why do students who clearly suck up to attendings tend to get better evals? This is not true of all attendings, as a good number of them evaluate you on what really counts. But then there are always some attendings (who generally aren't very good, spend round time discussing obscure topics (i.e. the economic solvency of keeping patients inpatient for MRI/EEG/echo/halter workup of first time sz's---there are worse examples but I can't recall right now) instead of actually discussing patient care or more serious topics in medicine), who don't ask for patient or topic presentations from students, and instead evaluate them based on how much the student sought them out in the halls to engage in suck up/small talk.... And if said student fails to do so, will be evaluated negatively based on observations the attending never actually was present to make.

 

[dbhvt]

I'm not there yet, but I understand IM rounds can be very very long. Any tips for how to stay plugged in and turn it into an educational experience instead of an endurance test?

 

[HarryRosenMD]

Why do students who clearly suck up to attendings tend to get better evals?

Nice question. Making a connection with someone on the team... esp. the attending can help you in several ways... both increasing the likelihood of a favorable grade and letter of recc. Whether or not this happens for purely selfish 'suck-up' reasons, vs. simply truly having a good time with someone is hard to differentiate. Its not objective or fair... but very little is. I was truly astonished by the amount of politics/ boys club that goes on within the field. It permeates every aspect... as I suspect it does of every other field. You need to learn as much as you can, and stay true to who you are. But theres always something to be said for getting into 'the boys/ girls club' so to speak.


Any tips for how to stay plugged in and turn it into an educational experience instead of an endurance test?

Nope Listen... you can try all you want to be interested in others' presentations... but the actuality is that you are:
A. Often tired
B. Concerned about your upcoming presentation(s)
C. Answering pages you are getting regarding your patients
D. Potentially admitting patients
E. Leaning like the tower of Pisa, as you are standing the entire time
F. Fighting off some sort of hunger/ thirst/ bowel mvmt/ urination pang
G. Wishing Caffeine came in IV form

Just focus on getting something out of each morning rounds session. As long as you learn something/ anything new each time... the rounds were worthwhile.

 

[Ypo.]

Which review book do you recommend? I had an attending tell me I needed to read Harrisons and only Harrisons.

 

[HarryRosenMD]

Which review book do you recommend? I had an attending tell me I needed to read Harrisons and only Harrisons

Buying Harrisons would be a waste of your time and money. Obviously a classic on its own... its only use is in the rare truly in depth reading required for some esoteric subject.

Big book:
Current Medical Diagnosis and Treatment 2008 by McPhee et al.

Handbook:
To be honest (and biased of course)... my book is awesome: The Consult Manual of Internal Medicine, being as in depth as you will need for the vast majority of disease syndromes. Check out the sample chapters at the website.

In general... you will likely buy several review books before settling down to your favorite... as its all a matter of personal style.

 

[Cards21aceking]

As a general question, what do you see as the most common mistakes that new 3rd years make when starting their medicine clerkship? And as a follow-up, are there any pieces of advice that you could offer to help avoid those common pit-falls?

 

[HarryRosenMD]

Hi...

Great question. The most common mistake is in being scared
Ultimately... your main goal is to learn. Try to relax and have some fun with it. Don't be scared to ask questions - that's your job!! Don't be scared to run everything by your intern - that's your job!! Dont be scared that you don't know how to function on the wards - you will learn. It's not rocket science. You will come to realize that there is a huge amount to learn... with you only being able/ responsible to grasp major fundamental concepts during your rotation - if your lucky - as it typically takes several years to truly build a strong foundation.
I realize that some students want to know everything - YOU CAN'T. No one can... so focus on the big picture. Don't read/ learn about Zebras - what a waste! Read - and read - and read about the disease syndromes your patients have: pneumonia, COPD/ asthma exacerbation, DVT/ PE, acute coronary syndrome, heart failure, renal failure, cirrhosis, diabetes, etc...
If a patient has a Zebra - dont take it. You need to grasp the fundamentals. The stronger your base... the better you will be as a physician for life. These next few years are your chance to ask away with minimal responsibility. Take advantage of it. Take in the big concepts like antibiotic treament and fluid management which will help you throughout your career.
There is no 'Golden' text. It doesn't exist, and never will, as everyone has their own personal way of learning. You will basically settle on 2 sources. One being a reference... with the other being your daily read - and read- and read. Definitely get the following for the wards:

Tarascon Pocket Pharmacopoeia - A fantastic compilation of all the medications you will be using from now on - being updated yearly. I like the Deluxe Edition - being bigger, with more information. Internal Medicine is about medications - so have this at your side at all times.

The Sanford Guide To Antimicrobial Therapy - A fantastic resource for antimicrobials - being updated yearly. The main use of this book for students is the table located in the middle, listing all antibiotics w/ their respective organism coverage - excellent.

Hope that helps.