One aspect of internal medicine that is unique to the UKCOM is the ability to select rotations (usually two weeks in duration). Some of these rotations include cardiology, MICU, and hematology. These are great opportunities to explore areas of future interest or to focus on weak areas for improvement.

At UKCOM, you can select from Chandler Hospital, Good Samaritan, and the VA for wards. Each of these offer fantastic opportunities to train in the breadth and depth of internal medicine. Most of the rotation was devoted to inpatient medicine, and as such the bulk of this article is devoted to general and specific advice to excel on wards. 1. Show up EARLY. During my first week of internal medicine, I found myself to be rushed in preparation for rounds and my performance in presenting patients suffered because of it. I found that showing up thirty minutes earlier allowed me to follow up labs, collect my thoughts, organize my presentations, and run plans by my residents prior to rounds. My improvement throughout the rotation can largely be attributed to this simple step. 2. Read about your patients. I would often follow a patient for more than one consecutive day and would read about a patient’s condition in the evening after coming home from the hospital. If you find information that evening that is relevant and changes management of the patient, present it on rounds the following day! 3. Ask attendings for feedback and expectations. This especially holds true regarding expectations for oral presentations on rounds. Attendings and residents can often have varying preferences regarding what they would like to see out of a medical student presentation. Some attendings might prefer longer, more detailed presentations with vital ranges, but others desire presentations that focus on pertinent positives and negatives. As a rule of thumb, new admissions warrant a thorough HPI and will likely take much longer to present. ESTABLISH EXPECTATIONS EARLY ON! 4. Develop your assessment and plan. As a spin-off of my last point, the assessment and plan are the most critical portions of your presentation. Many third-year medical students are timid with presenting an assessment and plan out of fear of being seen as too assertive. However, I feel that offering suggestions for changes to management is WHY you are training at an academic medical center! Ensuing discussions regarding your proposed changes are where learning takes place. I have found that attendings respond positively to student input on management of patients. 5. Practice calling consults. As a medical student, you will likely be looking for ways to be helpful to your team. One way to do this is by calling a consult. This can most certainly be an intimidating process, but it is one you will also likely be doing regardless of your future specialty. Always offer to call a consult to ease the burden on your residents and they will thank you! 6. Don’t focus on zebras. As a medical student, it can sometimes be tempting to immediately jump to rare diseases as the cause fora patient’s presentation. Fight this urge. Yes, you WILL encounter rare diseases while training at an academic medical center, but an atypical presentation of a common ailment is often more common than a textbook rare disease. If the search for common diseases does not pan out, at that time begin to include rare diseases in your differential. 7. Learn basic renal pathology. Medical students, residents, and attendings often agree that kidneys are perplexing. One guarantee is that you will encounter renal pathologies in your time on wards. Therefore, it is worth your time to have a firm grasp of common renal pathologies, especially acute kidney injuries. Being able to delineate between prerenal, postrenal, and intrinsic renal injuries and state in your presentations WHY a patient fits a certain diagnosis demonstrates clinical reasoning and sets you apart from other students. 8. Establish an approach to reading chest imaging. At this stage, few will expect you to be a radiologist. . . in fact, nobody expects you to be a radiologist (unless you are one). However, one situation I’ve found is that patients are often seen on rounds before a radiologist has interpreted the imaging. By taking the time to state your own findings (even if completely wrong), you are taking initiative and demonstrating an ability to think for yourself. 9. Develop an approach to interpreting ECGs. A rite of passage as a medical student is being handed an ECG on rounds and asked to interpret it. Developing a systemic approach to each ECG is critical. By identifying rate, rhythm, axis, wide or narrow QRS complexes, and regular or irregular, you can usually reason your way to accurately identifying a common tracing. Even if you are unable to recognize the pattern on the tracing, you can still supply useful information by stating the aforementioned qualities of the ECG by applying a structured approach to each reading 10. Learn to perform a detailed HEENT physical examination. I’ve found that this is an often-neglected portion of the physical examination. You can often find interesting findings when thoroughly examining these regions. Systemic disease often manifests in the oropharynx, ears, and eyes. For instance, oral ulcerations can often be found in patients with lupus, conjunctival pallor in anemia, and leukoplakia as an antecedent to oral cancer. However, most attendings are interested in hearing pertinent positives and negatives. By presenting relevant HEENT findings, you demonstrate thorough physical examination techniques that are likely to impress your attending.

The internal medicine rotation largely focuses on inpatient medicine, but continuity clinic was one of my favorite experiences of medical school thus far. In this component of a rotation, you are placed with the same preceptor for one afternoon weekly. The continued, one-on-one contact is the likely the longest you will be with the same attending in all of third year. This offers a great opportunity for a strong letter of recommendation as you work closely with the same physician for nearly two months. 1. Ask your attending for expectations regarding notes. My attending preferred that I continually see patients and instead have residents write notes to maximize my learning. Be sure to establish this prior to seeing your first patient. 2. Be familiar with USPSTF guidelines. As mentioned in the family medicine article, applying USPSTF guidelines to your patients ensures that they receive age-appropriate screening. 3. Work efficiently. Clinic is fast paced. As mentioned in the family medicine article, attendings are often under pressure to see many patients in a short amount of time. Make sure to streamline your presentations to convey the required information to the attending without including extraneous and superfluous details.

The internal medicine shelf exam is incredibly broad, but it also demands an appreciable amount of depth in many topics, with cardiology as the most heavily tested subject. Aside from traditional questions regarding knowledge of internal medicine’s various organ systems, biostatistics is a component of the exam that students often neglect. In addition to its intrinsic difficulties, this exam becomes challenging to study for after a long, exhausting day in the hospital. 1. Questions, questions, and more questions. Most students select UWorld as their question bank on rotations, and the internal medicine section encompasses more than 1,200 questions. This leaves you with no shortage of material to study. I suggest making this the backbone of your method of studying as the common (and many of the esoteric) topics will be adequately covered with this. Your success on the shelf exam is directed correlated to the number of questions you complete! 2. Select a text and stick with it. This allows you to fill in gaps in knowledge left by the question bank and consolidate material. In addition, it allows you to look up information. By sticking with the same text, you become comfortable with the resource and able to quickly look up information. I personally used Harrison’s Principles of Internal Medicine for the shelf, but I (obviously) did not make it through cover-to-cover. Instead, I used it as a reference. Regardless of your choice of text, make sure to pick a resource you find helpful and stick with it. 3. Focus on weak areas. I am personally guilty of studying areas in which I find interesting or already proficient in, likely due to it being comforting. DON’T DO THIS With limited time to study for an incredibly difficult shelf, pick up points where you can and try to minimize points/questions left on the table. 4. Know common, “bread and butter” pathologies. On wards, you are likely to see cirrhosis, heart failure, COPD exacerbations, myocardial infarctions, AKIs, and gastrointestinal bleeding. As a result, it is also likely that you encounter these same pathologies on future exams. Be comfortable with diagnosis, workup, and treatment of common pathologies and it will serve you well! 5. Don’t neglect ambulatory medicine. Given the vast amount of information covered, it can be easy to overlook this section. Make sure to review it as it is high-yield for both clinic and examinations.