Internal Medicine Clerkship Guide for 2022

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Internal medicine doctors are generalists—just like doctors who work in family medicine. They know the interplay of each organ system and often consider their patients deeply for many hours at a time.

Internal medicine is one of the most important core clerkships; it can lead to numerous other specialties, and the content of the USMLE 2 CK exam is 50-60% internal medicine. The internal medicine clerkship provides medical students with the opportunity to learn a vast range of medical knowledge and gain a better understanding of what it’s like to be an internal medicine doctor.

“He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.” – William Osler

This guide will cover the internal medicine clerkship, including when to place this rotation, how to make the most of your rotation, internal medicine resources, the Shelf exam, and the pros and cons of pursuing this specialty.

 

Intro to the Internal Medicine Clerkship

Clinical clerkships, also known as rotations, are when medical students practice medicine under the supervision of an established physician or health practitioner. Clerkships allow students to experience a specialty first-hand to see what it’s really like. This way, they can determine which field of medicine they feel most passionate about and want to pursue in their future career.

Most US medical schools require the following rotations:

Medical School Clerkship icons

Some schools may also additionally require other rotations, such as emergency medicine, radiology, anesthesiology, etc.

Internal medicine is the specialty that deals with the diagnosis, treatment, and prevention of an extensive number of diseases and illnesses that affect adult patients. It’s such a broad specialty that it’s difficult to categorize—there are so many different things you can do with it.

The internal medicine clerkship represents the gateway to numerous medical specialties and opens the path to fellowships in cardiology, oncology, nephrology, gastroenterology, rheumatology, hematology, infectious diseases, endocrinology, and pulmonary disease.

Internal medicine doctors are the generalists of generalists. They treat an incredibly wide variety of medical conditions, whether they be acute or chronic, common or rare, complex or straightforward. Pursuing this specialty requires you to be heavily involved with direct patient care. It’s also important to have a passion for learning because internal medicine doctors must analyze broad volumes of information in order to get their patients back to a healthy baseline.

Because of this, internal medicine is much more of an intellectual specialty compared to others. But that’s not to say that internal medicine physicians never use their hands; they can occasionally perform minor procedures, such as thoracentesis, paracentesis, intubation, and more, but it’s rare to perform these procedures after residency.

In the outpatient setting, it’s typical for internal medicine doctors to perform steroid joint injections, ultrasounds, Pap smears, skin tag or wart removals, and other similar, minor procedures.

But whether internal medicine sounds up your alley or not, the internal medicine clerkship is extremely important due to its impact on the Step 2 CK exam. The USMLE 2 CK exam contains 50-60% internal medicine questions. Since Step 1 is now pass/fail, the need to ace the internal medicine Shelf exam in order to be prepared for 2 CK is greater than ever.

The competencies trained in the internal medicine rotation also have a lot of crossover with other specialties. For instance, being able to read an ultrasound scan (US) not only serves cardiologists, but it’s also very useful in critical care and diagnostic radiology. Being proficient at taking a patient’s medical history not only benefits internal medicine doctors but it’s also helpful for psychiatrists.

 

When to Place the Internal Medicine Rotation

Where you place the internal medicine rotation depends on your interest in pursuing it as a specialty and when you plan to take the Step 2 CK exam. If you want to pursue internal medicine for residency, it’s most strategic to place this rotation second or third out of the total of four quarters of the year.

This will make sure you have a foundation of experience before you enter the rotation you feel the most passionate about. Placing it first, when you’re just getting the hang of your third year clerkships, may not be the best time for you to impress your seniors and attendings. Not placing it last ensures you’re able to get enough references for applying to away rotations and residency programs.

This will give you enough time to get used to the process while also leaving enough time to build connections. You don’t want to find out right before scheduling away rotations that you actually hate the specialty you thought you were going to pursue. You also may need time to acquire adequate letters of recommendation.

If you don’t plan to pursue internal medicine as a specialty, completing this rotation earlier can serve as a foundation for your next rotation since you will soak in a vast amount of information during this time. On the other hand, another practical option is to place this rotation last so that you can review all of the content you need to know for Step 2 CK, which contains 50-60% internal medicine questions.

 

Making the Most of the Internal Medicine Rotation

Structure

The internal medicine rotation is a mix of inpatient and outpatient.

The inpatient part of the rotation may seem daunting at first. Rounds will take an enormous amount of time. Sometimes you’ll be bored, and at other times, some pathology may catch your attention. However, it is up to you to make the most of this time.

Here are some tips for the inpatient rotation.

  • During rounds, answer each question the attendings provide you with. The objective isn’t to prove what you know or what you don’t; instead, it’s to test your knowledge. By the end of the rounds, you’ll have a clear picture of where the gaps in your knowledge are in regard to the cases you have seen. Jot these gaps in your knowledge down and follow up at home by reading about those pathologies.
  • If there is little activity, either find a place to study on your own (preferably with a PC station) or open up your Anki deck. The latter will greatly improve your breadth of knowledge, which is already a requirement of internal medicine. For the best Step 2 CK decks, see the Medical School Anki subreddit page. You can find several Anki decks on the page, but we personally recommend the latest AnKing deck.
  • Divine Intervention and Emma Holliday also have great 2-hour comprehensive review sessions for each clerkship. Emma Holliday recorded her review session a few years earlier than Divine, but her content is still very relevant. Divine videos were recorded more recently and may have more up-to-date content. Both are great resources. Watch their medicine Shelf review sessions, which can be found on YouTube, for a quick high-yield prep before the Shelf.
  • Get a pocket book as an on-the-go resource. This might take the form of the Oxford Handbook, the AMBOSS library, or simply the UpToDate app on your phone/tablet. UpToDate is more detailed, but it may be overwhelming. AMBOSS provides a great overview of knowledge important at the medical student level, but may not be the most up-to-date or detailed.

Not all schools offer an outpatient portion of the IM clerkship; however, if they do, this portion of your rotation will be less intense. At this point, you may have the opportunity to choose a sub-specialty clinic. For example, if endocrinology interests you, arrange with an endocrinology attending for your outpatient rotation. This time enables a medical student to:

  • Explore their IM interests
  • See what subspecialty fits their skillset
  • Network with physicians in their desired field

Important Topics to Understand Early On

Below is a list of high-yield topics for your internal medicine rotation. Having a good understanding of these topics early on will prepare you for practice questions and rounds to impress your attending.

Heart Failure

History – A patient with heart failure will complain of orthopnea, fatigue, and shortness of breath with effort. In order to classify their shortness of breath (SOB) in relationship with the effort, you can use the NYHA classification in the clinic.

  • Class I – SOB that ensues after vigorous exercise
  • Class II – SOB that appears with normal activity; the patient can still do their chores
  • Class III – The patient has a limitation in achieving their daily tasks due to SOB
  • Class IV – SOB at rest

Physical Exam – There will be a displaced apical impulse due to enlargement of the heart chambers. It is important to distinguish findings between left heart failure and right heart failure.

  • Left heart failure clinical findings include diffuse crackles bilaterally on auscultation, orthopnea, or paroxysmal nocturnal dyspnea.
  • Right heart failure clinical signs may include peripheral edema, hepatomegaly, hepato-jugular reflex, or jugular venous distension. This may indicate isolated right heart failure or that the left heart failure has progressed and has now caused right heart failure, since the most common cause of right heart failure is left heart failure.

Diagnosis

  • Chest X-ray shows diffuse interstitial markings at the hilum as well as Kerley B lines.
  • BNP is a marker of heart overload due to heart failure.
  • Echocardiography is the best initial step to differentiate between systolic HF and diastolic HF. The first one will present with a reduced EF (< 40%) while the latter has a preserved EF. It is more common to see systolic HF in MI and diastolic HF in the elderly.

Treatment

  • The medical management consists of ACEi and ARBs (decreasing the cardiac remodeling). Other medical treatments added are beta-blockers. Spironolactone is only useful for class III or IV types.
  • For symptomatic relief, digoxin is a viable option in the short term.
  • In patients with an EF < 35%, indicate an ICD for primary prevention of arrhythmias.

CAD/Angina/MI

History – Retrosternal chest pain with pain irradiating to the jaw or to the upper limb.

Physical exam – The patient can present with sympathetic activation, such as tachycardia, sweating, a sense of impending doom, or with PS activation (i.e., syncope).

Diagnosis – The diagnosis is made based on clinical presentation with an ECG. However, when the patient is known with previous MI, BBB, on digoxin, or with a pacemaker, the alternative to the ECG is the echocardiography. The next step is to administer the supportive treatment with morphine, nitroglycerin (not administered in right heart infarction), oxygen, and aspirin. When arriving in the ED, one can continue with the cardiac markers, such as troponin and CK-MB. The latter is better used for patients who had an infarction in the last week.

Treatment – If the pain started less than 90 minutes ago, the best next step would be a percutaneous coronary intervention with stenting. However, if the pain started more than 90 minutes ago, it’s recommended to start a fibrinolytic therapy.

  • The patient with MI will be discharged with BASIC
    • Beta blockers
    • Aspirin
    • Statins
    • Inhibitors of ACE
    • Control of modifiable risk factors – smoking cessation, exercise, diet

Hypertension

  • Diagnostic criteria
    • Two readings at more than two occasions show BP levels of higher than 140/90 mmHg
  • Other secondary causes
    • Hyperaldosteronism
    • Renovascular disease: renal stenosis/fibromuscular dysplasia
  • Lifestyle modification (modifiable risk factors)
    • Weight loss, exercise, low sodium diet, Mediterranean diet for patients with dyslipidemia, and smoking cessation
  • First-line drugs
    • ACE inhibitors or ARBs, especially in patients with renal disorders or diabetes
    • Thiazide diuretics in African American patients
    • Dihydropyridine calcium channel blockers

COPD

History – Usually, the patients are smokers who consume more than 20 packs per year. Their main complaint is shortness of breath at rest or with exercise. However, if the patient is young (~40 years) and has a familial history of COPD, you should suspect alpha-1 antitrypsin deficiency.

Physical exam – There are two classic presentations:

  • “Blue bloater” – obese patient with cyanosis and heavy breathing. This form is associated with chronic bronchitis.
  • “Pink puffer” – extremely thin patient who uses their accessory muscle for breathing (the metabolic demand is higher due to the reduced elasticity caused by the parenchymal destruction). This form is associated with emphysema.

Diagnosis

  • The best initial step is represented by pulmonary function tests. They are useful for the GOLD classification.
    • GOLD I: FEV1 > 80%
    • GOLD II: FEV1 50 – 79%
    • GOLD III: FEV1 30 – 49%
    • GOLD IV: FEV1 < 30%
  • The chest x-ray will show hyperlucency and hyperinflated lungs.

Treatment

  • Smoking cessation and oxygen therapy to increase the survival expectancy.
  • Short acting beta agonists at need or long acting beta agonists (LABA) and inhaled corticosteroids (ICS) for long term use in patients with more than 2 exacerbations per year.
  • If the conditions still remain uncontrolled, administer ipratropium to the LABA + ICS.

Acute Kidney Injury

Prerenal azotemiaRenal azotemiaPostrenal azotemia
CausesHypovolemia (dehydration, hemorrhage), third spacing (liver failure associating ascites), ↓perfusion (CHF)Glomerulonephritis, ATN, AIN, embolic disease, rhabdomyolysisObstruction (nephrolithiasis, BPH, congenital obstructions, pelvic tumors)
Fe Na< 1%> 2 %> 1% or more > 2 % (if severe)
BUN/Cr ratio> 20:1< 15: 1Variable
Urine osmolarity> 500 mOsm/kg< 350 mOsm/kgVariable

 

Anemia

Diagnostic criteria

  • Hemoglobin < 13 g/dL in males
  • Hemoglobin < 12 g/dL in females

Diagnostic workup

  • MCH, MCHC, MCV are used for determining if there is a microcytic anemia (MCV < 80 fL), normocytic (80-100 fL), or macrocytic anemia (MCV > 100 fL).
  • If there is a microcytic anemia, then suspect:
    • Iron deficiency anemia – continue the workup with ferritin, TIBC, serum iron. In this case, the patient will have high TIBC, low serum iron, low ferritin, high RDW, normal hemoglobin electrophoresis, hypochromic microcytosis on peripheral blood smear.
    • Anemia of chronic disease – the patient will have high ferritin, low transferrin saturation, and low serum iron.
    • Lead intoxication/Sideroblastic anemia – basophilic stippling is seen on peripheral blood smear. Ringed sideroblasts are seen in the bone marrow.
    • Thalassemia – low MCV, normal RDW, target cells on peripheral blood smear, normal or elevated iron, and ferritin. For beta-thalassemia minor, hemoglobin electrophoresis will show elevated Hemoglobin A2, while alpha-thalassemia minor will have normal hemoglobin electrophoresis.
  • If there is a macrocytic anemia, then suspect:
    • Vitamin B12 deficiency – patients will have both neurologic signs, such as paresthesias, alongside typical signs of anemia (pallor). Homocysteine and methylmalonic acid levels are high.
    • Folate deficiency – it lacks neurologic signs. Homocysteine levels are high, while methylmalonic acid levels are low.
  • A normocytic anemia can be caused by various conditions. One might consider:
    • Hemolytic anemia – high reticulocyte count is associated with it.
    • Anemia of chronic disease – in the first stages.
    • Iron deficiency anemia – in the first stages.
    • Aplastic anemia – can be seen with a low reticulocyte count.

Treatment

  • Iron deficiency anemia – iron supplementation
  • Lead intoxication – one can administer succimer or dimercaprol for severe poisoning
  • Anemia of chronic disease – treat the underlying condition
  • Vitamin B12 deficiency and folate deficiency – administer vitamin B12, respectively folate. However, administering folate in a vitamin B12 deficiency is called the folate trap. Patients will no longer have anemia, but their neurologic signs will worsen.
  • Aplastic anemia – treat the underlying condition. For example, if the patient is exposed to a radiation environment at work, suggest protective equipment. Also, in severe cases, they might receive packed red blood cells.

Diabetes Mellitus

Diabetes mellitus diagnostic criteria

  • Fasting glycemia > 126 mg/dL
  • OGTT (oral glucose tolerance test) > 200 mg/dL at two hours
  • HbA1c > 6.5%

Pre-diabetes diagnostic criteria

  • Fasting glycemia 100 – 125 mg/dL
  • OGTT 140 – 200 mg/dL at two hours
  • HbA1c between 5.7% and 6.5%

Follow-up

  • HbA1c shows glucose control for the last three months
    • A fraction of the hemoglobin from RBC gets glycated, a monosaccharide (glucose) attaching spontaneously to hemoglobin. Since the lifespan of a RBC is 90-120 days, HbA1c approximates the level of glucose to which the RBC was exposed for this period. Therefore, HbA1c reflects the blood glucose level for approximately three months.
  • Foot inspection in order to detect signs and symptoms of neuropathic foot ulcer (common complication)

Treatment

  • Lifestyle changes
    • Exercise (leads to lower levels of glycemia)
    • Weight loss for overweight patients (contributes to insulin resistance)
  • First-line pharmacologic treatment
    • Metformin (also promotes weight loss)
    • Avoid in patients with renal disease (risk of lactic acidosis)

Other pharmacologic treatments

  • Sulfonylureas (glipizide, glimepiride)
    • An important side effect of sulfonylureas is neuroglycopenic and adrenergic symptoms. As they stimulate the release of insulin from remnant beta cells, low glucose ensues. Patients will develop symptoms such as tremors, sweating, and confusion as the brain is deprived of glucose.
  • Insulin if the patient has advanced type II DM or if the patient has type I DM
    • Insulin is given to patients with type I diabetes because they lack pancreatic beta cells due to autoimmune destruction. Usually, they are given a rapid-acting insulin form, such as normal insulin, before each meal and a long-release insulin form, such as glargine.
    • If a patient with type II DM requires insulin, this is a sign of severity. It means that the majority of their beta cells are depleted and can’t compensate enough.

Other Important Topics to Review:

  • Pulmonary Embolism/DVT
  • Gallbladder Disease
  • Cirrhosis
  • Inflammatory Bowel Disease
  • Arrhythmias
  • Asthma
  • Chronic Kidney Disease
  • Acid-Base Disorders
  • Electrolyte Abnormalities
  • Thrombocytopenia
  • Empiric Antibiotic Therapy
  • Thyroid Disorders

Skill acquisition

Internal medicine is a clerkship made for developing diagnostic skills (mental frameworks) and practical skills.

Be picky about your patients to develop practical competencies. At the beginning of your rotation, make a list consisting of the skills you desire to build. Then consider the inpatients who have a pathology that requires those skills. Take a patient with renal colic to learn how to take an ultrasound of the kidneys. Building your experience in this way ensures you will have those diagnostic tools at your disposal by the end of the rotation.

When developing diagnostic skills, this two-part framework will help.

  • During the conversation with the patient, focus on the medical history they provide you with. Start with the main complaints (max 3) and then narrow down the differential diagnosis (Ddx). For example, if the patient’s main complaint is retrosternal chest pain, narrow down the Ddx by asking about what kind of pain they’re feeling, such as a burning sensation or pressure, the duration and timing of the pain (> 30 minutes or in the morning), and its radiation (e.g. interscapular radiation or radiating down the arm).
  • Towards the end of taking their medical history, keep three medical conditions in your mind to avoid anchoring. Once finished, differentiate between those three conditions by proceeding with the elements of the physical exam relevant to them.
    • E.g.: Aortic dissection vs. MI
      • Take the pulse for both arms; patients with aortic dissection will have a significantly lower BP measurement for one of their arms.
      • On auscultation, a patient with MI may develop a mitral regurgitation murmur due to papillary muscle rupture.
    • After the conversation, create a management plan. Come up with the labs required for your patient as well as diagnostic exams. At the end, create a treatment for them. Once written, run through the plan with your attending to gain feedback and insight for the case.

More broadly, these are the skills you should learn before or early on in the internal medicine clerkship.

  • Learn how to read EKGs
  • Learn how to read Chest X-rays
  • Learn how to present on rounds. (Provide a full history and physical for new patients and a brief SOAP presentation for ongoing patients).
  • As above, learn to present your assessment well so that everyone understands your thought process. Whether it is right or wrong, state a concise, confident plan.
  • Learn the basic approach to antibiotics, such as common first line empiric treatments for common diseases (UTIs, pneumonia, cellulitis, etc.)
  • Learn the basic approach to hospital medicine. Learn the basics of the wards, such as what to do every morning and what to check for (labs, imaging). Know the basic needs of a patient when they’re staying at the hospital, such as diet orders, repleting electrolytes, fluids, pain management, etc.)

Scores and Calculators

Internal medicine has a wide variety of conditions. Oftentimes, there are certain calculations that need to be done to objectively approach care. Many of these calculations can be found on various phone apps, such as MDCalc. You can make these calculations ahead of time and present them on rounds when appropriate to impress your attending.

An exhaustive list would only transform this article into a textbook, but here is some key information that may help you during your rounds.

This is a list of some common scores that may be calculated on your internal medicine rotation.

ASCVD risk (atherosclerotic cardiovascular disease)

  • Estimating the risk of cardiovascular disease is a must in all patients aged 40-75 and is useful for knowing what to recommend to your attendings. For example, in high risk patients, consider interventions such as stenting for CAD (coronary artery disease). By contrast, in intermediate risk patients, one might choose a prevention protocol that includes statins and aspirin.
  • The best way to calculate this is with a calculator. Nevertheless, a good rule of thumb for determining high risk patients is:
    • Multiple ASCVD diseases, more precisely > 1 of the following:
      • MI
      • Stroke
      • Symptomatic PAD (peripheral artery disease)
      • Acute coronary syndrome in the last 12 months
    • One ASCVD disease + ≥ 1 risk factor:
      • Age > 65 years
      • LDL > 100 mg/dL (on max. statin)
      • Comorbidities – CKD, DM, HTN, CHF
      • Heterozygous familial hypercholesterolemia
      • Currently smoking
  • Other Common Scores
    • CHA2DS2-VASc Score
    • Child-Pugh Score
    • CURB-65 Score
    • FENa
    • FEUrea
    • Light’s Criteria
    • MELD-Na Score
    • qSOFA
    • Serum Ascites Albumin Gradient
    • SIRS & Sepsis Criteria
    • Stool Osmolar/Osmotic Gap
    • TIMI Score for STEMI and Unstable Angina/NSTEMI
    • Well’s Score for DVT/PE

 

Useful iPhone Apps for the Wards

  • MDCalc is a free app that allows you to calculate different risk/score calculations (as mentioned above).
  • UpToDate helps you find the most up-to-date information in medicine.
  • Hospitalist Handbook helps you quickly learn how to approach different diseases or conditions that are common in the hospital setting.
  • Journal Club allows you to look up summaries of key clinical trials that are relevant for different diseases or conditions to present them on rounds.
  • Bates’ Physical Examination allows you to look up how to approach various chief complaints in terms of history taking and physical examination.

 

Internal Medicine Clerkship Resources

It is critical to your success that you learn the content from appropriate resources.

We recommend the AnKing Anki Deck or Step-Up to Medicine, depending on if you prefer flashcards or books. If you prefer videos, the Boards & Beyond videos + White Coat Companion study aid or OnlineMedEd are both great resources as well.

One should provide you with enough information. Try to quickly pre-read some of these resources to understand the general concepts, then jump into the questions. After completing and reviewing a UWorld block, refer back to these resources to fill in any gaps.

The most important resources for internal medicine are the question banks, which includes either UWorld or AMBOSS. Both are excellent resources for your internal medicine rotation. Schedule at least one block of questions each day after your wards. Think of the block like an exam (i.e., timed and random). Not only will this method help you to familiarize yourself with the time pressure from the exam, but it will also improve your retention of the material. Doing questions from various topics in the blocks is an effective study technique called the interleaving effect.

If the number of questions makes this too difficult, divide the questions by system—just note that that actual Shelf won’t be like this. Review your answers carefully. For those you answered incorrectly, seek to understand why you were incorrect. For the correct answers, explain to yourself why you didn’t choose the other answers. This active recall method forces you to test other areas of your knowledge while enhancing your ability to eliminate answers in the exam. The latter is useful when having to make an educated guess during the exam.

A secondary resource is a good reference book, such as the AnKing Anki Deck, Step-Up to Medicine, or the Boards & Beyond videos + White Coat Companion. These will help to fill any gaps in your knowledge. They will be most useful after encountering a case whose pathology you didn’t master. After the UWorld block and review, reading a bit about your patient will get you a long way on the wards.

Lastly, Anki decks are an invaluable on-the-go resource. You may also create Anki flashcards based on the questions you miss in UWorld or AMBOSS.

 

Internal Medicine Shelf Exam

The internal medicine Shelf exam will require more intense studying given the volume of information within the clerkship. Given the internal medicine Shelf exam includes the majority of the different organ systems, it is extremely important to stay on track with your studying throughout the rotation. With over a thousand UWorld questions for the clerkship, cramming these last-minute questions should be avoided at all costs.

Tips for the Internal Medicine Shelf Exam:

  • Familiarize yourself with the test conditions by taking a Clinical Mastery Self-Assessment one week before the exam.
  • Take a first pass through the questions to build momentum. Answer the easy questions, mark the ones you are unsure of so that you can review them during the mini-breaks, and leave any questions you don’t know the answer to.
  • Compare and contrast between diseases that are commonly tested together. Notice the similarities and differences between these diseases because that’s how they will be tested on the Shelf.
    • For example, knowing the physical exam and diagnostic findings between obstructive lung diseases and restrictive lung diseases and being able to differentiate different obstructive lung diseases from each other, such as COPD and asthma. Both may present with wheezing, but asthmatic patients will improve significantly after albuterol administration. Knowing these comparisons well will allow you to predict common test questions.
  • Write out different work-ups for common chief complaints. For example, draw out a flow chart of your differential diagnoses for chest pain. Within this chart, make sure you write out which tests you would order first and how those tests will help differentiate the possible diagnoses.
  • A helpful test-taking strategy is to try to find the 3 wrong answers rather than the 1 correct one. Sometimes you may not be confident that a certain answer is correct. However, you might be able to find evidence to prove that certain answer choices are wrong. If you find evidence to support why 3 out of the 4 answer choices are incorrect, by default, you have found the correct answer, even if you weren’t sure why. Sometimes in medicine, you have to be comfortable with the unknown.
  • In terms of “best next step” questions, think cheap, least invasive, and what test will get you the information you need. This will go a long way to make sure you don’t pick answer choices for any unnecessary diagnostic tests or treatments.
  • In order to avoid going too fast and making errors, take some mental breaks within the exam.

 

Residency Choices: Pursuing the Internal Medicine Specialty

Internal medicine is one of the most accessible specialties from a competitiveness standpoint. In our MSI competitiveness index, it ranks middle of the pack, with an average Step 2 CK score of 248 and 6 publications. Moreover, considering that the training only takes 3 years, it’s also on the shorter side of the spectrum.

View our comprehensive Specialty Competitiveness Index, which assesses specialties based on USMLE Step 1, Step 2CK, Top 40 NIH, publications, and more.

The internal medicine residency is a gateway to most medical specialties. There’s essentially a fellowship for everyone.

If you are an achievement-driven, type A personality, you might consider cardiology. It is one of the most competitive fellowships in a continuously changing domain. In 2021, it was also ranked as the third most compensated specialty on Medscape, with an annual compensation of $459,000.

If you are an empathic person who knows how to handle sensitive situations, oncology might be for you. Oncology is on the higher end of compensation ($403,000 annually), you’ll be able to keep a regular schedule, and it’s a technology-driven field. Furthermore, it is a great field for people who want to pursue research.

If you are not disgusted by bowel movements and prefer procedures, then gastroenterology will be a great choice. Compensation-wise, it is at the higher end of the spectrum ($406,000). The hours are more predictable, and the calls are usually taken at home. On rare occasions, a patient may require an endoscopy in the middle of the night.

On the other hand, internal medicine provides the benefit of flexibility. Plus, it permits entering practice after only 3 years of training. It’s also a specialty that’s high in demand. Another great flexibility asset is that IM programs are part of joint programs. This means that by the end of your residency, you’ll be board certified in at least two specialties. Some examples are IM/dermatology, IM/EM, IM/psychiatry.

Learn more about whether or not the internal medicine specialty is right for you: So You Want to Be an Internal Medicine Doctor (video and article).

 

Final Thoughts on Internal Medicine Clerkships

From a mental perspective, the internal medicine clerkship is a heavy clerkship. Each medical specialty requires a diagnostic prowess that has less importance in other procedural-heavy clerkships, such as surgery or OB-GYN. Nevertheless, mastering the IM clerkship will greatly enhance your Step 2 CK score, as it makes up the bulk of the exam. Another advantage is that the same mental gymnastics will ease your pediatrics and psychiatry rotations.

This clerkship is an opportunity to develop procedural skills that can be transferred to most of the specialties. Regardless of whether you choose to pursue internal medicine and one of its several subspecialties or if you choose an entirely different training path altogether, there’s great utility in this rotation if you approach it correctly. Learning to perform an ultrasound will be helpful even if you are a cardiothoracic surgeon, and as a dermatologist, you’ll benefit from learning how to biopsy skin lesions during this rotation.

The internal medicine rotation is an opportunity to acquire a breadth of medical knowledge that can be applied to a wide variety of specialties and subspecialties. The rotation will put your mental abilities to the test, but everything you learn during this rotation will accelerate whichever specialty you decide to pursue.

 

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