Ahh, third year…when 8-hour lecture days are a thing of the past; when your mornings are early and your coffee is strong; when you work longer and harder than you thought possible, but when it all becomes worth it because you’re finally participating in patient care. Third-year, in my opinion, has been the hardest year of medical school thus far. It is physically exhausting, as the hours can range from as little as 8 hours per day to as much as a 30-hour overnight shift, but generally land somewhere in the 12-14 hour range. It’s mentally taxing, as you’re challenged intellectually on a daily basis, encountering new patient cases, seeing complications of ‘bread-and-butter’ cases you thought were simple, and still having to fit time in to study for standardized tests. It’s emotionally demanding, as you finally feel a sense of ownership over your patients, you see firsthand the plight of the sick individual, you struggle to find time for your loved ones outside of work, and it might even be the time when you see your first patient pass away. Conversely, it has also been the most rewarding year. Having an active role in patient care for the first time is truly intangible. It’s humbling, being the first face they see in the day when you wake them up at 0400 for pre-rounds. It’s invigorating when your treatment plan gets validated by the team and you see the patient improve. It’s worth the extra hours when you see a patient you’ve taken care of get discharged after a long hospital stay, who proceeds to thank you for your role in their care.
With your feelings being at the extremes, each rotation can feel like a whole new world. This special Med School Insiders (MSI) mini-series aims to provide a 30,000-ft view of the various clerkships that you will encounter during your MS3 year to better prepare you for your time on the wards.
“The goal isn’t to be brilliant…it’s to strive for expertise.” – Dr. Gurpreet Dhaliwal
Internal Medicine is the largest specialty and one of the most in-demand when looking at recent Match data. It is an extremely broad specialty and is the gateway to many sub-specialties like gastroenterology and cardiology. You will have “med-student moments” where you look silly in front of the whole team, and you will have moments where you are functioning as an intern, calling consults, doing admission history and physicals, and proposing plans for patient care that actually get used. It is an exciting rotation, so let us explore it a little more!
I am sure that there is variability within each school’s curriculum design. At my home school, our Medicine block was 3 months long, with 2 inpatient months and 1 outpatient month. Variability aside, you will be assigned both inpatient and outpatient experiences throughout your rotation.
Inpatient: The hours are long, so buckle up! The inpatient medicine rotation served as a great knowledge base for the future of my patient care practices. You finally are exposed to in-depth patient care and long hospital stays. You learn how to manage common diagnoses, craft masterful presentations, and you get to experience handling a large patient load. It is a very rewarding, yet exhausting, rotation!
Outpatient: The outpatient side of the rotation was more similar to primary care clinics that I had been apart of previously. However, some schools allow for you to pick specialty clinics to attend, such as urgent care, orthopedics clinic, etc. It can be difficult to see patients when your patient has a longstanding relationship with the attending because you automatically know less about the patient than the provider does, and you will invariably miss something in your history taking. Whatever clinic you end up in, try to take on new patients as often as possible, and learn the initial workup and management of common outpatient problems.
A note about student wellness: Attend your personal medical or mental health appointments! Open communication with your team is the best way to help foster an environment that is good for your physical, mental, and emotional health. If a holiday happens during your rotation, communicate with your team early to figure out expectations and schedules, especially if you are trying to plan a trip.
Tips and Tricks
1) Get yourself a pocket reference book! The Pocket Medicine books are widely popular, but Maxwell’s reference is also widely used. You cannot really go wrong with your choice, but they come in handy when you are crafting your assessment and plan to impress your attending.
2) Know your normal lab values! Yet another use for your pocket reference books! Make it a habit to know if lab values are normal or abnormal just by glancing at them, as a quick interpretation of lab data is a crucial tool when taking care of your patient load.
3) Cherish your pimping! I use that word mainly because all medical students know what it means: to be put on the spot with a relevant question from a resident or attending. It is a terrifying moment, but most superiors do not actually care if you know the answer or not! Approach it with honesty and humility – if you know the answer, great! Speak up, and ask follow-up questions. If not, great! Admit you do not know, and then listen and take notes to what the answer is. Some of the best learning opportunities on your Medicine rotation will come from pimping questions – being put on the spot like that really makes it hard to forget that tidbit of information.
4) Download invaluable phone apps! MDCalc is a necessity for your Medicine rotation, so you can calculate various scores that can help guide decisions on patient care. UpToDate is great to have on your phone if you already have a subscription. ePSS and epocrates are less high-yield but provide current guidelines and medication dosing, respectively.
CAVEAT: Do NOT be the student that has their phone out all the time. People will notice and assume you are texting your loved one or browsing Instagram. Choose your moments, or be clear why you are using your phone. The golden rule: do NOT pull out your phone on rounds!
I mentioned in my previous Clerkship Review (Pediatrics) that you should absolutely check out the NBME website that breaks down the questions on the various Shelf exams, found here for Medicine. Of note, 55-65% of your test will be outpatient vignettes, and 20-25% will be from the Emergency Department (ED)! Take that into account as you proceed through the rotation; take every opportunity when admitting patients from the ED to learn the first steps in management, as they are high yield for the Shelf.
The best study advice for this block would be to approach each patient case as if it were a vignette on your test. Get assigned to diagnoses you have not seen before, and aim for the bread-and-butter diagnoses like congestive heart failure, chronic obstructive pulmonary disease (COPD), cirrhosis, etc. In my opinion, avoid taking on rare diagnoses (for example, Langerhaans Cell Histiocytosis) as they are unlikely to appear on the Shelf. Rather, follow along with your team for those cases to learn about the disease. Take the ‘patient-as-teacher’ approach to your Medicine patients, and use these opportunities as your primary method of studying. You are far more likely to remember the 3 COPD patients you managed over the course of your inpatient months than you are to remember the 10 COPD vignettes you came across on UWorld!
As with all rotations, UWorld will be the mainstay of studying throughout your Medicine block. However, with this block, it’s a little different (and I’ll take a minute to explain):
1) There are over 1,300 UWorld questions for the Medicine block/shelf. Over the course of a 3-month period, that’s “only” 15 questions a day! But we all know how time gets away from us on busy rotations, especially during your inpatient months. Suddenly you’re struggling to find time to do a solid block of questions because the hours on Medicine are long! So decide what your plan is at the beginning of your rotation – map it out! Keep in mind that you do NOT have to finish all UWorld questions to be successful on the Shelf…but it definitely can’t hurt!
2) Combining UWorld with any other resource is a challenge that everyone deals with. I would not use more than 2 resources for this block since UWorld is so daunting for this particular rotation.
3) Anecdotally, the most commonly used resource for the Medicine Shelf other than UWorld is STEP Up 2 Medicine. It is a long textbook that is well-organized and does not over-explain. Personally, I used it more for STEP 2 studying than I did for my Medicine block.
4) In my personal opinion, Case Files and Pretest have little utility in this block for the reasons mentioned above. However, if you have previous success and are comfortable using those particular modalities, I would encourage you to use what your study habits have shown to be effective.
5) Online Meded is a fantastic online resource that has multiple videos covering a variety of different diagnoses, explaining their pathophysiology and management. Its short lecture format makes it easily accessible, yet easy to dissociate from without the pressure of having to sit there for hours. My favorite way of using this modality was to play the videos while making/eating breakfast prior to going to the hospital, or listening to the videos in my car during my commute. It is a fairly passive way of learning, but some mnemonics and organizational tools still are stuck in my head. The videos and accounts are free, but they also offer other paid resources that you can explore on their website.
6) If you have struggled with Shelf exams in the past, do not hesitate to ask MedSchoolInsiders for help! We offer an array of resources and tutoring from experienced physicians who scored in the top percentiles of their class to help you better prepare for this beast of an exam (it was the hardest Shelf of the year for me and many of my classmates).
Looking back on my Medicine rotation, it was one of the best learning experiences in medical school. I feel like at the end of it, I genuinely felt comfortable managing patients, which was valuable to me (not to say that I was overconfident – I know I still have much to learn). The patients I encountered I still remember to this day. I saw patients die after a long inpatient hospitalization…I took care of patients who had no loved ones come visit…I had patients thank me for spending time with them or checking back in on them after rounds were over…and I had families thank me for helping to take care of their loved ones. It is a roller coaster of emotions, and the rotation taught me a lot about what kind of doctor I want to be. It does have a steep learning curve, long hours, and it is probably the hardest Shelf of the year…but in the end, it is all worth it.
Medicine is a tough rotation, but provides ample opportunity to serve as a wide foundation of knowledge that will carry over into your other rotations; not just knowledge of diseases, but also of how to manage patients. It will demand masterful time management skills but will reward you with awesome stories and experiences.