When I was picking my schedule for M3 year, I was a bit nervous to start off with IM as it's known to be one of the more challenging clerkships. But, I knew that it would be a great foundation for the rest of the year and that my knowledge from boards would carry me through. I'll be honest, I didn't think I would like IM, so another reason I wanted to have it first was so that I could "get it out of the way." But to my surprise, I was a bit sad to end my rotation.
What is Internal Medicine?
I feel like for the longest time I didn't quite know what it was, but IM (internal medicine) is the medical specialty that focuses on the prevention, treatment, and diagnosis of adult diseases. It sometimes gets confused with family medicine, but family medicine doctors also see pediatric and Ob/Gyn patients in addition to their adult patients. Although some family medicine doctors work on inpatient (in the hospital) medical services, a bulk of the doctors that see patients in the hospital are the internal medicine docs (the internists). Internists act as the team captain of a patient's medical care and call in specialty services for more complicated cases. This is due to the fact that internal medicine doctors deal with complicated patients, so of course, they aren't expected to be experts on every part of the body. There are specialists (e.g. Gastroenterology, Hematology/Oncology, Infectious Disease, Nephrology, Cardiology etc.) that handle those cases where the patient's care is outside of the internist's knowledge base. That being said, internal medicine doctors do know a ton and a majority of their patients have multiple active problems to manage, so they have to know how to treat the patient in a way to get these problems stabilized, so the patient can safely go home.
After residency, internal medicine doctors can choose to do inpatient (as a hospitalist), outpatient (in the clinic), a combination of inpatient/outpatient medicine, or do a subspecialty (like those specialties mentioned above). So, many doctors that know that they want to specialize in a particular area of the body will train as an internist and then continue their training with a fellowship in their area of interest. In that way, internal medicine is a great way to explore the medical subspecialties if you know that you want to practice adult medicine.
Before discussing the rotation, there are a couple things that I think I should define for the novice med folk as well as the non-med folk. In inpatient medicine, "rounding" means that you go and see your patients as a team. Who is on your team depends on how the team is structured. At community hospitals, a team consists of at least a senior resident and two interns (as well as a teaching attending for some parts). And in my case, I was the medical student on the team. At an academic hospital, our team was pretty large. We had an attending, a third-year resident, a second-year resident, two interns, two sub-Is (4th-year medical students doing their acting internship), and two medical students. When we "pre-round" that means that you go and see your patients on your own prior to rounding as a team so that when you round with the attending doctor (the doctor that oversees the work of the resident team) you are ready to present your plan for the patient.
Finally, the last term to define is "call." If you've watched any medical shows or have seen any of the jokes about being a doctor you've heard the term being "on-call." What it means in general is that you are the doctor or the team that is in charge of patients at a given time and that you are contacted to care for them. In internal medicine, what it means to be on call depends on your hospital. At my community site, Being on call meant that your team would stay past sign-out to care for the patients until the night team showed up. We were also the team that responsible for responding to codes and accepting new admissions from 3:00 pm until the night team came in at 7:00 p.m. (we didn't accept any admissions to our team prior to 3:00 pm though) At my academic site, we were on call from 7:00 am to 7:00 pm. We accepted all new admissions, responded to codes, and if there were admissions overnight after our call, they would go to our team until the next team started their call the following morning. And being "post-call" means that it is the day after you are on call. If you did overnight call that means that you are just coming off being on call for the whole night and you probably didn't get much sleep if the night was busy. Thankfully, we didn't have to do any overnight calls as M3s, but it is something to look forward to in residency.
Rotating Through As An M3
The specifics of your internal medicine rotation will depend on what your school requirements are, but I believe most internal medicine clerkships are between 8-12 weeks in duration. Our school happens to have affiliations with many of the community hospitals in the Chicago, so our IM rotation was an 8-week rotation split into 4 weeks at an academic center (our home institution or the Veteran's hospital) and another 4 weeks at a community hospital with one half-day a week spent in an outpatient clinical setting during the entire 8 weeks. For my clerkship, I started with 4 weeks at a community hospital and ended with 4 weeks at our home hospital. Personally, I had a great experience at both, but the vibe from each experience was a bit different.
At the community hospital, the schedule was a bit more consistent and we only had one call day a week. On the weekends, I only had to come in when my senior resident was working. If she worked on Saturday, I was off on Sunday. Our weekend day usually consisted of us rounding on our patients together, I would work on my notes, and then as soon as I finished, she'd send me home. The goal was to get out early on the weekends and I'd say I was usually always done before noon. I definitely appreciated starting off with a schedule like that and I definitely missed it when I was on my second month of IM.
What my community month schedule looked like:
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Monday-Thursday (regular, non-call days)
- 6:30-7:00 A.M. - Get sign-out from the night team, look up labs, ask the night nurse if there were any events overnight, and jot down some notes for the patients I was following.
- 7:00-8:00 A.M.- Round with my team on our new/critically ill patients. Our teaching attending would come around to see the new patients and this is usually when she would pimp me (a.k.a ask me questions about my medical knowledge...I still don't know why they call it that lol)
- 8:00-9:00 A.M.- Morning Lecture. This was usually on a topic that the residents were learning. Occasionally, we had our own student lecture instead, but either way, they were focused on teaching us a topic in medicine (i.e. EKGs, Treating a patient with heart failure, etc.)
- 9:00-12:00 P.M.- Finish rounding on the patients we didn't get to see before morning lecture, work on coming up with plans for our patients, call consults, and work on notes.
- 12:00-1:00 P.M.- Noon lecture. Same as above, but usually for these we had our own student lectures.
- 1:00-4:00 P.M- Finish notes and prep everything for sign-out to the team on call. Sign-out was scheduled for 3:30 P.M., but sometimes it happened later depending on how many patients we had on our team and whether it had been a busy day. As a medical student, they usually sent me home by 5:00 as long as I had finished my notes.
- Call days: Same schedule as above, but the day was longer and we were in charge of responding to codes.
- 3:30 P.M.- Get sign-out from other teams (there were 5 teams, so on-call days you were carrying all those patients until the night team came in)
- 3:30-7:00 P.M. - Take all new admissions, respond to pages for any of the patients we were caring for, and prep sign-out for the night team. Any new admissions got distributed among the teams the next morning according to how many patients each team had, so even if we admitted them while we were on call, that didn't mean they would all get admitted to our service. We didn't really present patients to our attending, so post-call days were just like regular work days.
As you can tell, an average workday was about 10+ hours depending on the schedule. On the days that I had clinic, I usually stayed until 6:00 p.m. And usually, I was at the hospital by 6:15 a.m. every morning (even on weekends). Our call day ended at 7:00 p.m. but I was usually there until 8:00 p.m. But, on an average day I was usually home by 5:00 p.m. Which wasn't too horrible and I really appreciated the fact that my weekend days were pretty light and consistent. That really helped me make it through the month, and as I was busy it really flew by.
During my academic month, the schedule was a whole other ball game. We were on call every four days which meant that most of the weekends during that month I was either on call or post call. And as we presented all our new patients on our post-call days. This meant earlier mornings in order to get everything ready to round at 7:00 a.m. (We'd typically come in at 5:30 or so to pre-round on our patients...These were the days I didn't get much sleep). As most of my days off were either a weekend day if we weren't on call or post call, I don't think I had a weekend day that was a regular work day.
Our general schedule:
Non-call day:
- 6:30-8:00- pre-round on patients, talk to nurses, work on your presentation.
- 8:00-9:00- Morning report. This is where the chief resident would do a case presentation for all the residents and we worked on coming up with a diagnosis. There was always coffee and for the most part. the cases were pretty interesting.
- 9:00-11:30- Morning rounds. We'd go see all our patients as a team, we'd present to our attending, and if time permitted, the attending would teach us something relevant to the patients on our service. If we had time after rounds, we'd start tackling our task list before heading to lecture.
- 12:00-1:00- Noon lecture. We went to the internal medicine department for a lecture presented by one of our attendings or professors.
- 1:00-5:00-Getting our work done. This was when we'd work on notes, call consults, help the residents with all the work that we didn't finish in the morning. If the day wasn't particularly busy and we had finished the work for our patients, the senior resident would send us home early (3:00 pm or so).
Call-day:
The same schedule as above, but we were on call until 7:00 p.m. and the day could get hectic as we were getting all the new admissions and responding to codes. I want to say the latest I ever left the hospital was 9:00 p.m.
Expectations as an M3
As this was our first rotation, the expectations were pretty lenient. At this point, we were more so expected to get used to working in a hospital setting after coming off of two years of being strictly academic. They wanted us to get used to talking to patients, working on writing effective notes, presenting patients to our attending, and getting comfortable working on a medical team. What we were allowed to do really depended on our site. At my community site, I feel like my role was more limited. I was allowed to see the patient and write progress notes, but I didn't do much else. My notes were also for my practice and didn't count as much for patient care.
Since my home institution is a teaching hospital, we were allowed to do so much more. I was allowed to call consults, talk to families, put in orders/meds (they still had to be signed by the residents), and my notes were actually used in patient care. The residents would check over our notes, add in an additional information, and the attending would sign off on what everyone had written. As we were more involved in our patient's care, there was way more pressure to do everything well. As you didn't want to make mistakes in your patients care and look bad in front of your attending. But since they did give us more responsibility, it really helped me feel like I was a part of the team and for the first time what it felt like to be a doctor.
Prepping for the Shelf
Unfortunately, at the end of each rotation, we have to take an exam to be evaluated on what we've learned. This meant that in addition to working a full-time job, we were also coming home to study for an exam. As the breadth of information tested on the internal medicine shelf mirrors that tested on our board exam, it was a lot of information to review. It was the first time that I was in this situation and I handled it as best as I could. It was definitely really hard to have the motivation to come home and study after a long day at work, but somehow I did it.
As far as resources, most people recommended finding a review book (i.e. Step-Up to Medicine or Case Files) and reading that cover-to-cover in addition to doing practice questions on Uworld. Personally, I am not a textbook person and I found it really hard to get through reading a review book, so I just focused on doing practice questions. I believe there are 1,400 or so questions for internal medicine on Uworld and I got through about 1,000 of them. I used some online videos ( Online MedEd is a great resource) for topics I was weak in before my exam. But, throughout the rotation, I was looking up information on my patients on UpToDate every day and learning that way as well. For me, that was enough to do decently well on my shelf exam and in combination with a great clinical grade it worked out well for my overall grade on the rotation.
My Take-Aways
As I mentioned at the beginning of this post, I was pleasantly surprised at how much I enjoyed my time on internal medicine. I will say that something that I know really contributed to my experience was that both of my teams were great. I had so much fun with them when we weren't busy practicing medicine that it didn't feel like we were at work. I know this wasn't true for some of my classmates on IM, so your team can really make or break your experience. It was the first time that I really got to experience medicine full on and I loved it. I enjoyed taking part in a patients care and when I was able to get really involved, it confirmed that I had chosen the right field. I won't sugar coat it though, there were some days that were really rough. I spent most of the two months just feeling exhausted by the long hours and worried that I wasn't studying enough for my shelf exam. And the learning curve from being an M2 to being an M3 is pretty steep, but eventually, you do get the hang of it. By the end, I was so tired and ready for a much-needed break (hence the laid-back past five weeks), but sad that I had to leave my team.
Overall, I realized that I really enjoy inpatient medicine (clinic is not my fave). I don't mind long days or rounding and rounding will be way more fun when I'm the attending that gets to ask all the questions. As I had just taken Step a couple weeks before starting this rotation, it was really cool to see the things I had studied in practice. I felt so smart and like I mentioned above, it was the first time in the past years of schooling that I actually felt like I was becoming a doctor and not just studying for another class. And actually working with people was so rewarding when you could see them get better under your care and witness that you are making a difference. At this point in time, my heart is still saying pediatrics (even though my teams were trying to convince me to choose IM...It might possibly be my back up), but IM will hold a very special place as it was where I started my journey as an M3 and where I learned that I do really enjoy this field. It was certainly not an easy rotation, but I learned so much, I had so many great experiences ( I got to do my first arterial blood gas draw on a patient) and I feel ready to take on the rest of my M3 year.
I know that was very long, but I wanted to give a detailed account of my time on IM. I start my Ob/Gyn rotation on Monday, and I can't wait to share my experience at the end of that.
Take care,
- Gen<3
