Welcome to the learn-everything rotation. Ready or not, there is no limit to the amount of studying you can do for Internal Medicine. It will be the most challenging exam of your clinical year, and it may be one of the more challenging clinical experiences (depends on where you rotate). Nevertheless, forget your GPA and exam score. Consider that this is also your best opportunity to prepare for clinical practice.

On this rotation you will see a wide range of diseases, both acute and chronic. You will see things that you may not see again for the rest of your career. You will see sick patients with rare diseases recover. And you will see common chronic diseases reach their end stages. You will see inpatient procedures and outcomes. Most importantly, you will witness the collaboration between specialists and hospitalists and the teamwork that goes into optimizing patient outcomes. Whether you pursue internal medicine or not, this rotation will be invaluable to your future career.

 

My Experience

This was another away rotation for me. I lived with my parents for five weeks while rotating at the University of Alabama at Birmingham. Maybe I felt like I was in high school again, but it was nice to be back home with family. PA school is such a maelstrom that at times I feel guilty for not calling home enough and for always talking about how busy I am. I know my mom appreciated having me around (even if I was always studying).

The rotation, itself, was not terribly work-intensive. My hours were typically 7a-4p. I had a different preceptor every couple of days, but they were all excellent and enjoyed teaching. When I arrived in the morning, they would give me 4-5 patients to follow throughout the day. I would spend the first hour looking through their labs/notes since admission. Then I would set out on my own to round on patients. At noon I would be done, eat lunch, and then sit down to write progress notes on each of them. Then I would present my patients and accompany my preceptor as we rounded on each patient again. It wasn’t a terribly long day, but there was always enough to do.

My favorite part of internal medicine was the number of opportunities I had to make a difference in a patient’s care. While I often feel like a burden on rotations, I was a little more independent on the hospitalist service. I would usually examine the patient before my preceptor, and my assessment and plan would actually speed up care, not delay it. Occasionally, I would be the first to catch an important finding such as new-onset acute abdomen or fluid overload.

I also had ample opportunities to give patient education. While you get practice with this on every rotation, you generally don’t have time to really sit down with a patient and hash out the details of their disease. One particular patient stated that he did not get along with his diabetes educator (who was apparently rude). His diagnosis was new, and he was still in the dark about how to manage diabetes. As a student with a light schedule, I had the opportunity to sit down with him for almost an hour, talking about diabetes care. He was appreciative, and hopefully it made a difference in his life.

If there was something I didn’t like about the rotation, it is that there is not much procedural work. Typically, you play the role of a matchmaker, coordinating patient-care with specialists, who then perform the tests/procedures required. So if you are someone who enjoys hands-on work, then this may not be your field.

 

Advice/Lessons-Learned

  1. Start studying on day negative-one. Many students get in the habit of ‘taking it easy’ the first week or two of their rotation and then doing the bulk of the work at the end. It is not a good strategy in general, but especially not on internal medicine. I made this mistake and found myself overwhelmed before the test. The best time to start studying is the weekend before you start your rotation. You will hate yourself initially and then thank yourself later.
  2. Learn from your patients. This is advice that applies to every rotation, but especially internal medicine. You will see many complicated patients in various stages of illness. Don’t miss an opportunity to learn from them. If there is something that you are not familiar with, look it up THAT NIGHT. You can study something from a textbook a million times and the knowledge will never ‘stick’ the way it will when you have encountered it in clinical practice.
  3. Write your own assessment and plan from scratch. Generally, the patients you see will already have notes from other providers in the system. It is pretty standard for students to browse through previous notes when writing their own and simply ‘update’ a previous A&P. Doing this will save you time and effort, but it will also rob you of valuable learning. To build an A&P for an inpatient, you have to develop a plan for literally every chronic and acute illness in the patient’s chart. So if a patient has hypertension, even if it is well managed, it must be included in your plan. These A&Ps are sometimes 15 items long. Making them from scratch is a pain in the butt. However, it is also an awesome opportunity for practice. Do this and then compare your plan to previous notes to see what you missed.
  4. Be thorough. You may notice your preceptors do abbreviated exams on this rotation. They have fifteen patients to see and years worth of clinical gestalt. But that doesn’t mean that they are always right. In my opinion, a thorough clinical exam should be done no matter how long you have been practicing. I say that in part because I have had many experiences in my clinical year where I picked up on important findings that my clinical preceptor did not. There was nothing major on my internal medicine rotation that occurred, but it did happen several times throughout the year (why wouldn’t you do a neuro exam on a patient with severe back pain?). Experience does not mean that you get to skip steps. It should mean that you never skip steps.