Emergency Clinical Guide Presents The Internal Medicine Clerkships

The Internal Medicine clerkship consists of one month of outpatient experience, and two months of inpatient experience - one each at Fletcher Allen (Burlington) and at Champlain Valley Physician's Hospital (Plattsburgh, NY). The four month block is completed by a month of outpatient family practice.

The field of Internal Medicine (IM) is dedicated to the health of adults. It differs from family practice in that IM does not include pediatric or obstetrical issues, and typically includes only limited exposure to gynecology. During your months in IM, you'll be exposed to patients with an enormous variety of medical conditions, as well as basically healthy patients for regular exams and health-maintenance issues.

You work closely with house staff during the inpatient months. The house staff tend to be very reasonable, friendly, and committed to making a real difference in your education. The IM rotation is the one in which most students gain their strongest skills in "floor management," meaning the ability to efficiently organize their day and their responsibilities. The focus of the experience is geared towards learning as much about your patients and their conditions as you can, and you're expected to make a contribution. On this service in particular, it's essential to know your patient better than anyone else on the team does. Fortunately, this isn't difficult to do, as the schedule is open enough to allow you time to spend with your patients, and to read.

Regardless of your eventual specialty, the majority of the topics you will face in Internal Medicine will be essential to you in your career. You are expected to read daily, and to understand the basic principles of the pathophysiology, diagnosis, and treatment of the conditions being treated by your team. Four good potential sources of the information you'll need are Harrison's, MD Consult, journals (particularly JAMA and NEJM - you should subscribe to a service called "Journal Watch"), and the pocket book by Ferry. Your notes (which you write on each of your patients daily) should reflect that you understand the disease process that you're treating - in other words, try to explain what symptom or imbalance you're planning to address with a particular treatment, or what you expect to find with a given diagnostic approach - and what you'll do in response to that finding.

The IM house staff tend to not be interested in giving you busy work or keeping you in the hospital late without reason, and they will often go out of their way to help you understand concepts and to keep you involved with the care of your patients.

Call is q4, and they use a night float system - this means that except on Friday and Saturday nights, you go home around 10:00 on your call nights, unless you get a late admission (which does happen, and which can keep you in the hospital past midnight until you finish the workup). Non-call nights are usually over around 5:00. You take admissions (new patients) every other day - it alternates between morning admissions and afternoon/evening admissions. Each team is composed of one or two interns and an upper level resident, you may be assigned cases with any of the house staff. You can expect to see the majority of conditions listed below, and the best time to learn about them is while you're treating them. Pay particular attention to diabetes, COPD, chest pain, anemia, CHF, hypertension, depression, and infectious disease (especially UTI, URI, pneumonias, and cellulitis).

This can be a fairly intense month, particularly at first, although it gets much easier as you gain the necessary skills. The residents will spend lots of time with you, and the teaching can be exceptional if you're interested. There are daily lectures with lunch provided, and most days have additional teaching scheduled. You'll have extensive opportunities to improve your case-presentation skills, and you will be asked to perform a physical exam, observed by your teaching attending, at the end of the month, usually on the patient of your choice. This month is also your best opportunity to improve your skills reading chest x-rays and learning about EKG's.

Call is q3 or q4, and when you're on call, you spend the night in a room provided to you by the hospital. Non-call nights are usually over around 5:00. When not on call, you commute each morning and afternoon via ferry in Grand Isle (about 1/2 hour from Burlington) - the cost is picked up by CVPH. You take admissions throughout the week. There are either three or four upper-level residents on the rotation at a time, and each student is assigned to a specific resident for the month. Again, you can expect to see the majority of conditions listed below, and the best time to learn about them is while you're treating them. Again, pay particular attention to diabetes, COPD, chest pain, anemia, CHF, hypertension, depression, and infectious disease (especially UTI, URI, pneumonias, and cellulitis). The experience differs from FAHC in that the patient population is slightly more diverse, and tends to be from a lower socioeconomic background than you may find in Burlington.

Clinically, this month tends to be less taxing than the month at FAHC. There is a structured teaching experience almost every day from various members of the faculty, and each week there are conferences via telemedicine. The commute can be draining over the course of the month, although it can be fun to spend the down time with your classmates. The cafeteria is much better than FAHC.

This month is spent with a general internist somewhere in Vermont, usually Chittenden County. Although you'll still see patients with all of the conditions listed below, the presentations won't be acute - you'll learn how these diseases are managed on a continuing basis. Also, the initial presentation of many conditions is made to the primary care provider - this month is an excellent opportunity to hone your diagnostic and history taking skills. Of course, you'll perform many many physical and screening exams, and depending on the environment in your particular office, you may be able to gain valuable experience in injection &/or venipuncture.

A great deal of the material that you're tested on from this month is material that you may not be directly taught, depending on your attending. You're expected to be familiar with basic screening exams, their indications, and their interpretation. These include Pap smears, breast exams, mammography, rectal/prostate exams, colonoscopy and sigmoidocscopy, mental status exams, and very importantly - blood chemistries (see electrolytes and blood for help). You should know basic health maintenance information, and particularly you should be familiar with smoking cessation techniques, as well as becoming comfortable discussing substance abuse, spousal abuse, elder abuse, cancer risks, immunizations, diet, exercise, etc.

You may or may not be asked to take some call nights with your attending - this varies widely among the various practices.