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Third year clerkships part one: Internal medicine, pediatrics, & psychiatry

You’re finally ready to start your clerkships—AKA the reason you went into medicine! Welcome to the fun part of medical school.


This is a dense topic so we will split it in two parts. Here, we will discuss the internal medicine, pediatrics, and psychiatry clerkships. In the next post, we will discuss the surgery, OB/GYN, and family medicine clerkships.


Though this can be the most rewarding and interesting part of medical school, it can also be one of the most mentally and physically demanding parts. Not only do you have a full time job of working in the hospital but you also have to set aside time to study daily. But don’t worry, every student gets through it and you learn to manage as you start to prioritize your time better.


What can you expect from each of your rotations?


We’ll break it down by rotations since it is often specialty dependent.


Internal medicine:

This one’s a beast. As part of the internal medicine rotation, most medical schools will have one month of inpatient medicine, one month of outpatient medicine and sometimes an additional month of either a consult/subspecialty service or another inpatient month.


Here, we’ll focus on inpatient medicine, since it’s the most demanding service. Schedules will vary based on the medical school but the following is a pretty average schedule. Each morning you will attend morning report, chart review your patients (find out what happened overnight, interpret new labs, follow up any workup that has resulted, etc.) and then pre-round on your patients (ask them how they’re doing, perform a physical exam, talk to nurses, etc.). You will likely then round with the residents and fill them in on your patients. Mid-morning, you will round with your attending physician. They will likely use this time to teach at the bedside and we would encourage you to take advantage of these opportunities. After that, you’ll spend the rest of the day completing your notes, performing tasks, and will likely have teaching sessions with the residents and/or attending.


When presenting, we recommend you use the SOAP format for an existing patient that the attending already knows (Subjective, Objective, Assessment, and Plan) or present the full H&P presentation if the patient is new to the service. In the subjective portion, discuss how the patient feels, what happened overnight, etc. In the objective portion, discuss labs, ins & outs, vitals, imaging, physical exam, etc. For assessment, discuss your interpretation of the results and what you think is going on with the patient. For the plan, discuss how you think the patient should be managed. Make sure to follow up on any recommendations from consultants and look at telemetry! Don't be afraid to talk to your residents and ask their opinion on your assessment/plan and have them help you come up with good differentials and management strategies. Attendings will have different preferences when it comes to specifics of presentations, so we would recommend asking them or your residents on the first day so that you can find out their style. Make sure when reporting labs to talk about how they compared to the day before! It's important to know the trend over the last few days.


How can you shine?


Take ownership of your patients. You should know every lab, every new imaging result, and anything that affects care of the patient. This is YOUR patient and you should know just as much as the residents do about your patient.


Spend time with your patients. You have the most time out of everyone on the team (even though it doesn’t feel like it!), so try to get additional history from patients, be a listening ear if they need comfort, and talk to family if necessary (with the OK from your residents of course).


Take the initiative and go above and beyond what is asked of you. Volunteer to request medical records if needed, help with procedures, and do whatever you can to make the residents’ lives easier. If your team looks good, you look good.


Advance your learning. Whether you’ve been assigned a topic to read up on or not, learn as much as you can! Bring up articles to your team, discuss important topics, and volunteer to look up a concept if you don’t know the answer.


Seek feedback. Ask your attending how you're doing and what you can be doing better. There's always room for us to improve!


In the outpatient setting, you will likely see patients for annual physicals, sick visits, and management of chronic issues such as hypertension, diabetes mellitus, and hypothyroidism. You'll be able to put your Step 1 brain to work and do more in depth investigation that often isn't possible in the hospital.


In terms of consult/subspecialty services, there are so many to choose from! These include hematology oncology, GI, endocrinology, nephrology, cardiology, pulmonology, infectious disease, among others. You will either be in the hospital, in the clinic, or a mix of both.


Try to learn as much as you can since this will be the most relevant rotation to you, especially for your shelf!


Resources for the shelf: Uworld, Step Up to Medicine, Case Files, OnlineMedEd.

Pediatrics:

Babies!!! It’s hard not to get excited.


The pediatrics clerkship is typically divided into inpatient, outpatient, and consult/subspecialty services.


The pediatrics inpatient service is very similar to the internal medicine inpatient service, so much of the advice above is applicable. The main difference here is that you will likely be relying on family members to provide you with a history, as the patients are often too young to provide you with any information. Both family and nurses are great resources on this rotation. The physical exams will also differ, depending on the age of the child. Some students will also spend time in the NICU and/or newborn nursery which are valuable experiences as well.


In the outpatient clinics, you will likely be doing many well child visits, sports physicals, and sick visits. This is a great learning experience! Even if you don’t pursue pediatrics as a career, much of the information you learn can be applied to your current/future family or can be used to answer questions from family members or friends. Use this time to hone your physical exam skills, perfect your ability to make differential diagnoses, and brush up on common pediatric illnesses for your shelf.


Pediatric subspecialty services are similar to those of internal medicine and include cardiology, nephrology, allergy/immunology, GI, endocrinology and much more. Use this time to figure out what you like!


Finally, take Vitamin C and make sure to get your flu shot. Most medical students will get sick at some point on pediatrics; its a rite of passage!


Resources for the shelf: Uworld, Case Files, OnlineMedEd.


Psychiatry

Psychiatry is a highly applicable specialty, especially if you plan to do primary care. Most psychiatry rotations are structured as inpatient psychiatry, outpatient psychiatry and psychiatry as a consult service. Some students will even have the opportunity to work with children and adolescents in the clinic as well.


The inpatient service will look similar to any other inpatient service with the exception of the physical exam focusing on the psych and neuro exams in detail. You will often have to deal with patients who are very distressed and often times you will round with the group instead of individually. Make sure that you are compassionate and refrain from judgment. Use this time to learn about your different psychiatric drugs including anti-psychotics, anti-depressants, ADHD medications, and any other relevant medications.


The outpatient service often consists of patients with chronic depression, ADHD, anxiety, OCD, schizophrenia, and other psychiatric illnesses. You will be able to see how medications can be titrated based on persistence or resolution of symptoms or changed based on side effects.


Resources for the shelf: Uworld, First Aid for Psychiatry, Case Files, OnlineMedEd.


Stay tuned for part 2!


--C&W

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