4th Year Overview

Duration

The clerkship in Internal Medicine is a fast paced 8-week experience. It is divided into three activities: conferences and classes, inpatient ward rotations, and ambulatory continuity clinics. Ward rotations are four weeks in duration and end on the last Friday. Students will then be off until starting the next rotation the following Monday morning. During these rotations you will be assigned to ward teams and take call according to the published team call schedule. You can expect at least 9 - 10 night calls during the 2 blocks of ward rotation. 

Team Assignment.
You will have two four-week block assignments to an inpatient team.  Each "team" is typically composed of a faculty attending, one senior medical resident (PGY-2), one or two interns (PGY-1), and three to four medical students - a total of eight to nine persons.  The student is a member of the team and participates actively in the care of assigned patients and may assist with the care of other team patients as needed.

Ward Activities.
While on rotations, specific responsibilities and educational activities include Attending Round and Work Rounds.  Bedside rounds tend to be management focused and patient oriented.  This is where your learning can be most productive.  This time should also be used to develop effective doctor-patient and doctor-doctor communication skills.  Longer academic discussions that do not require the patient's participation can usually be held in one of the conference rooms.

Call.
During ward rotations you will be on call with your ward team for the purpose of working up new patients and to observe and participate in the care of acutely ill patients.  The call system is similar although not identical at the various campuses.  You should expect to work up 2-4 patients during most long call periods and one to two patients when on short call.  You may remain in the hospital on your "on-call" nights to participate in cross-coverage and acute care activities for the entire call period (on-call beds will be available).  However, residents are authorized to release students after patient care requirements have been met or (9:00 pm).

Patient Evaluation.
You are expected to "work-up" 4-6 new patients each week (2-3 patients each call day). In general, you should average at least four patients per week. You should write a full history and physical examination, and record the initial database. You should define the problem list for each patient, starting with the presenting problem and include a differential diagnosis for each problem. A plan of action for each problem should be devised and recorded.

See your patients as soon as possible after they are assigned to you. Your completed evaluation should then be written up and, if time permits, reviewed with your resident or intern before presenting to your attending physician on rounds.  A copy of at least one write-up per week should be given to your attending for evaluation.  When it is returned to you, turn it in to the clerkship coordinator for placement in your file.

Online Patient Log (OPLOG)
In keeping with the accreditation standards of the Liaison Committee on Medical Education (see section I), the objectives for clinical education must include quantified criteria for the types of patients, the level of student responsibility, and the appropriate clinical settings needed for the objectives to be met. Accordingly, to document and permit a review of your patient experience, a log of all patients evaluated by you should be maintained and kept current throughout the clerkship.

 As soon as you get a patient assigned, record the required information in the Online Patient Log (OPLOG), listed on the Office of Academic Affairs home page.  List all patients on whom you have done a complete history and physical exam.  In general, you should average at least three patients per week.  Thus, you will be able to evaluate 24 or more patients during an 8-week medicine clerkship.

 The log entry for each patient should include the following:

• Patient’s initials, age, sex
• Date of encounter (usually the date of admission or clinic visit)
• Primary Diagnosis (the main problem for which the patient was seen or admitted)
• Secondary Diagnosis (an active problem or comorbidity which must be evaluated or treated during the hospitalization or visit)
• Third Diagnosis (this block provides space for a third active problem orcomorbidity which must be evaluated or treated during the hospitalization or visit)
• Procedure:  an entry for procedures is not required for the Internal Medicine Clerkship clinical setting/location of the encounter
• Hospital
• Clinic
• Level of student responsibility:
• Performed and recorded an H&P
• Limited encounter, e.g., office visit or daily ward visit for which a note was written
• Performed or assisted with a procedure
• Patient’s medical record number entered in section “Additional Notes”

It is important for you to enter the information on each patient you work up.  In addition to the ward patients please include any clinic patients that you are able to personally obtain a history and perform a physical examination.  Take a look at the Master Data Collection Key in the Enclosures section.  This will give you an idea of the various diagnostic groups for patients seen during your Internal Medicine clerkship.  While our goal is for you to evaluate 24 or more adult patients with various internal medicine problems during your clerkship, you should also evaluate at least one patient from each of the diagnostic groups to facilitate your learning experience.

You will have an opportunity to review this information at the mid-rotation evaluation conference but should also periodically review your patient types with your resident and attending to ensure a good spectrum of learning opportunities. During the seventh week of the clerkship, the clerkship director will once again review your log book entries. If it appears that you will not meet the goals by the end of clerkship, remediation will be necessary. This will involve reading one or more paper cases in the area(s) of deficiency.

The OPLOG provides a means of monitoring the scope and diversity of your learning experience.  It is to be kept current throughout the clerkship.  No additions should be made after the last working day of the rotation. 

Information Access.
Textbooks are limited in terms of the scope and timeliness of information.  To make sure that you are aware of new developments in medicine, try to regularly scan some of the key journals such as The New England Journal of Medicine, JAMA, etc.  Consider performing a computerized literature search to find articles pertinent to a specific clinical question at least once a week.  The National Library of Medicine (PubMed) at http://ncbi.nlm.nih.gov/PubMed is ideal for this.  Bookmark this site on your PC and use it frequently.

Scheduled conferences.
Check your student lecture schedule for topics, time and location. 

Attendance.
Attendance at all student conferences is mandatory.  Student conferences are designed to supplement the patient contact experience by introducing the student to a number of major medical illnesses.  Conferences are scheduled daily (Mon.-Fri.) at 8:00 am and 9:00 am.  Check your Master Schedule on WebCT for specific topics.  Conferences on ECG/chest x-ray interpretation and test preparation are also scheduled throughout the clerkship.  Check your master schedule posted on WebCT for specific items.  You are expected to complete assigned reading prior to each scheduled conference.

 Absences.
If you find you will be late or absent from any clerkship duties call the clerkship coordinator, Valerie Turner, as soon as possible (preferably by 8:30 am).  Also, please notify your attending and resident.  A student absence form (see FORM section) should also be completed and signed by the clerkship director.  You are allowed 4 days of excused absence during an 8-week clerkship.  Also, please remember the guidelines for years 3 and 4 require there be no unexcused absences during clerkships.

 Clerkship Patient Interview and Examination Exercise.
You are required to interview and examine a patient while being observed by an attending.  This should occur during the third or fourth week of the clerkship.  Have your attending complete and sign the observation form (see FORMS section).

 Elective Rotations
You will participate in a one-week elective in a subspecialty of your choosing. Available subspecialties include MICU, CICU, or one of the following consult services: Cardiology, Endocrinology, Hematology/Oncology, Infectious Disease, Nephrology and Pulmonology.

You will be evaluated on your performance during your Internal Medicine Clerkship using the rating categories Honors, High Pass, Pass, and Fail. The grading scheme is as follows:

High pass is only given on the NBME Exam and the overall final grade (see below). A high pass score on the NBME is 70-79 percentile.

Other components:
          Professionalism
                    Pass:  dimensions of commendation > dimensions of concern
                    Fail:  dimensions of commendation < dimensions of concern

          Inpatient Write-ups
                    Pass:  turn in 7 or more write up
                    Fail:  turn in less than 7 write ups
                   Observed History and Physical
                              Pass:  completed
                              Fail:  incomplete

Overall Honors Grade:       

• Honors NBME Exam score 80 or above
• Honors in one other major component (clinical evaluation or OSCE)
• No Fail grades
• Pass all “other components”

Overall High Pass Grade:

• NBME Exam Score 70-79 percentile
• Honor in one other component
• No Fail grades
• Pass all "all other components"

Overall Pass Grade:

• Fail to meet criteria for Honors
• No Fail grades
• Failure of one or multiple components:  see the current TTUHSC Medical Student Handbook for guidelines.

NBME Exam:  The National Board of Medical Examiners Medicine Subject Exam

Clinical Evaluation:  Evaluations by faculty physicians and house staff using the TTU-HSC Clerkship Evaluation Form

OSCE: Objective Structured Clinical Examination given at the end of the clerkship.

 

Mid Rotation Evaluation

Half way through the clerkship you will have a one on one meeting with the Clerkship Director to review your clerkship experience to date.  This conference is designed for you to give feedback about the clerkship and how you are meeting your training objectives.  It is also designed to give you feedback about your clinical performance to date.  You will be given a questionnaire entitled “Mid-Rotation Evaluation and Review” (see Section V). Prior to your appointment with the Clerkship Director, please complete the sections clerkship experiences and self-assessment.  Also, be sure to have your log book current so your patient care experiences to date can be reviewed with the Clerkship Director.