I recently finished my first clinical rotation of PA school: internal medicine. It was a fast and furious 4.5 week, but I learned a ton and came out with some tips that I think would be super helpful for anyone (MD, PA, DO, NP, etc.) rotating through medicine to have.
These tips are all based on my experience from my rotation as well with recommendations from some colleagues. It’s just advice, you’ve got to do what works for you! That being said, let’s jump right in.
10. Be ready for a challenge; you will be tested
Maybe my IMIP (internal medicine inpatient) experience left me a bit charred - to be fair, I’m still recovering. Myself and three of my classmates were thrown into the belly of the beast that is internal medicine at a big teaching hospital in downtown Atlanta for our very first clinical rotation. It was humbling enough to be surrounded by some of the world’s smartest and most esteemed physicians, residents, interns, and medical students, but charging head first into the entirety of medicine fresh out of didactic was quite literally trial by fire. All I could do was hang on for dear life and try my best to make a little bit of progress every single day. You may end your day in tears, feeling dumb, or feeling like you don’t know anything, but rest assured that this entirely normal and that everyone goes through it. Consider it a rite of passage of sorts.
You were accepted into school because you were identified as someone who is A. awesome, B. wicked smart, and C. a life-long learner. Medicine is a dynamic and rapidly evolving field; there’s something new to know every day! We had daily lunch conferences which addressed all different topics in medicine so that everyone can stay up to date on the latest updates in medicine, research, and changes to guidelines. Everyone is continually learning and improving, so don’t feel bad if you don’t know something or forgot what the only two medications that have been proven to reduce mortality in heart failure* are like I did. Two thumbs way up, you got THIS!
9. Learn your bread and butter diagnoses
Heart failure, hypertension, diabetes, urinary tract infections (UTI), chronic obstructive pulmonary disease (COPD), asthma, gout, DVT/PE, myocardial infarction, kidney disease, hyperlipidemia, HIV, and electrolyte abnormalities are common; common things occur commonly!
(*In case you’re wondering, it’s ace inhibitors and beta-blockers.)
If there are any diseases that I would suggest anyone studying up on before their internal medicine rotation it would be these. Many of the patients that you’ll see will have several chronic medical conditions and often present with acute exacerbations of their ongoing disease. Studying up on the pathophysiology and typical treatment regimens for these everyday bread and butter diagnoses will make your life that much easier when you step foot onto wards day one of your medicine rotation.
8. Practice your oral presentation
No one wants to do this, but if you practice just a couple of times a week before your rotation you will thank yourself, trust me. Giving an oral presentation is tough; it’s a lot of information that needs to be organized and synthesized into a concise, coherent, and reasonably well thought out presentation that you will soon be giving on rounds in front of your team of residents, interns, medical students, and peers. No pressure.
Mastering the oral presentation takes a long time, a lot of practice, and repetition. To make matters worse, every attending physician is different in how they like their patients presented. The only way to know how they like it is to ask or to give your standard presentation and let them inform you of what they want to know vs. what you might leave out next time.
My suggestion is to break your presentation down one piece at a time and don’t move on until you feel comfortable; chief complaint with duration, history of present illness, past medical history, family history, social history, review of systems, vital signs, physical exam, labs, imaging, assessment, plan. Find some old patient vignettes and practice doing your opening statement and HPI. If you can capture your audience in the first few seconds of your presentation you’ll likely keep them engaged for the rest of it, which is why it is so important to be able to confidently begin your presentation with a clear and concise chief complaint and HPI.
Ask a faculty member, upperclassmen, or colleague to listen to your presentation and provide you with feedback. It can be uncomfortable and awkward to present a patient, especially as a new clinical student, but it is a valuable tool that you will have to use over and over again. So, embrace the suck and take it one step at a time. I promise you that it will start to come naturally once you do a few and get some practice and repetition in. Be patient with yourself, learn from your mistakes, and try to get a little bit better every day. Soon you’ll be getting compliments on your impressive oral presentations like a boss.
7. Get a pocket resource book
There are a ton of pocket resources out there. If you’re a member of the AAPA (American Academy of Physician Assistants) and you should be, you probably have the Maxwell pocketbook. Maxwell is a useful tool, but you will probably want a pocket resource that goes a bit a more in-depth. I really like the MDPocket book for Physician Assistants: Internal Med/ER edition except for its lack of a table of contents or index – not having that was ultra-frustrating.
The other pocketbook that I use and what you may want to get is the Pocket Medicine: The Massachusetts General Hospital Handbook of Internal Medicine. All of its content is evidence-based and provides you with the research publication that its guidelines are based off. If you follow me on YouTube, you have seen me make mention of this book before. It’s an excellent reference (with an index!) that is a reliable tool to have and use in between patients on rounds.
6. Get these apps for your smartphone, you will use them frequently
Some of my favorite apps include MDCalc, Epocrates (there’s a free version and a full version), DynaMed Plus or UptoDate (subscription required), the CDC guideline apps, uCentral, and Journal Club. To be fair, in my limited time I only used these few apps, but I am sure that there are plenty of other great ones for internal med. Let me know if there are any apps that you have used and liked!
5. Know your labs, what they measure, and how to interpret them
• Complete Cell Count with differential (CBC)
• Basic/Complete metabolic panel (Chem 7/14)
• Arterial/venous blood gas
• Liver function tests (AST, ALT, Alk Phos, etc.)
• Your special tests such as troponin, lipase, procalcitonin, lactic acid, brain natriuretic peptide, CK-MB, etc.
As you progress through your rotation, you will start to pick up on which labs are pertinent/important for different pathologies (i.e. Creatinine, BUN, GFR, CrCl for kidney function). You will be ordering and interpreting labs on every single patient you see, so you’ll want to be especially astute in this area. It is also good to know the normal ranges for these labs, but this is difficult to really nail down until you have some clinical context (at least it was for me).
4. Get familiar with the typical electrolyte abnormalities, their complications, and how to correct them
The significant electrolytes that we worry about are Sodium, Chloride, Potassium, Calcium, Magnesium, and Phosphorus. These can be too high or too low in the bloodstream and come with their own set of problems and complications. These abnormalities can be caused by a plethora of things including diabetes, vomiting/diarrhea, kidney disease, liver disease, iatrogenesis (when we cause the problem, typically due to medication), and more. Electrolyte abnormalities frequently occur so knowing their manifestations, complications, and treatments will greatly serve you when you come across them in your patients, and you will!
3. Find 1-2 resources that work for you and STICK with them
For me, this was OnlineMedEd (OME), an online resource that provides concise 10-20-minute-long chalk talk-style lecture videos covering topics in medicine. OME was an invaluable resource as I am a multi-modal learner and learn best when I have someone to walk me through the broad strokes of a topic with visuals and audio. Once I have a basic, foundational understanding of a subject I can then go back and fill in the details on my own. OME was the perfect resource for me, and I am so glad that I found it. You have to find what works for you though because not everyone learns in the same manner.
I also loved having the book Clinical Pathophysiology Made Ridiculously Simple. Again, I need to read it, hear it, see it, and sniff it before I know it. No this isn’t the most efficient modality of learning, but that’s what I’m stuck with. This book was great for giving me a comprehensive, but simplified overview of a pathology so I could at least know a little bit about what’s going on even though I may not have known the exact diagnosis algorithm and treatment guidelines. I supplemented my pathophysiology reading with Porth’s Essentials of Pathophysiology. I also used Cecil’s Essentials of Medicine and the USMLE Step 2 CK First Aid book.
2. Use the patient’s problem list to guide your learning
What’s a problem list? Well, to put it bluntly, it’s a list of medical issues that your patient has or has had in the past that you will use to formulate your assessment and care plan. This list is organized into a systems-based problem list (i.e. neuro, psych, cardio, pulm, etc.) or a priority-based list (i.e. 1, 2, 3). For the sake of brevity, we will use the priority-based problem list, starting with the patient’s most severe/critical problem (i.e. acute myocardial infarction) and then continue on with the less pressing issues (hypertension – controlled, etc.).
Generally speaking, on your medicine rotation you’ll pick up and start following one patient at a time. I recommend focusing on your one patient’s problem list and studying up on their chronic medical problems, at least as a new clinical student. Working on one patient a time will give you the opportunity to know your patient backward and forwards while learning/re-familiarizing yourself with the framework of treating common pathologies that may or may not have forgotten from didactic year.
If you try to learn too much at a time, you will find yourself overwhelmed and stressed. If your patient has a problem list a mile-long, and they often do, focus on the top 2-3 problems. When you get home, pull up a couple of YouTube videos, review the chapter in your book, or use another resource to brush up on the problem so that when you come back the next day to present your patient on rounds, you will be prepared to discuss some of the patient’s pathophysiology as well as treatment options based on evidence that you looked up.
1. Don’t be afraid of getting pimped
What did you just say? Getting pimped? What??? Don’t worry; it’s not what it sounds. The practice of “pimping” in teaching hospitals is a long-time tradition that involves the attending physician asking the residents, interns, and students questions about medicine on rounds. These questions can range from being very simple and basic, “what’s the most common EKG finding in a patient with a pulmonary embolism?” to questions that are straight up cruel “could you tell me the exact mechanism that leads to acute encephalopathy and altered mental status in geriatric populations who present with an infection?”
Your attending is testing your knowledge to assess your level of understanding. Often times you may not have the answers to their questions, and that’s okay. A simple, “I don’t know that answer, but I will be reading up on it tonight,” tends to be a relatively benign response that won’t invoke too much embarrassment. These questions aren’t meant to embarrass you or demean your knowledge base, but to assess your progress and stimulate your thinking. Don’t be afraid of being wrong! Making mistakes is how we learn, improve, and ensure that we don't make the same mistake twice.
To summarize, internal medicine is a fantastic but challenging rotation. You will be exposed to many of the chronic medical conditions that pop up in medicine which will greatly serve your career in medicine, regardless of which specialty/field you go into. This rotation tends to have long hours, so be sure to rest up, stay hydrated, and keep proper nutrition - your brain will thank you. Be a sponge and absorb everything you can. I hope that you are on a great team with some outstanding teachers that care about your education because this can make or break your rotation. If on the off chance that the team you are on is less than subpar, you will need to take the initiative for your learning. Be relentless with your questions, don’t be afraid to speak up and get involved, and do plenty of reading. Remember, you are a student, your job is to LEARN!
If you have any other tips, recommendations, or resources for internal medicine, please feel free to share them with me via e-mail.
About the author:
Stephen Benton is a current PA student who was born in England, raised in Colorado, and now attends PA school at Emory University in Atlanta, Georgia. He began pursuing medicine as a career after completing his degree in performing arts and music, as he realized how much he craved having a more direct impact on the well being of his community. Follow Stephen on Instagram and visit his website at PagethePA.com.