Rotation Recap: INTERNAL MEDICINE

My 6th rotation was inpatient internal medicine. Much of this rotation demonstrates just how much internists work as a team and coordinate with specialists who ultimately work toward providing care for the ‘whole patient’. The patients you will encounter can range from an acute Emergency Department admission to palliative care in those who may be too unstable to return home before they pass.
Overall, I did not expect to LOVE this rotation as much as I did! Applying your knowledge to interpret lab results and put to test everything learned in didactic is so rewarding, challenging, & kind of (really) fun! But Remember, even if you aren’t someone who is interested in doing Internal Med or working as a hospitalist that your purpose as a student is to learn & absorb as much information as possible!

So here’s the low-down on my personal experience & a few tips I would give to those of you who have yet to do your IM rotation:
Location: Tennessee
Hours: 12 hour shifts that were typically 7am-5pm if we were rounding on inpatients, sometimes we would work admitting shifts from 1pm-8pm  (luckily for me, I only had day shifts…but don’t be surprised if your preceptor works nights as well)
Preceptor: Internal Med Hospitalist
Attire: Business Casual (this varies depending on the hospitalist group you work with, some prefer professional attire and others scrubs)

Responsibilities of the PA Student: As a student at this hospital it was difficult to be “hands on” without supervision, so my responsibilities were limited. Thankfully my preceptor loved to teach and was very wise -I still learned A TON despite the lack of autonomy. For those of you who may not have preceptors who go out of their way to test you on what you think the next step in treatment may be- take the initiative! Remember that you will only have this rotation once and you more you put in to it, the more you will gain.

What to expect:
-       Developing your bedside manner: Because IM focuses on the entire patient, get ready to listen and provide the patient with the plan of care. Your ability to answer questions while in the patient room will definitely evolve with each encounter & develop the more you research their disease state.
-       Death and dying: People go to  the hospital to die- sounds obvious, but keep it in mind to mentally prepare. This rotation was the very first time I cared for a patient as they died in front of me. Although it wasn’t an acute situation, it was an experience I’ll remember for the rest of my life. Learning to empathize with loved ones/family members, offering condolence as a provider, and effectively communicate with them about reality of death. It’s likely that those who have been terminally sick or those who have an aggressive illness have suffered a great deal prior to your care. As the patient has experienced this illness, their family has as well- inform them that dying is not always a painful experience & the usefulness comfort measures bring to the patient as they go through the dying process.
-       Complex patients: As students were taught from the bottom up, from the simple diagnoses then on to complex diagnoses with multiple components. Don’t be surprised if most of your patients have multiple issues wrong with them while hospitalized- from a septic endocarditis with a history of an autoimmune disease who needs management from all ends à to a patient recently diagnosed with cancer having adverse effects from chemotherapy which then turns into a nosocomial infection from their lack of systemic defense to fight off all of the infections in the hospital. Just remember to take one problem at a time & consider how their medication and the side effects can impact other problems they may already have.
For the majority, internal medicine is learning how to actually help the patient in the best way possible without adding more drugs to their regimen- getting down to the bottom of the problem(s), turning unstable patients into stable patients, and reducing their problems that may be caused by polypharmacy.
-       Electrolyte abnormalities/Acid-Base Balances: Know common electrolyte disturbances in your common populations: geriatrics, diabetics, and those in respiratory failure.
-       Drug Users: these guys show up VERY frequently. Know the common pathologies like Endocarditis, Sepsis, Cellulitis, Hepatitis, HIV/AIDs, etc.
-       Patients with chronic issues that include primarily: know these disease states like the back of your hand, know their treatments, & which drugs to avoid in these populations.
o   Obesity
o   Kidney & Heart disease
o   COPD

How to prepare for your IM Rotation:
-       Be prepared to go the extra mile on this one. You’re likely going to see a lot of patients and work long hours. Be sure to make yourself useful to your preceptor, if there’s something you can do, offer to do it for them! This is true for all rotations, but especially on this rotation – learning to apply any skill when you notice a need for assistance will not only impress your preceptors but also give you the opportunity to practice the skills you’ve acquired so far
-       Have a go-to app to look up diagnoses, presentations, labs, etc
o   My go-to apps: UpToDate & Medscape
-       Learn your common diagnoses, but get in the habit of thinking of a wide range of differentials: This rotation came with so many new cases of pathology I had not been familiar with so be prepared to see a great variety of patients.
-       Get a detailed History/Physical & Practice your oral presentations: If you’re fortunate enough to venture out on your own to do H&P’s, know how to give a smooth and informative oral presentation. Give your preceptor the pertinent information and in an appropriate order of presentation.
-       Know your labs and how to interpret them: Knowing when and which labs to order can sometimes be really easy and other times more difficult. Will the lab you have in mind help diagnose or treat the patient- basically, are you ordering the lab/rad for a purpose? & if evaluating new labs, what does the trend appear to be? Pay attention to trends!  Doing this can give you an idea whether the patient is experiencing an acute or chronic complication based on how extreme or minor labs have evolved.
-       Know which resources work best for you & refer to them often: This point goes back to the apps you prefer to use, but in addition to that be sure to know what resources provide information that sticks with you long term. Personally, I use Online MedEd when I need a starting ground and/or an algorithm to follow and then I use UpToDate to fill in with details or a quick search when I’m in between patients

What I learned:
-       Use the patients medication list to fight the unknown for you. Before you give yourself a headache trying to figure out the root of the patients issue, look over their medication list and ask about new/changed doses of medications.
-       Go over the entire disease states that you don’t know fully. Making the connection between the cases you see each day and disease states from the books will help you retain the information and details that may seem to just blend in with similar diagnoses.
-       Don’t wait until last minute to study for the EOR, this exam has a very broad range of topics that covering at a good pace should definitely be of interest if you’re looking to score well on EORs.


Instead of trying to go over each and every disease state listed on the PAEA topic list (aka TNTC) for this EOR, take an IM practice test FIRST to guide your studies so you know which areas you need to work on most! Remember, work smarter, not harder.

Material I recommend studying (Again this is just my opinion, if you already use something that works for you- continue using it!):

-       PAEA Topic List with a focus on that information given the PAEA blueprint. PAEA gives you the breakdown percentile of sections likely to appear on the exam, so you’ll know where to focus your studies: https://paeaonline.org/wp-content/uploads/2018/06/internal-medicine-blueprint-20180524.pdf
-       Online MedEd + UpToDate, as previously mentioned
-       Brief yourself on ventilator settings, CPAP, BiPAP & when they’re used (mainly for
clinical competence, I’ve uploaded a pdf here): https://drive.google.com/open?id=1fkarkfCUWpJxucKKcX6S6wk42B6u8331
-       Brief yourself on the Beer’s List (medications to stay away from in the geriatric
population)

- Become familiar with the NIH Stroke Scale or download the MDCalc app: https://www.mdcalc.com/nih-stroke-scale-score-nihss

Helpful documents I’ve been passed down these documents for rounding H&P’s and Admissions (I can’t take credit for the beauty, but printing these out the first few times you round will get you organized & guide your interview/presentation)
Admission Template: https://drive.google.com/open?id=1-4TKDrrPuqmZ2ijnvw37B-181lkWAFG6
H&P Template: https://drive.google.com/open?id=1Ztg-Sf42VkqLossMyyxKfTz3yTsfTwLq

Ashley MunnsComment