Internal medicine doctors are generalists—just like doctors who work in family medicine. They know the interplay of each organ system and often consider their patients deeply for many hours at a time.
Internal medicine is one of the most important core clerkships; it can lead to numerous other specialties, and the content of the USMLE 2 CK exam is 50-60% internal medicine. The internal medicine clerkship provides medical students with the opportunity to learn a vast range of medical knowledge and gain a better understanding of what it’s like to be an internal medicine doctor.
“He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.” – William Osler
This guide will cover the internal medicine clerkship, including when to place this rotation, how to make the most of your rotation, internal medicine resources, the Shelf exam, and the pros and cons of pursuing this specialty.
Clinical clerkships, also known as rotations, are when medical students practice medicine under the supervision of an established physician or health practitioner. Clerkships allow students to experience a specialty first-hand to see what it’s really like. This way, they can determine which field of medicine they feel most passionate about and want to pursue in their future career.
Most US medical schools require the following rotations:
Some schools may also additionally require other rotations, such as emergency medicine, radiology, anesthesiology, etc.
Internal medicine is the specialty that deals with the diagnosis, treatment, and prevention of an extensive number of diseases and illnesses that affect adult patients. It’s such a broad specialty that it’s difficult to categorize—there are so many different things you can do with it.
The internal medicine clerkship represents the gateway to numerous medical specialties and opens the path to fellowships in cardiology, oncology, nephrology, gastroenterology, rheumatology, hematology, infectious diseases, endocrinology, and pulmonary disease.
Internal medicine doctors are the generalists of generalists. They treat an incredibly wide variety of medical conditions, whether they be acute or chronic, common or rare, complex or straightforward. Pursuing this specialty requires you to be heavily involved with direct patient care. It’s also important to have a passion for learning because internal medicine doctors must analyze broad volumes of information in order to get their patients back to a healthy baseline.
Because of this, internal medicine is much more of an intellectual specialty compared to others. But that’s not to say that internal medicine physicians never use their hands; they can occasionally perform minor procedures, such as thoracentesis, paracentesis, intubation, and more, but it’s rare to perform these procedures after residency.
In the outpatient setting, it’s typical for internal medicine doctors to perform steroid joint injections, ultrasounds, Pap smears, skin tag or wart removals, and other similar, minor procedures.
But whether internal medicine sounds up your alley or not, the internal medicine clerkship is extremely important due to its impact on the Step 2 CK exam. The USMLE 2 CK exam contains 50-60% internal medicine questions. Since Step 1 is now pass/fail, the need to ace the internal medicine Shelf exam in order to be prepared for 2 CK is greater than ever.
The competencies trained in the internal medicine rotation also have a lot of crossover with other specialties. For instance, being able to read an ultrasound scan (US) not only serves cardiologists, but it’s also very useful in critical care and diagnostic radiology. Being proficient at taking a patient’s medical history not only benefits internal medicine doctors but it’s also helpful for psychiatrists.
Where you place the internal medicine rotation depends on your interest in pursuing it as a specialty and when you plan to take the Step 2 CK exam. If you want to pursue internal medicine for residency, it’s most strategic to place this rotation second or third out of the total of four quarters of the year.
This will make sure you have a foundation of experience before you enter the rotation you feel the most passionate about. Placing it first, when you’re just getting the hang of your third year clerkships, may not be the best time for you to impress your seniors and attendings. Not placing it last ensures you’re able to get enough references for applying to away rotations and residency programs.
This will give you enough time to get used to the process while also leaving enough time to build connections. You don’t want to find out right before scheduling away rotations that you actually hate the specialty you thought you were going to pursue. You also may need time to acquire adequate letters of recommendation.
If you don’t plan to pursue internal medicine as a specialty, completing this rotation earlier can serve as a foundation for your next rotation since you will soak in a vast amount of information during this time. On the other hand, another practical option is to place this rotation last so that you can review all of the content you need to know for Step 2 CK, which contains 50-60% internal medicine questions.
The internal medicine rotation is a mix of inpatient and outpatient.
The inpatient part of the rotation may seem daunting at first. Rounds will take an enormous amount of time. Sometimes you’ll be bored, and at other times, some pathology may catch your attention. However, it is up to you to make the most of this time.
Here are some tips for the inpatient rotation.
Not all schools offer an outpatient portion of the IM clerkship; however, if they do, this portion of your rotation will be less intense. At this point, you may have the opportunity to choose a sub-specialty clinic. For example, if endocrinology interests you, arrange with an endocrinology attending for your outpatient rotation. This time enables a medical student to:
Below is a list of high-yield topics for your internal medicine rotation. Having a good understanding of these topics early on will prepare you for practice questions and rounds to impress your attending.
Heart Failure
History – A patient with heart failure will complain of orthopnea, fatigue, and shortness of breath with effort. In order to classify their shortness of breath (SOB) in relationship with the effort, you can use the NYHA classification in the clinic.
Physical Exam – There will be a displaced apical impulse due to enlargement of the heart chambers. It is important to distinguish findings between left heart failure and right heart failure.
CAD/Angina/MI
History – Retrosternal chest pain with pain irradiating to the jaw or to the upper limb.
Physical exam – The patient can present with sympathetic activation, such as tachycardia, sweating, a sense of impending doom, or with PS activation (i.e., syncope).
Diagnosis – The diagnosis is made based on clinical presentation with an ECG. However, when the patient is known with previous MI, BBB, on digoxin, or with a pacemaker, the alternative to the ECG is the echocardiography. The next step is to administer the supportive treatment with morphine, nitroglycerin (not administered in right heart infarction), oxygen, and aspirin. When arriving in the ED, one can continue with the cardiac markers, such as troponin and CK-MB. The latter is better used for patients who had an infarction in the last week.
Treatment – If the pain started less than 90 minutes ago, the best next step would be a percutaneous coronary intervention with stenting. However, if the pain started more than 90 minutes ago, it’s recommended to start a fibrinolytic therapy.
Hypertension
COPD
History – Usually, the patients are smokers who consume more than 20 packs per year. Their main complaint is shortness of breath at rest or with exercise. However, if the patient is young (~40 years) and has a familial history of COPD, you should suspect alpha-1 antitrypsin deficiency.
Physical exam – There are two classic presentations:
Acute Kidney Injury
Prerenal azotemia | Renal azotemia | Postrenal azotemia | |
Causes | Hypovolemia (dehydration, hemorrhage), third spacing (liver failure associating ascites), ↓perfusion (CHF) | Glomerulonephritis, ATN, AIN, embolic disease, rhabdomyolysis | Obstruction (nephrolithiasis, BPH, congenital obstructions, pelvic tumors) |
Fe Na | < 1% | > 2 % | > 1% or more > 2 % (if severe) |
BUN/Cr ratio | > 20:1 | < 15: 1 | Variable |
Urine osmolarity | > 500 mOsm/kg | < 350 mOsm/kg | Variable |
Anemia
Diabetes Mellitus
Diabetes mellitus diagnostic criteria
Pre-diabetes diagnostic criteria
Other pharmacologic treatments
Other Important Topics to Review:
Internal medicine is a clerkship made for developing diagnostic skills (mental frameworks) and practical skills.
Be picky about your patients to develop practical competencies. At the beginning of your rotation, make a list consisting of the skills you desire to build. Then consider the inpatients who have a pathology that requires those skills. Take a patient with renal colic to learn how to take an ultrasound of the kidneys. Building your experience in this way ensures you will have those diagnostic tools at your disposal by the end of the rotation.
When developing diagnostic skills, this two-part framework will help.
More broadly, these are the skills you should learn before or early on in the internal medicine clerkship.
Internal medicine has a wide variety of conditions. Oftentimes, there are certain calculations that need to be done to objectively approach care. Many of these calculations can be found on various phone apps, such as MDCalc. You can make these calculations ahead of time and present them on rounds when appropriate to impress your attending.
An exhaustive list would only transform this article into a textbook, but here is some key information that may help you during your rounds.
This is a list of some common scores that may be calculated on your internal medicine rotation.
ASCVD risk (atherosclerotic cardiovascular disease)
It is critical to your success that you learn the content from appropriate resources.
We recommend the AnKing Anki Deck or Step-Up to Medicine, depending on if you prefer flashcards or books. If you prefer videos, the Boards & Beyond videos + White Coat Companion study aid or OnlineMedEd are both great resources as well.
One should provide you with enough information. Try to quickly pre-read some of these resources to understand the general concepts, then jump into the questions. After completing and reviewing a UWorld block, refer back to these resources to fill in any gaps.
The most important resources for internal medicine are the question banks, which includes either UWorld or AMBOSS. Both are excellent resources for your internal medicine rotation. Schedule at least one block of questions each day after your wards. Think of the block like an exam (i.e., timed and random). Not only will this method help you to familiarize yourself with the time pressure from the exam, but it will also improve your retention of the material. Doing questions from various topics in the blocks is an effective study technique called the interleaving effect.
If the number of questions makes this too difficult, divide the questions by system—just note that that actual Shelf won’t be like this. Review your answers carefully. For those you answered incorrectly, seek to understand why you were incorrect. For the correct answers, explain to yourself why you didn’t choose the other answers. This active recall method forces you to test other areas of your knowledge while enhancing your ability to eliminate answers in the exam. The latter is useful when having to make an educated guess during the exam.
A secondary resource is a good reference book, such as the AnKing Anki Deck, Step-Up to Medicine, or the Boards & Beyond videos + White Coat Companion. These will help to fill any gaps in your knowledge. They will be most useful after encountering a case whose pathology you didn’t master. After the UWorld block and review, reading a bit about your patient will get you a long way on the wards.
Lastly, Anki decks are an invaluable on-the-go resource. You may also create Anki flashcards based on the questions you miss in UWorld or AMBOSS.
The internal medicine Shelf exam will require more intense studying given the volume of information within the clerkship. Given the internal medicine Shelf exam includes the majority of the different organ systems, it is extremely important to stay on track with your studying throughout the rotation. With over a thousand UWorld questions for the clerkship, cramming these last-minute questions should be avoided at all costs.
Tips for the Internal Medicine Shelf Exam:
Internal medicine is one of the most accessible specialties from a competitiveness standpoint. In our MSI competitiveness index, it ranks middle of the pack, with an average Step 2 CK score of 248 and 6 publications. Moreover, considering that the training only takes 3 years, it’s also on the shorter side of the spectrum.
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The internal medicine residency is a gateway to most medical specialties. There’s essentially a fellowship for everyone.
If you are an achievement-driven, type A personality, you might consider cardiology. It is one of the most competitive fellowships in a continuously changing domain. In 2021, it was also ranked as the third most compensated specialty on Medscape, with an annual compensation of $459,000.
If you are an empathic person who knows how to handle sensitive situations, oncology might be for you. Oncology is on the higher end of compensation ($403,000 annually), you’ll be able to keep a regular schedule, and it’s a technology-driven field. Furthermore, it is a great field for people who want to pursue research.
If you are not disgusted by bowel movements and prefer procedures, then gastroenterology will be a great choice. Compensation-wise, it is at the higher end of the spectrum ($406,000). The hours are more predictable, and the calls are usually taken at home. On rare occasions, a patient may require an endoscopy in the middle of the night.
On the other hand, internal medicine provides the benefit of flexibility. Plus, it permits entering practice after only 3 years of training. It’s also a specialty that’s high in demand. Another great flexibility asset is that IM programs are part of joint programs. This means that by the end of your residency, you’ll be board certified in at least two specialties. Some examples are IM/dermatology, IM/EM, IM/psychiatry.
Learn more about whether or not the internal medicine specialty is right for you: So You Want to Be an Internal Medicine Doctor (video and article).
From a mental perspective, the internal medicine clerkship is a heavy clerkship. Each medical specialty requires a diagnostic prowess that has less importance in other procedural-heavy clerkships, such as surgery or OB-GYN. Nevertheless, mastering the IM clerkship will greatly enhance your Step 2 CK score, as it makes up the bulk of the exam. Another advantage is that the same mental gymnastics will ease your pediatrics and psychiatry rotations.
This clerkship is an opportunity to develop procedural skills that can be transferred to most of the specialties. Regardless of whether you choose to pursue internal medicine and one of its several subspecialties or if you choose an entirely different training path altogether, there’s great utility in this rotation if you approach it correctly. Learning to perform an ultrasound will be helpful even if you are a cardiothoracic surgeon, and as a dermatologist, you’ll benefit from learning how to biopsy skin lesions during this rotation.
The internal medicine rotation is an opportunity to acquire a breadth of medical knowledge that can be applied to a wide variety of specialties and subspecialties. The rotation will put your mental abilities to the test, but everything you learn during this rotation will accelerate whichever specialty you decide to pursue.
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