Core Clerkship in Internal Medicine
Clerkship Director: Susan C Brewer, M.D.
Assistant: Pamela Swann
The Core Clerkship in Internal Medicine consists of an eight week rotation during the junior year. At the Memphis campus, the clerk will rotate through two of the following hospitals: the Regional Medical Center, the VA Medical Center, the Methodist University Hospital, and Baptist Hospital-Nashville.
The educational effort of the Clerkship centers around the ward team. This will provide each student the opportunity to learn the basic principles of Internal Medicine, not only through direct patient contact, but also by observing and interacting with faculty and house staff. Each ward team will typically consist of an attending physician, a second or third-year resident, and two third-year medical students. The third-year clerk is a participating member of the ward team with responsibilities for patient care. The ward experience is enhanced by the faculty didactic series, Chief rounds, the Observed Structured Clinical Experience and Hematology laboratory.
The Medicine Core Clerkship is designed to introduce the third-year medical student to the field of internal medicine. More specifically, the goal is to develop in the student a thought process which incorporates history, physical examination, and results from laboratory tests in order to arrive at a logical diagnosis, and in a general fashion, to describe an appropriate treatment plan. The clerkship is specifically not designed to encompass all aspects of internal medicine nor is it designed to recruit or develop internists. The clerkship is designed to provide the basic skills necessary to produce well-trained junior medical students. Objectives for the Internal Medicine Core Clerkship:
- provide compassionate treatment for all patients, respecting their privacy and dignity
- conduct patient centered encounters, perform and document both complete and focused histories and physical examinations appropriate for level of training and present the findings in a logical and concise manner;
- develop a problem-oriented method of patient evaluation, evaluate data, identify problems, and plan proper action using scientific evidence and clinical judgment;
- apply principles of health promotion and disease prevention;
- work effectively with other health professionals in order to provide patient-focused care;
- improve basic skills in routine technical procedures: obtain blood samples, arterial blood gas, peripheral intravenous line, observe a lumbar puncture and observe a paracentesis;
- demonstrate literacy in the use of computers, medical informatics, and other technology to support patient care decisions.
- become familiar with the principles that underlie normal human aging;
- demonstrate knowledge of core internal medicine disease processes, including symptoms, diagnosis, and treatment;
- recognize the risk/benefit of medical intervention;
- recognize that health and illness involve psychological, biological, cultural, ethnic, gender, age, and socio-economic components;
- develop an analytical approach to problem solving and clinical reasoning;
- improve understanding the scientific basis, indications, and interpretation of common diagnostic modalities;
- improve knowledge of therapeutics and therapeutic decision-making;
- develop skills in recognizing patients with immediately life threatening conditions and be understand the appropriate initial actions;
- become familiar with the principles of preventive medicine, health maintenance and how environment affects health and disease;
- develop awareness of both traditional and non-traditional modes of care.
Practice-Based Learning and Improvement
- develop a medical curiosity which will stimulate life-long learning and self-education and use information technology in support of your own education.
- develop an evidence-based approach to medical management
Interpersonal and Communication Skills
- develop interpersonal skills that build rapport with patients, families and other members of the health care team;
- improve ability to counsel and educate patients;
- communicate effectively in both oral and written format.
- develop conduct and behavior appropriate for a medical professional as outlined in the “General Guidelines for Professional Behavior and Conduct in the Clerkships.”
Typically two third-year students are assigned to each ward team at the following hospitals: the Regional Medical Center (four teams), the VA Medical Center (five teams), Methodist Central (three teams), and Baptist-Nashville (one team) All of the hospitals in Memphis have no overnight call, but have a "night float" team. On a "long call" day, the team takes admissions for 12 hours. You should take call with the night float team once each week.
Clerks can expect to “work up” one to two new patients per call and to follow a maximum of five patients at any given time. You will occasionally go into call with five patients, but if a particularly interesting patient is admitted, you may be expected to work up and follow this new patient. In this case, the intern and resident alone can follow one of your patients. Student work hours are well defined in our student work load policy which is referenced below.
Student Work Hours Policy CenterScope 2011-2012 p 145:
- Duty hours will be limited to 80 hours per week averaged over a four-week period, inclusive of all in-house call and patient care activities.
- Continuous on-site duty, including in-house call, will not exceed 30 consecutive hours. Students may remain on duty additional hours to participate in transferring care of patients, conducting outpatient clinics, maintaining continuity of medical and surgical care, and attending required didactic activities.
- Students will be provided with one day in seven free from all educational and clinical responsibilities, averaged over a rotation, inclusive of call. One day is defined as one continuous 24-hour period free from all clinical, didactic, and administrative activities.
- Students should be provided with a 10 hour period after in-house call during which they are free from all patient care activities.
Blood and Body Fluid Incident
Regional Medical Center:
- Notify the attending and/or senior resident.
- Call the Hospital Epidemiology Unit (day) 545-7900 or by beeper 1-800-283-0028, ext. 9959, or 392-9697 (evenings, weekends, or holidays).
- Report the injury to Occupational Health (formerly the Primary Care Clinic) at the Medplex as soon as the exposure occurs or the next business day (if occurring on weekend or holiday) at 545-7166.
Veterans Administration Medical Center:
- Notify the attending and/or senior resident.
- During normal business hours (8:00 AM-5:00 PM), report to Employee Health, 523-8990, ext. 5538. After hours, report to the Emergency Room and report to Employee health the next business day.
- Notify the Chief Resident, senior resident, or Dr. Sands.
- Report to the Emergency Room.
- Notify the attending and/or senior resident or Dr. Fassler
- Report to the Emergency Room.
Guidelines for Professional Behavior and Conduct in the Clerkships
See the UTHSC Catalog pp 233:
The clinical rotations in the third and fourth years of medical school place demands and requirements on the students that go significantly above and beyond academic achievement as measured by performance on tests and by the ability to field questions learned through didactic instruction and reading. The student is also accountable for his or her behavior in each of the following areas:
- Professional and Ethical Conduct: The welfare of patients and their families is of foremost concern. Students must show respect and courtesy for patients and their families, even under difficult situations such as being challenged or provoked. Students must safeguard their patients' confidentiality. There are to be no casual communications regarding patients in public places, such as hallways, elevators, cafeterias, gyms, etc.
- Punctuality, Responsibility, and Reliability: Students are expected to be available and present for all scheduled Clerkship activities. Any absences must be approved by the Clerkship Director in advance. Make-up assignments will be determined by the Clerkship Director; absences due to illness may require a physician's statement. Chronic tardiness is unacceptable. A clerkship typically does not run on an 8:00 AM-5:00 PM workday schedule; students are expected to stay until the work is done.
- Getting Along with Other Members of the Medical Team: Good relationships with nurses, aides, ward clerks, security personnel, and anyone else involved in the care of the patient are absolutely essential. Students are expected to be courteous to all hospital employees.
- Getting Along with Clerkship Staff: Students need to be polite and respectful to people other than the patients, faculty and residents, and hospital employees. Much of the daily work in keeping a clerkship going falls on the shoulders of administrative assistants, secretaries, receptionists, and other staff. Students are expected to be considerate of and courteous to all of these employees.
- Getting Along with Peers: Students are expected to have pleasant working relationships with their fellow students. This includes an equitable sharing of the workload and helping and supporting each other.
- If clerkship directors receive consistent complaints about a student in any of these areas, the student's grade will be affected. Serious problems with unprofessional or unethical behavior, in the judgment of the clerkship director, will result in a failing grade even if the student has done well on the written or oral examinations and on the wards. Also, complaints about unprofessional or unethical behavior may be reflected in the Dean's letter, even if the student has received good evaluations from supervising attendings and residents, and has good test scores.
- There may be times when any student has a personal problem or a personality conflict that impairs his or her ability to function properly on the clerkship. It is the student's responsibility to notify the clerkship director if this is occurring. The clerkship directors will do their best to help; however, it is impossible to make allowances after the fact.
Many questions arise regarding grading. Beginning May 2008, the grades will be determined as follows:
- Preceptors' evaluations - count 1/3 each for a total of 2/3
- Shelf exam = counts 1/3 with a passing score of 65.
Students who fail to achieve a passing score of 65 on the NBME Medicine subject exam but who pass the clinical portion of the Clerkship will be allowed to re-take the subject examination. This exam must be completed by August of the following academic year and can only be taken once. A second failure or failure to take the repeat exam by the deadline will result in a final grade of F. Passing the Departmental exam will result in eligibility for a final grade of B for the Clerkship, assuming satisfactory clinical assessments.
If there are questions or ambiguities regarding the grading in the Department of Medicine, please contact the Clerkship Director personally. There is frequently a great deal of misinformation and misunderstanding when information is obtained from other sources.
Questions have also arisen regarding how one should study for the examination. Given that this examination is a standardized test, it is extremely difficult to study in any logical fashion. It is the recommendation of the Clerkship Director that students concentrate their reading on the problems of the patients who are currently on their service, either their own or their peers. Students should also attend the assigned student lecture series and read on those topics that are discussed. Again, it is not the purpose of this Clerkship for the student to obtain an encyclopedic data base of Internal Medicine, but more importantly to develop a method of logical thought processes. Students are strongly advised NOT to cram for the examination during the final two weeks of the Clerkship at the expense of their clinical responsibilities. This is unnecessary, and in general, counterproductive. Remember, your performance on the ward is a much greater determinant of your grade than the test.
The objective for the M-3 Internal Medicine Medical student education is for students to acquire a fundamental knowledge of internal medicine while developing skills of physical examination, history taking, case presentation and various procedures: starting IV’s, venipuncture, paracentesis, and lumbar punctures. Students will be expected to demonstrate an adequate basic fund of knowledge, interest in learning, technical skills, ability to organize data and formulate hypothesis, ability to relate to patients, staff, and other physicians. The goals, objectives and projects for the Internal Medicine Clerkship are the same at all UT sites (Memphis, Knoxville, and Chattanooga).
Students are assigned to a Service Medicine Team, typically consisting of an attending physician, one resident, and one or two interns. Rounds occur daily and students are expected to be active participants. Each Service Medicine Team is “on daytime call” every fourth day. The Internal Medicine Residency utilizes a “Night Float” Team of residents and interns to handle night time call from Sunday through Thursday. This allows the medical student to leave the hospital around 5 PM on most days and by 7 PM on the day the Team is on “call.” Students have overnight call about two weekends each month (Friday or Saturday). Students usually have one weekend day off duty.
Students also attend all Department of Medicine Conferences (Mid-day conferences, Ambulatory care conferences, and Grand Rounds) as well as specific medical student lectures (one to two times per week) on a wide variety of internal medicine topics. Three days during the Clerkship are designated for skills training to allow students to become proficient in starting IV’s, drawing blood and blood gases.
The Chattanooga Unit, through the generosity of the hospital, provides living arrangements (modestly furnished apartments) and meals for all students who participate in rotations in Chattanooga – all at no cost to the student.
The Department of Internal Medicine in Chattanooga sponsors one of nine residency programs based at Erlanger. We offer ten positions at each of three levels of training. Our Internal Medicine Residency is specifically designed to educate good general internists whose goal is to practice general internal medicine or pursue subspecialty training. Clinical training occurs at Erlanger Medical Center, a modern health care facility offering residents experience in primary, secondary, and tertiary medical care under the supervision of outstanding faculty. Our residency is dedicated to providing a superior learning environment for training residents to practice the highest quality of internal medicine. Our Program is fully accredited and is designed to provide optimum, first-hand experience and didactic education in the broad field of internal medicine. More than 6,000 patients are admitted annually by general internal medicine faculty, related subspecialty faculty, residents, and students.
For other information about our clerkships (housing, meals, etc.) or residency programs, go to utcomchatt.org.
The Department of Medicine sponsors up to six (6) third year medical students for their mandatory 8 week block Internal Medicine Core Clerkship. The students work closely with a team consisting of two interns, one upper level medicine resident and one medicine attending. The student is provided an opportunity to learn the basic principles of Internal Medicine, not only through direct patient contact, but also by observing and interacting with faculty and house staff. The third-year clerk is a participating member of the team with responsibilities for patient care. The core lecture series is provided by the upper level house staff physicians. Students meet with the chairman and medicine program director for Professor Rounds 3- 4 times per rotation. Teaching rounds and morning report also enhance the learning experience.
Students are on call with their assigned intern every third day alternating day and night call. New patients are assigned to the students on their call day. Third year clerks are expected to spend call nights in the hospital Student call rooms are provided.
Third year clerks will see new patients in the ED and patients ready for transfer to the medical team from the intensive care units. Students are expected to see their assigned patients on a daily basis assessing their clinical course and developing a differential diagnosis with an evaluation and therapeutic plan. Close supervision is provided and yet adequate autonomy is provided to allow physician skills to develop that can only be learned via independent study/experience. Students are encouraged to perfect their basic skills of phlebotomy, BP checks arterial punctures to obtain blood gases and IV placement during this time. Students are afforded opportunities to observe and perform diagnostic procedures such as thoracentesis, paracentesis, and joint aspiration.
One well-crafted history and physical is to be turned in to the attending each week. Emphasis is placed on the history, physical and assessment with a detailed differential diagnosis. This is to be reviewed with the attending before the next call day.
The outpatient experience is limited but available for students who desire to see patients in the ambulatory setting—the student usually sees patients with the assigned team intern but allowed to see outpatients with the assigned resident or attending.
Two study books are available for checkout from the Department of Medicine. We recommend the Lange Series for Medicine for the first 2-4 weeks followed by the MKSAP for Students 3 for the remainder study period. Harrison's remains the textbook of choice for detailed reference as well as online availability of MD Consult. For more information about the clerkship, you may contact the Knoxville Student Affairs Office. To inquire about our residency program, please visit the UT Graduate School of Medicine website.