Michael Dworkin, MD
How to crush the medicine clerkship
Updated: Nov 13, 2020
Medicine is complex. Doing well on the medicine clerkship isn't. Read on for tips on how to get honors on your medicine rotation!
How to prepare for your medicine clerkship One week before the rotation, email the resident you'll be with and briefly introduce yourself in one sentence. Ask where and when to meet them on the first day of the clerkship. Here’s an example email you can send before you begin on medicine wards:
Subject: Medical student starting on medicine wards next Thursday.
Body: Hello, I'm an MS3 looking forward to starting my medicine clerkship next week on Thursday. I was wondering: what time and where should I meet you? Is there anything I should know before starting? Thanks! -Your Name
What to study before starting your clerkship
It's never too early to begin studying for the medicine clerkship.
First, check out our blog post on the best clinical resources to help you crush your clerkships and USMLE Step 2 CK exam, as well as our post on how to use Anki during medical school.
If you have time, watch OnlineMedEd videos and review StepUpToMedicine before your first day. If you're starting on a general medicine service, start with cardiology, infectious disease, pulmonology, renal, GI, heme/onc, endocrine, rheumatology, and dermatology. If it's is a pulmonary consult service, start with pulmonology, then work through the aforementioned list in the same order. As you watch the videos, make Anki Flashcards or review the corresponding cards in the MedSchoolGurus Internal Medicine Anki Deck.
Download the OnlineMedEd videos or the audio files onto your phone so you can listen to them on your commute.
Apps to use for the Medicine Clerkship
To study throughout the clerkship, download the UWorld app, AMBOSS Q-Bank and Knowledge app, and the Anki flashcard app onto your phone.
For rounds, download your respective EMR app if one is available. Use UpToDate to look up basic treatment plans, Epocrates to look up medications/dosing, MDCalc to conduct simple calculations and look up relevant equations, and GoodRx to look up local medications if you have an outpatient component of your medicine rotation. Familiarize yourself with these applications before your rotation so you can quickly access them when needed.
What to do during your first day
Meet your residents and team and ask your attending what the team expectations are of you. For example, say "I wanted to ask you about what the expectations for the rotation and if you have any tips or advice". Ask your residents about what you should be doing every day as this will vary greatly from institution to institution and service to service. Ask if you should write notes and how this process works. Medical student notes are officially billable as of 2018, so you'll likely be asked to follow your own patients and write notes on them. More on how to take a H&P and write notes later on this post.
What to study during the first month of the rotation
Do a first pass of medicine during the first month. I.e., do all the 1200+ IM Shelf UWorld questions at a rate of 40-100 cards per day, watch all the OnlineMedEd videos, and do Anki Flashcards either from the material covered on UWorld and OnlineMedEd or from the MedSchoolGurus Anki Deck. You should try to do all due Anki cards every day if possible, but you should absolutely do all practice questions every single day.
Go through the organ systems in the following order: cardiology, infectious disease, pulmonology, renal, GI, heme/onc, endocrine, rheumatology, and dermatology.
On UWorld, it should take you about 5 days to work through cardiology, 3-4 days to work through each of ID, pulmonology, renal, GI, and heme-onc, 2-3 days to work through endocrine, and 1-2 days to work through each of rheumatology and dermatology. This should be a total of 22-32 days. Adjust this schedule accordingly if your rotation is only a month long.
General advice on how to be a good med student on clerkships Be on time, clean and well groomed, professional with everyone you encounter, and willing and available to work hard and help out. Be straightforward and communicate clearly and deliberately with teammates. Know your patient very thoroughly – better than anyone on the team. Don’t lie or make stuff up – if you didn’t examine something and are asked about it, just say you didn’t examine it. Ask questions or for advice during downtime or when walking somewhere with your resident as opposed to when things are hectic.
If you’re told to go home for any reason, say “Ok, thanks! I’ll see you tomorrow!”.
How to start a day on medicine
Go to the hospital early. How early? A rough rule of thumb is to arrive to the team workroom (30 minutes + 9 minutes per patient) early. This will give you time to pre-round on all of your patients.
How to pre-round on medicine patients
Review vitals, labs, and new studies that have resulted for each patient first. Review ins and outs on any patient who is being diuresed. Go to the patient's room. Find their nurse and ask if there were any events overnight. Ask the nurse“Do you have Mrs. Swell in bed 35? Great! I’m Michael with the medicine team. How’d she do overnight?”. Go in into the room. Ask the patient how they’re doing with their chief complaint. Then ask a detailed review of systems related to the organ system(s) of their chief complaint. Always ask about chest pain, shortness of breath, nausea, vomiting, diarrhea, constipation. Ask any other relevant review of systems.
Be focused in your physical exam. Examine heart, lungs, and perform abdominal palpation for everyone (but only report relevant exam findings). Examine the area(s) related to the chief complaint. For example, if a patient has shortness of breath, make sure to thoroughly auscultate the posterior lung fields, as well as check fluid status via checking for peripheral edema, jugular venous distension, and moist mucus membranes.
How to present a SOAP note to a medicine attending
If you’ve never presented a medicine SOAP, make sure ask practice first with a resident before delivering it to an attending. Be brief in your presentation and make good eye contact. Make sure to include name, a quick identifying one liner, and relevant events overnight, interval changes in symptoms, changes in physical exam, relevant studies that have resulted, and plan. E.g., if you're trying to present a 60 year old female who was admitted two days ago for dyspnea due to a CHF exacerbation:
One liner. Miss Swell is a 60 year old female with CHF who was admitted two days ago for dyspnea and was found to have pulmonary edema due to CHF exacerbation.
Subjective. There were no acute events overnight. Her dyspnea is improved this morning.
Objective. She is afebrile, normotensive, and net negative 2 liters over the last 24 hours. She is now off of nasal cannula and is breathing comfortably on room air. Peripheral edema is reduced, now to the level of the ankles. Lungs are now clear to auscultation bilaterally. Chest radiograph this morning shows interval resolution of pulmonary edema. Labs are notable for a creatinine of 1.3, up from 1.0 yesterday.
Assessment/Plan. Overall, Mrs. Swell is a 60 year old female admitted for dyspnea due to CHF exacerbation, now resolved.We will switch her to her home dose of oral lasix today and repeat a BMP tomorrow to monitor her mild AKI. She likely can go home tomorrow, pending physical therapy evaluation. I will call her outpatient cardiologist and make her an appointment for a week from tomorrow.
Developing/ Asking Questions
As a third-year medical student, you are not expected to have answers to all diagnostic or therapeutic questions regarding your patients, so having questions is not a bad thing! In fact, asking questions demonstrates that you are thinking critically about these aspects of patient care. When residents are presenting, be sure to listen to their assessments / plans and write down questions that you have regarding their patients or treatment decisions. Be tactful about asking these questions - save them for asking during down time with the team as opposed to asking them right after the resident presents, as this may make you look like you are trying to show off. Do not ask questions that you know the answer to in order to look smart. Sometimes, if you ask an attending a question, they will ask you to look up the answer and teach it to them. If this happens, use UpToDate to the best of your ability and try to come up with a short explanation for the team.
How to use your downtime wisely
You will likely have tons of downtime to study on medicine, even during a busy clinical day. For example, after you finish writing your notes and tucking in your patients, you'll probably be stuck sitting in the workroom with the rest of the team. While you can't yet leave, you should study. Do UWorld questions via your smartphone during this downtime, as well as during morning report, noon conference, and grand rounds, as these lectures are often geared towards residents. If you have met your quota for the day, flip through the IM Essentials Flashcards on your phone. You can also flip through Anki on your smartphone during downtime. Make notes on the back of your rounding sheet throughout the clinical day on high yield things you learned and want to add to Anki later when you get home. Download the OnlineMedEd audio files to your phone and listen to them on your commute.
You'll probably get home sometime between 6-8:30 on most medicine services which operate during the workday. Your time at home should be used wisely. Try to study for at least 1.5-4 hours after you get home every day. It can be difficult to study after getting home, so you may instead choose to go straight to the library after wards, work for a couple hours, and then go home and relax. Carve out time in your calendar to do the things that help you de-stress.
What to study after the first month of the rotation, and how to study for the medicine shelf
Once you have finished the 1200 UWorld IM Shelf questions, you should then try to do as many of the 1400 AMBOSS IM Shelf questions as your schedule allows. These questions repeat many of the vignettes from UWorld, so you should be able to move through them at a rate of 80 – 100 questions per day, while adding / unsuspending Anki cards relevant to new concepts or missed questions (by the way, if you don't know what is meant by "unsuspending", please see our article on how to use Anki in med school). To save time, unselect the hardest question type (5 hammers) as those generally cover extremely low-yield details for your IM Shelf. You can select all the subjects if you want a general review, but if you find that you’re struggling in a specific area then it may be better to simply focus on your weaker areas since there are so many questions.
As you progress through the UWorld or AMBOSS question banks, brush up on weak areas with OnlineMedEd videos and quickly referencing StepUpToMedicine. Make your own Anki cards, or study the cards from the MedSchoolGurus Anki Deck for your incorrect questions or any new concepts that you encounter while doing practice questions.
How to study for the medicine shelf
Watch the Emma Holliday medicine shelf review video and make corresponding Anki cards or study the flashcards from the MedSchoolGurus Internal Medicine Anki Deck. Complete all of the four NBME Clinical Mastery Series practice shelf exams. Review each with your MedSchoolGuru on the same day you completed the exam to identify how you could have improved your test taking strategy. Make sure to create or unsuspend Anki cards corresponding from your incorrect questions.
Once you are a week away from your shelf exam, stop doing new questions if you have progressed to a second question bank such as AMBOSS, and redo your incorrect questions from both UWorld and AMBOSS until there are no incorrect questions remaining. The day before your exam, review your NBME tests once more to get a better sense of the question-writing style of the NBME exam writers, since it tends to differ slightly from UWorld / AMBOSS.
For more information about our shelf exam and USMLE tutoring services, check out medschoolgurus.com. To schedule a free 15 minute consultation session, visit medschoolgurus.com/contact.