M-III Internal Medicine clerkship
University of South Carolina School of Medicine-2009-2010
2 Medical Park • Suite 402
Phone 803.545.5316 • Fax 803.545.5349
Table of Contents
Goals and Expectations of the Internal Medicine Clerkship 2
How to Learn on the Internal Medicine Clerkship 3
Suggestions for Success 5
Ways to Excel on the Internal Medicine Clerkship 7
Your Internal Medicine Clerkship 10
Goals and Objectives 10
Attendance Policy 10
Call Schedules and Work-hour Rules 11
Typical Daily Schedule 11
MICU Rotation 12
Medical Student Morning Report 13
Chairman’s Presentation 13
Simulation Workshop 15
Formal Didactics 15
Nutrition Activity 16
Grading and Evaluation 17
Formal Clerkship Objectives 19
Core Competencies and Patient Encounters 22
Welcome to your Internal Medicine clerkship. We are genuinely delighted to have you join
us for this short period. On the clerkship, you will likely only get a small glimpse into the
world of internal medicine. Nevertheless, through this experience, we expect that you will
acquire fundamental skills, reinforce and expand your knowledge, and develop personally
and professionally. We hope that this experience drives you to want to learn more and
experience more of what internal medicine has to offer. We wish you the most exciting,
stimulating, rewarding, and transforming experience possible over the upcoming weeks.
Caroline Powell, MD, MSCR email@example.com
803 540 1000 or 545 5317 – office
803 954 6652 – pager
803 201 9910 – cell
803 754 7019 – home
Mary Beth Poston, MD, MSCR firstname.lastname@example.org
803 540 1000 – office
803 954 5419 – pager
803 479 7567 – cell
Davinder Lally, MD email@example.com
803 540 1000 – office
803 954 2316 – pager
803 920 9540 – cell
Megan Gleaton firstname.lastname@example.org
803 545 5316
Advice from the Clerkship Directors in Internal Medicine national organization
Goals for the Clerkship
The primary focus of the medicine clerkship is to increase your capacity to function as a caring,
increasingly independent, but supervised clinician on an interdisciplinary internal medicine
In seeking to achieve the goals of the clerkship, we believe it is important for you to understand
what internal medicine is and what qualities characterize the ideal internist. In the broadest
sense, internal medicine is medicine for adults. Internal medicine is by far the largest medical
specialty; as such, internal medicine constitutes a major part of the overall landscape of
medicine. Internists care for a broad spectrum of patients, ranging in age from adolescence to
the ever growing elderly population. Practitioners include primary care general internists who
care for adult patients who may present with any problem. Internal medicine also includes sub
specialists, such as cardiologists, nephrologists, oncologists, critical care physicians, and
many others, who focus on the care of patients with specific diseases and disorders. Many
subspecialties of internal medicine are heavily procedure-based.
An internist’s practice may be mostly office-based or hospital-based. The internist coordinates
the care of the whole patient by working in concert with colleagues, values a strong patient-
doctor relationship, and applies the best scientific evidence. The internist is a clinical problem-
solver who is able to integrate pathophysiologic, psychosocial, epidemiologic, and “bedside”
information to address urgent problems, manage chronic illness, and promote health. Internists
frequently participate in research; many teach students and residents.
“An internist is a physician who can embrace complexity yet act with simplicity.” Louis
Pangaro, MD, Vice Chair for Educational Programs, Department of Medicine, Uniformed
Services University of the Health Sciences.
Basic Professional Expectations of Third-year Clerkship Students
Attend all clerkship activities on time. If you must be absent, get permission in advance.
Dress professionally. The way you dress makes a statement about your school,
hospital, and the medical profession; it may influence the way you are perceived by your
patients. If you have any question about what constitutes professional dress, consult
your clerkship director.
Treat every member of the health care team, the clerkship team, and every patient with
Answer your pager and email in a reasonable time frame.
Make sure your handwriting is legible and ensure every note includes your name, role,
Preserve confidentiality--do not discuss patients in public places and destroy all papers
with patient specific information that are not part of the medical record. Do not look in
the chart (paper or electronic) of any patient for whom you and your team are not
How to Learn Most Effectively on the Internal Medicine Clerkship
Most learning will take place outside of the classroom, through experiences with patients and
interactions with your team. While you may be offered a series of lectures, the bulk of your
learning needs to be self-directed. It is essential that you read regularly to answer the
questions you encounter each day. Take responsibility for your own education. Make sure that
through your reading, experiences, and didactics, you meet the goals of the clerkship.
Understand and clarify, if necessary, the expectations your residents, attendings, and
course directors have of you.
Keep a list of questions that arise during your day and seek the answers.
Be an active participant in your patients’ care. Be the “go-to” person for all your patients.
Each problem or question that arises is an opportunity to learn.
Be a team player. Be available to help all other team members, including other
Be around-do not expect your team to find you when something important is happening.
Although you may not always recognize it, you are an integral member of the team. Do
not underestimate your importance. Knowing where you fit in and fulfilling the part is
very important. As a junior member of the team, it is generally best to be malleable and
“go with the flow” of your team. However, if you have an important question or concern,
it is equally important that you ask the question or express the concern. Your
statements will often result in a valuable contribution to the education and work of the
team and to patient care.
Try to be observed and solicit feedback on a regular basis, both positive and
constructive. Constructive feedback is essential to your growth in your third year.
Learning moments may come when you least expect it. Pay attention at all times, even
when the focus is not on you or your patient.
Strive to practice evidence-based medicine. It is our responsibility to bring the best
scientific evidence to every clinical decision that is made. Use evidence-based clinical
practice guidelines whenever possible and learn from them.
Demonstrate that you are a self-directed learner by reading during the medicine
clerkship. Your education will depend on it.
Learn from your patients whenever possible. Read about all of your patients in depth.
The goal is to integrate your basic science knowledge and its application to your patient.
Supplement reading about your patients with periodic use of a review book with test
questions to ensure you cover core topics and are prepared for examinations of your
It is important for you to gain broad knowledge about the spectrum of medical illnesses as it
may be impossible for you to see patients with all conditions about which you need to learn
during your clerkship. Follow a structured reading program. It is helpful to have an overview
textbook of medicine, one which you can read in depth, ideally from cover to cover; over the
course of the clerkship (examples include Internal Medicine Essentials for Clerkship Students,
Cecil Essentials of Medicine, Paauw’s Internal Medicine Clerkship Guide, First Exposure
Internal Medicine: Hospital Medicine). A reference textbook of medicine is recommended for
most patient-related reading (Harrison’s Principles of Internal Medicine, Cecil Textbook of
Medicine, ACP Medicine).
Students also need additional resources to read in greater depth; review articles from the
literature or electronic resources are good resources to access. You will also want to have
access to small texts for rapid reference (on bedside rounds or in the emergency department,
for example). The Washington Manual of Medical Therapeutics is invaluable for formulating
treatment plans and writing orders. Ferri’s Care of the Medical Patient and The 5 Minute
Clinical Consult also serve this function. These books can be purchased for PDAs for slightly
more than their print counterparts (www.skyscape.com has many titles). However, they will not
be adequate for helping you understand differential diagnosis, pathophysiology, etc. When it
comes time to prepare for the clerkship final examination, many students use MKSAP for
Students, an excellent resource produced by the American College of Physicians (ACP) and
the Clerkship Directors in Internal Medicine that contains questions with detailed explanations
that are organized around the core CDIM training problems.
ACP’s Physician Information and Education Resource (PIER) is an electronic resource that
provides evidence-based guidance for managing clinical problems. Access to PIER is free for
ACP members and membership is free for students. UpToDate is another excellent electronic
resource for investigating specific clinical questions. However, these resources will be less
valuable for overview reading of larger clinical topics (an overview of congestive heart failure,
for instance). Additionally, the Internet provides access to an enormous library of medical
information as a rapid reference.
Students should be self-directed learners and share what they have learned with their
colleagues. This practice of continuous, ongoing learning will be necessary throughout your
career. When you read, consider preparing a single-page summary; be prepared to present
this synopsis to your team. You should do at least one topical presentation per four-week
rotation. If your attending or resident does not assign you a topic, pick a clinical subject that
interests you and is relevant to at least one of the patients on your current team. If you are
having trouble choosing a topic, ask for help from your attending or resident. If you have been
given a specific topic to research, do not be afraid to ask for guidance. A concise, summative
handout is a nice touch.
Suggestions for Success in the Inpatient Setting
Your job in the inpatient setting is to care meticulously for the limited number of patients you
are assigned, while at the same time learning as much as you possibly can. At times, service
and learning may be at odds but generally speaking they coexist quite well. It is useful to
recognize that the faculty and house officers you work with are attempting to balance
competing demands as well.
Actively and enthusiastically participate in rounds.
Demonstrate effective organizational skills.
You will learn more, have more fun, contribute more to patient care, and be less stressed if you
keep yourself, your schedule, and your patient information organized. It will come as no
surprise to you that being a doctor is a very hectic business. There is a lot to remember. Start
training yourself to be organized now!
Carry a calendar and mark all conferences and call days right away.
Develop a system for keeping patient data and tasks at your fingertips (note cards, fill-
in-the blank templates, PDA).
Have information about your patients immediately available (e.g., vital signs, laboratory
data, diagnostic studies, medications).
Communicate effectively with patients and their families.
You have the ability to make an important impact on the care and experience of your
patient. You will likely spend more time with your patients than other members of the
team. Your patients may see you as their primary provider, in effect, as “their doctor.”
Spend additional time learning about who your patient is—understand their social,
economic, personal background, and values.
After diagnostic and therapeutic plans have been formulated with the assistance of your
resident and attending, return to the bedside and discuss them with your patients.
Feel free to have personal and emotional discussions with your patients. You will have
the ability to comfort your patients during times of anxiety and fear. You will likely benefit
from these discussions as much as your patients. Some sensitive discussions, like
disclosing very bad news, should be conducted by more senior members of the team,
but you can still be available to provide additional information and support to the patient
and family once this information has been presented. Discuss with your team and
Show competency with patient care responsibilities.
Be fully prepared and on-time for work rounds everyday and have all pertinent data
available. Have a daily plan for each of your patients.
Take the lead in talking with your patients during work rounds.
Try to be the first one to get the important pieces of information about your patients.
Have all notes and orders promptly co-signed. You may want to carry order sheets with
you on rounds. Discuss this strategy with your team.
With the guidance of your resident, contact and communicate with all consultants.
Participate (including just watching) in as many procedures as possible, even if you are
not following the patient.
Try to accompany your patient to any diagnostic evaluations that occur during the
Write admission orders on all patients that you admit. (Even if the intern has already
completed this task, it is very instructive to write your own.)
Assist your interns with cross-coverage.
Learn about the other patients on your team. You should have at least a basic
understanding of what is going on with all the patients on the team.
Pitch in and be of assistance to your resident and intern when your other responsibilities
are taken care of. However, you should not do this to a degree that interferes with your
Integrate fully into the team.
Clarify your role on the team. Ask what is expected of you and deliver it. Show your
Offer to help other members of your team with their patient care if you fulfill your other
responsibilities. This cooperation will allow you to make a greater contribution to patient
care and give the team more time for teaching. Offer to research topics and contribute
educational presentations in teaching conferences.
Ask for guidance in your reading. Bring what you have learned back to the team. Ask
questions when you cannot find the answers yourself.
Ask for feedback. Respond to the feedback you receive.
Top 10 Ways to Excel on the Internal Medicine Clerkship
1. Find out what your residents and preceptors expect of you. Meet and try to
exceed their expectations. Follow through on every assigned task.
2. Be actively involved in the care of your patients to the greatest extent possible.
Go the extra mile for your patients. You will benefit as much as they will.
3. Go the extra mile for your team. Additional learning will follow. The more you put
in, the more you will gain.
4. Read consistently and deeply about the problems your patients face. Raise what
you learn in your discussions with your team and in your notes. Educate your
team members about what you learn whenever possible.
5. Learn to do excellent presentations as early as possible. This will make you more
effective in patient care and gain the confidence of your supervisors to allow you
more involvement in patient care.
6. Ask good questions.
7. Speak up—share your thoughts in teaching sessions, share your opinions about
your patients’ care, constructively discuss how to improve the education you are
receiving and the systems around you.
8. Actively seek feedback and reflect on your experiences.
9. Keep your goals focused on the right priorities, in the following order: patient
care, learning, and personal satisfaction. You should always strive to meet all
10.Always be enthusiastic. Be caring and conscientious and strive to deliver
outstanding quality to your patients as you learn as much as you can from every
Be caring and conscientious and strive to deliver outstanding quality to your patients as you
learn as much as you can from every experience.
The development of professionalism is an explicit and important goal of your clerkship. In
2002, the American Board of Internal Medicine Foundation, American College of Physicians
Foundation, and the European Federation for Internal Medicine wrote a charter on
professionalism that has gained widespread support (see the charter at
www.abimfoundation.org). It starts by stating that “professionalism is the basis of medicine’s
contract with society.”
The fundamental principles of professionalism are as follows:
Principle of primacy of patient welfare.
Principle of patient autonomy.
Principle of social justice.
The charter’s set of professional responsibilities are as follows:
Commitment to professional competence.
Commitment to honesty with patients.
Commitment to patient confidentiality.
Commitment to maintaining appropriate relations with patients.
Commitment to improving quality of care.
Commitment to improving access to care.
Commitment to a just distribution of finite resources.
Commitment to scientific knowledge.
Commitment to maintaining trust by managing conflicts of interest.
Commitment to professional responsibilities.
It is important to note that some of these principles are occasionally at odds with one another,
and in these situations it is important to be able to recognize and effectively negotiate these
conflicts when they arise. There are a number of ways to grow your level of professionalism
over the course of the clerkship.
Do your best to get to know your patients well. Understand who they are and why they
have the problems that they have. Treat every patient as you would hope your family
member would be treated. As you invest in your patient, they will invest in you, and this
will allow you to experience something that you may not have had before – a true
Follow your patients over time; call them after they have left the hospital to find out what
happened to them.
Be an advocate for your patient whenever necessary. Discover for yourself what Francis
W. Peabody, MD, articulated: “The secret to caring for the patient is caring for the
Reflect actively on your actions and experiences, on a regular basis. After each
interaction, especially those in which you find you are having strong emotions, spend
some time considering and analyzing what you have experienced. Write it down.
Discuss your thoughts with your peers and advisors.
Be honest to yourself and others. It is honorable to say, “I don’t know.”
Be aware of the “hidden curriculum.” This refers to that which is taught outside the
classroom and which may not be the best examples. Think critically about everything
that you are taught, no matter the source.
Work to improve the quality of the system in which you work. Every medical system has
weaknesses, gaps, inefficiencies, and processes that allow errors to occur. Be a part of
the solution. Consider ways that the system might be improved and pass them along.
Learn from your mistakes. You will make mistakes. We are human, and we can expect
no less of ourselves. And, as a learner, you do not yet have all the knowledge and skills
to practice independently. Strive to never make the same mistake twice. Share your
experiences with your peers, so they can avoid repeating mistakes. Learn as much as
you can about ways to prevent making important errors (and there is a growing
literature on how to do this), and be willing to adapt your practice to provide the highest
quality and safest patient care.
If any problems occur during your clerkship, let your clerkship director know as early as
The Internal Medicine clerkship is one of the most important experiences of medical school.
Regardless of what specialty training you ultimately pursue, you will unquestionably advance
your knowledge and skills on this clerkship.
Ultimately, we will view this as a successful clerkship experience if it makes you a better
caregiver, improves your skills, improves your confidence in yourself, helps you to become
more professional, and helps you to become more aware of your career preferences. You will
be one step further to where you ultimately will be—a skilled, caring, knowledgeable physician
in the area of your choice.
You will only have one Internal Medicine clerkship. As much as we may try to make
experiences consistent, no two Medicine clerkships are ever the same—from school to school
or from student to student. You, your patients, your team, your preceptors and attendings, and
your hospital and clinics will ultimately determine the outcome of this experience. This
clerkship will shape you, even if in small ways. You will carry your experiences from these
weeks with you for the rest of your professional career. We encourage you to do everything
that you can to make the very most of this experience. We hope that this handbook has served
as a guide of how to do exactly that. We wish you the very best clerkship experience possible.
Your clerkship director feels genuinely privileged to accompany and guide you.
Your Internal Medicine Clerkship
Your M3 clerkship consists of essentially 8 weeks of inpatient wards. Four weeks will be spent
at the VA Medical Center and 4 weeks will be spent at Palmetto Richland Hospital. Some
students will have the opportunity to spend 2 weeks in the Medical Intensive Care Unit at
Richland. There will be 2 full days of didactic learning, included as part of Orientation Day and
on the day of your mid-term exam. Your mid-term exam is a 1 hour test, based on board exam
and shelf test style questions. It is for your learning and is not graded. You must complete the
exam however as a requirement of the rotation. There will also be one afternoon of clinical
topic lectures, and one afternoon will be spent in the simulation center. You are encouraged
(but not required) to join your intern, resident, or attending for one or more half day in the
resident clinic over the course of the rotation.
Overview of Goals / Learning Objectives:
To develop clinical skills in medical interviewing, physical examination, and medical
decision-making through observation and active participation in medical care.
To develop skills in developing differential diagnoses
To develop skills in interpreting laboratory data
To understand the pathophysiology of medical illnesses and use this information to
direct the evaluation and treatment of patients.
To learn basic differences between inpatient and outpatient medical practice.
To understand the importance of using an evidence-based approach to medical care.
To work as part of a health care team (systems-based practice) in the management of
medically complex and socially diverse patients.
Attendance is required at all conferences, including morning report, Grand Rounds and
noon conference. Pre-rounding on patients in preparation for morning report or working
rounds is expected on all days.
If you have previously scheduled commitments, please notify the Clerkship Director and
we can try to help you switch your call schedule to get the weekend/day off you need.
If an emergency situation arises (illness, family emergency), please call or page the
clerkship director, Dr. Caroline Powell at 954-6652 (pager), 201-9910 (cell). If the
clerkship director is not informed of the absence, it will be considered unexcused. The
need for making up time missed will be determined on a case by case basis.
Call Schedules and Work-hour Rules
We follow the USC SOM student work hour rules. At Palmetto Richland, the call schedule is 1
in 4 until 9 pm weekdays, and overnight on Fridays and Saturdays. There has to be a 10-hour
break between the time you leave the hospital and return the next morning.
If you are rotating in the MICU, you are required to stay overnight on 2 nights as determined by
the MICU attending or fellow.
At the VA Medical Center, the call schedule is 1 in 4 until 9 pm on most nights. There is no
night float resident at the VA, so your team will be staying overnight. You are required to stay
overnight with your team on 2 nights. When on call overnight, your total number of hours in the
hospital may not exceed 30 hours (i.e. you should leave the hospital by noon or after noon
conference on your post-call day).
You will get one day off in 7 averaged over a period of 4 weeks. All students have their “switch
weekend” off. The last call will be on Tuesday of week 8. You are done with clinical duties after
noon conference on Wednesday before OSCE.
Student work hours regulations allow for student attendance at afternoon lectures even on
Typical Inpatient Daily Schedule (PHR and VA)
7-8 am Pre-round on your patients
8-9 am Morning Report / Chairman’s presentation / Grand Rounds
9-12 pm Work / teaching rounds with the attending
12-1pm Noon conference
1-4 pm Patient care
Special lectures and presentations
Ambulatory experience (optional)
Medical Intensive Care Rotation (MICU)
Some students will have the opportunity to rotate through the MICU for 2 weeks of their
rotation. During your time in the MICU, you will be assigned interesting patients to follow and
write daily progress notes just as on the wards.
During the rotation you will take two nights of overnight call. As per the work hours regulations,
you will be done with clinical duties after noon conference on your post-call day. You will be
required to prepare and present at least one brief topic presentation to the MICU team as part
of the rotation. Ideally this will be based on a patient case you have seen during your time in
Typical schedule Palmetto Richland MICU:
7 am – Check in with Pulmonary fellow in MICU (5th
floor PHR) (day 1)
Discuss with the fellow/residents about what time you should arrive during the
remainder of your rotation
8-9:30 am – Morning Report / Grand Rounds / Lectures
8:45-9:30 – Monday, Wednesday, Friday – Morning lecture
9:30-12 pm – Attending Rounds
12-1 pm – Noon conference
1-5 pm – Patient care, special lectures, procedures
Goals / Learning Objectives:
To observe the MICU course of patients presenting with acute respiratory
failure, shock, acute GI bleeds, DKA, acute coronary syndromes, and
other medical illnesses requiring critical care.
To observe the collection, synthesis, and presentation of complicated
patient data in an organized and efficient manner.
To recognize potential clinical diagnoses on the basis of CXR findings.
To become familiar with the indications, risks and benefits, overall
technique, and data interpretation for arterial blood gas analysis and
pulmonary artery/central venous catheter placement.
To begin to develop skills in managing patients requiring mechanical
To begin to define, recognize, and describe the basic pathophysiology of
acute hypoxemic respiratory failure, acute ventilatory failure, septic shock,
cardiogenic shock, and hypovolemic shock.
To become familiar with the practice of critical care medicine at Palmetto
Health Richland and VA Medical Center, and the process by which a
multidisciplinary approach to patient care is utilized to optimally manage
Medical Student Morning Report
In order to offer more directed assistance with oral presentations and clinical reasoning – at
the appropriate learning level for students – a separate morning report will be held for medical
students only at PHR and for medical students and interns at the VA. There will be 1-2
attendings present to run these sessions.
The following offers an outline and guidelines for the sessions at PHR:
Monday – Large group Morning Report (for all students and residents) – 8:15 – 9:00 AM, PHR
basement conference room
Tuesday, Wednesday, Friday – Student Morning Report – 8:15 – 9:00 AM, Basement
conference room PHR
2 medical “post-call” students will present cases admitted the previous day
Be prepared to present the case in a concise but comprehensive fashion - history and
complete physical exam. This does take practice.
Be prepared to justify any tests, imaging ordered
Be prepared to explain the differential diagnosis and the most likely diagnoses
Be prepared to briefly explain one learning issue – what did you learn from this case
that you would like to share with the other students? What is your “take-home point”?
Discuss each of these points with your team.
Attending faculty will vary. Learning issues will vary by case presented. Each attending
will be prepared with a brief teaching topic based on the case or with clinical pearls that
arise as the case unfolds.
Thursday – Grand Rounds
At the VA, these sessions are held Monday, Tuesday, Wednesday, and Friday 8-9 am.
Students should be prepared to present admissions from the previous day.
These are formal case and topic presentations held on select Thursday afternoons during the
rotation. As the name suggests, these presentations are made to and evaluated by our
Department Chair. They also offer you a chance to teach your peers. This is a requirement of
the rotation and all students should attend each session. Formal guidelines developed by the
Department Chair are included in this handbook.
Chairman Presentation Guidelines
M-3 Clerkship Presentation
Prepare and deliver a formal case presentation with discussion of a key problem of the case (pathophysiology,
differential diagnosis, medical ethics, therapeutics, and/or social, make the audience work through the case,
stump the attending, etc.)
• Develop concise, appropriate, rehearsed case presentations
• Have thorough familiarity with all aspects of case
• Develop skills of case presentation to carry to all disciplines
• No more than 8 minutes, 37 seconds to present case
• Discussion of some aspect of the case of your choosing for 10-15 minutes: NO PowerPoint
• Radiological studies, electrocardiograms, pathology specimens, etc. as appropriate will always enhance a
• Do not read; no or minimal use of notes
• Stand up before your audience
See form for evaluation of student
“Persistently Polished, Precise Presentation”
It is a presentation of the case not a reporting of the history and physical.
You should demonstrate your knowledge and understanding of medicine in your case presentation.
Good presentations are a result of practice and thoughtful consideration. Good presentations are not reporting of
everything you know about the case. Information needs to be integrated and refined before spoke.
DO NOT READ – WE CAN READ! (We Hope)
YOU MUST PRACTICE
Presentation should rarely last >5 minutes. Summarize, integrate data.
HPI should cover most of history; ROS pertinent to HPI, etc., almost all information pertinent to case should be
presented in 2 or 3 paragraphs. NO specific references to ROS unless identifies a separated unrelated problem
covered in an accurate HPI. Social history, past medical history if vital to case and covered in an accurate HPI.
DO NOT REPEAT. “As I mentioned,” or “as I said” means you are repeating. SAY IT ONLY ONCE.
Medications are always reported.
Family history is of no significance in an 80 year old with a stroke; don’t include what is not necessary to
understand case. THINK BEFORE YOU SPEAK.
Pertinent positives and negatives in history and physical display of your thought process and knowledge of what is
or is not important.
Present case as if to communicate the story to a busy, valued consultant who needs to know about the case in
detail, but not too much detail. You are calling on your cell phone and it is costing $1.00 a second!
Simulation Center Workshop
Each student will participate in a Simulation workshop during the rotation. Prior to this
workshop, you will be required to view / read the appropriate Procedures Consult
tutorials in order to fully understand indications, contraindications, preparation,
procedure steps, post-procedure care, and complications. This will ensure your getting
maximal benefit from the limited time we have for hands-on activities in the Simulation
Goals / Learning Objectives:
1. To draw venous blood using a model.
2. To place a central venous catheter in the internal jugular vein under
ultrasound guidance. To identify important structures on neck ultrasound. To
practice skills technical ultrasound skills such as measuring and saving images.
3. To perform a lumbar puncture on a model.
4. To observe and participate in a simulated cardiac / respiratory arrest (“code”).
Students will receive formal lectures clinical reasoning, EKG interpretation, Chest Xray
interpretation, laboratory interpretation, antibiotics, thyroid / neck ultrasound, congestive heart
failure, HIV, acute kidney injury, and anemia. These will be given on orientation day, midterm
day, and one afternoon during the rotation so as to not interrupt patient care and resident
teaching. A Geriatrics lecture is available on Blackboard and should be studied in preparation
for completing the Senior Mentor project due for this rotation. In addition, students will meet
with Dr. Humphries for bedside teaching in physical exam skills (especially cardiac exam) once
per week – 3:00 pm Tuesdays at PHR (basement conference room) and 1:00 pm Thursdays at
VAMC (5 East nurses station). Dr. Brett will also meet with students rotating at PHR on select
Fridays after noon conference to discuss heart sounds.
Nutrition Activities for M3 Clerkship (Part of CSAD)
The practical application of nutrition therapy is important to clinical practice. Medical nutrition
therapy can begin with primary intervention and follow through to care at end-stage disease.
Each clerkship provides a unique opportunity to use nutrition principles in patient care.
On the CSAD for this clerkship you will find “Participate in a nutritional assessment or other
activity”. The clerkship director may provide nutrition lectures or patient assessment
opportunities during your rotation. If these hands on opportunities are not available, you may
do the online nutrition case study design for this clerkship.
Go to: www.nutrition.med.sc.edu look under “clerkship”
1. Click on the name of your current rotation
2. Read ONE of the cases. (Remember, you only need to do one per clerkship.) Think
about the practice questions. When you are ready…
3. Take the quiz (be sure to type in your name and current clerkship) and submit. Print out
the receipt if you want to have a back-up paper showing that you took the quiz.
4. The quiz results will come to my email. They will be graded pass/fail (5/10). Your name
will then be sent to the clerkship director so you can be given credit for participation in
the online nutrition activity.
You may call or email me if you have any problems or concerns about the online case studies.
Lynn Thomas, DrPH, RD, CNSD
Grading Policy & Evaluation Procedures
The following is an overview of the various evaluation methods and procedures.
• CSAD observed functions (“Blue card”)
8 written H&P’s
Daily progress notes
Written admission orders
Written discharge instructions
EKG and CXR interpretation
Observed H&P – Requires attending observation
Venous blood draw
Senior mentor fall risk assignment
Observed endoscopic procedure
Central venous line placement under ultrasound-guidance
Participation in a “code”
• Subjective assessment using specific measurement scale- 50%*
• Appropriate personal and professional conduct- Unprofessional conduct can result in an
“incomplete” with need for remediation of all or some portion of the clerkship
• Objective Structured Clinical Evaluation (OSCE)- 20%*
• National Board of Medical Examiners Subject Exam (shelf test)-30%*
• Multiple choice midterm examination
• Each student is given the opportunity to evaluate the case presentation series, his or
her attending physicians, and the residents with whom he/she worked with. A clerkship
evaluation is completed by each student.
*These items comprise the numerical grade. Other items must be completed for successful
completion of the course.
The department policy regarding successful completion of this clerkship is that a student must
receive a passing grade on all components of evaluation in order to pass the clerkship itself.
Failure of the clinical portion of the OSCE will require remediation as Department determined
by the Clerkship Directors. Likewise, the time frame in which this remediation occurs will be
determined by the course directors and/or Education Committee. As to failure of the shelf
exam, retesting will occur in December for periods 1 and 2 and in June for periods 3, 4, and 5.
Those failing in period 6 must take the retest in August. If the second attempt at the shelf exam
is successful, the final shelf exam score will be an average of the two scores. A second failure
of the shelf exam will necessitate repeating the entire clerkship. Until such time that all three
components are successfully completed, the student will receive an “Incomplete” for the
clerkship but will be permitted to continue on the other clerkships. Likewise, failure to submit
CSAD, Patient Encounter Information, and/or the online clerkship evaluation will result in an
In order to complete the rotation, you must turn in the following items:
Completed Observed H&P form
Completed Senior mentor fall risk assessment
Completed CSAD (“blue”) card
Completed PEC data – to be entered into New Innovations
You may receive an “Incomplete” if these items are not completed in a timely fashion.
You should enter data on your medical patients into New Innovations. In addition, you should
keep a record of the types of medical conditions to which you are exposed and have the
opportunity from which to learn. A table has been provided on the back of your CSAD card for
collecting this data for review by the clerkship directors. This information is used to ensure that
you are seeing the variety of patients and medical conditions needed for an optimal Internal
Medicine clerkship learning experience.
Over the course of the rotation, you should receive formal feedback from each intern, resident,
and attending with whom you work closely. On average, you should receive formal feedback
every 2 weeks. You should also be aware that most teachers consider any constructive
criticism feedback and will offer suggestions, criticisms, and advice throughout the day as part
of feedback on your performance. But don’t be shy about asking for formal feedback. Formal
feedback from clerkship directors will be provided on the day of the midterm (or during weeks
4-5) and during week 8 if needed or requested.
Formal Clerkship Objectives
1. Elicit a through and pertinent patient history, adapting it to the urgency of the time allowed for the
interaction. Include the following history:
A. Chief complaint
B. History of present illness: Describe the significant attributes of a symptom, including location
and radiation, intensity, quality, temporal sequence (onset, duration, frequency), alleviating
factors, aggravating factors, setting associated symptoms, functional impairment, and patient's
interpretation of symptom.
C. Past medical history
D. Health maintenance history
E. Family and social histories, etc.
F. Review of Systems
2. Conduct a thorough physical examination. Include the following:
A. Describe the four methods of physical examination (inspection, palpation, percussion,
and auscultation), including where and when to use them, their purposes, and the
findings that they elicit.
B. Position the patient properly for each part of the physical examination.
C. Perform the physical examination for a patient in a logical, organized, respectful, and
through manner, giving attention to the patient’s general appearance, vital signs, and
pertinent body regions.
3. Use information gathered from the patient’s history and physical to complete the following:
A. Describe physiologic mechanisms that explain key findings in the history and physical.
B. Include a discussion of the diagnostic value of the history and physical examination
C. Formulate a differential diagnosis (problem list) based on the findings from the history and
D. Formulate a plan of patient evaluation and management, including diagnostic studies and
consultations, therapeutic efforts, education of patient, and follow-up plans using an evidence-
4. Participate in the selection of diagnostic studies with the greatest likelihood of providing useful
results at a reasonable cost.
5. Interpret laboratory data including basic metabolic panels, liver functions tests, blood counts,
arterial blood gases.
6. Assess each problem further by synthesizing and analyzing the data obtained from the diagnostic
7. Demonstrate familiarity with basic clinical procedures of internal medicine.
8. Prepare written, comprehensive, and focused new patient workups. Include the following features
when clinically appropriate:
A. Provide a history of the present illness accurately, objectively, chronologically, without
repetition, omission, or extraneous information.
B. Provide comprehensive physical exam information with detail pertinent to the patient’s
C. Provide a succinct and unified list of all problems identified in the history and physical
D. Provide a differential diagnosis for each problem.
E. Provide a diagnosis/treatment plan for each problem.
9. Present orally, clearly, and concisely the plan of problem evaluation and patient management.
10. Participate in discussion with the patient care team (faculty, staff, etc.) during teaching sessions.
11. Communicate positive interpersonal skills with patients and staff. Include the following:
A. Demonstrate respect and appropriate listening skills, including both verbal and nonverbal
B. Demonstrate effective verbal skills, including appropriate use of open- and closed-ended
questions, repetition, facilitation, explanation, and interpretation.
C. Describe how patients’ and physicians’ perceptions, preferences, and actions are affected
by cultural and psychosocial factors, including how these factors affect the doctor-patient
12. Relate successfully to patients, families, and professionals. Include the following:
A. Demonstrate appropriate listening skills, including both verbal and nonverbal techniques.
B. Demonstrate interest and responsibility in patient care and patients’ needs.
13. Display professional attitudes to learning. Include the following:
A. Demonstrate good, consistent work habits.
B. Demonstrate inquisitiveness.
C. Demonstrate evidence of a desire to learn and improve by reading, studying, and
D. Demonstrate an ability to respond positively to constructive criticism.
14. Recognize, evaluate, and treat common adult medical problems in both inpatient and outpatient
settings. Include the following:
A. Cardiovascular Diseases
1. Valvular heart disease
2. Congestive heart failure
3. Ischemic heart disease
4. Pericardial disease
5. Peripheral vascular disease
B. Respiratory Diseases
2. Pulmonary vascular disease
3. ARDS and pulmonary critical care
4. Lung cancer
C. Renal Disease
1. Fluid and electrolyte disorders
2. Hypertension/vascular disorders of kidney
3. Acute renal failure
4. Chronic renal failure
D. Gastrointestinal Disease
1. Neoplasms of the GI tract
3. Peptic Ulcer Disease
4. Gastrointestinal bleeding
5. Diseases of the Liver and Biliary System
b. Cirrhosis, complications
2. Leukocyte disorders
4. Coagulation disorders
5. Leukemia / lymphoma
6. Myelodysplastic syndromes
1. Oncologic emergencies
2. Solid tumors
G. Metabolic Diseases
1. Principles of nutritional support
2. Hyperuricemia and gout
H. Endocrine Diseases
1. Thyroid disorders
I. Diseases of Bone and Bone Mineral Metabolism
J. Musculoskeletal and Connective Tissue Disease
1. Rheumatoid arthritis
4. Crystal-induced arthropathies
5. Infections of joint spaces
K. Infectious Diseases
1. Host defenses
2. Fever and febrile syndromes
3. Bacteremia and septicemia
5. Pneumonia (includes tuberculosis)
6. Urinary tract infections
7. Immunocompromised host
8. Management of/approach to the HIV+ patient
9. Cellulitis and osteomyelitis
L. Neurologic Diseases
1. Disorders of consciousness and higher brain function, including syncope
2. Drug and alcohol abuse, including alcohol withdrawal
3. Autonomic dysfunction
4. Sensory dysfunction
5. Cerebrovascular disease
6. Seizure disorders
M. The Aging Patient
1. Biology of Aging
2. Identify preventive standards for the various adult age groups, to include counseling
3. Evaluate the effects of illness on the adult and his/her family
N. Cutaneous Disease
1. Infectious Disease (Impetigo, HPV, Herpes, Tinea)
4. Skin Cancer
5. Skin breakdown and wound care
The core competencies and recommended patient encounters for the M3 Internal
Medicine Clerkship in Columbia and Greenville are summarized below.
These clerkship goals are based on the national recommendations of the Clerkship Directors
in Internal Medicine, as summarized in the “Clerkship Directors’ in Internal Medicine Core
Clerkship Curriculum Guide”. This reference may be found at
The Clerkship Directors will ensure that students meet these goals by
1. Communicating these goals to students, supervising residents and faculty physicians
2. Monitoring the students’ patient encounter logs every two weeks, including a formal
assessment at the midpoint of the rotation
If any deficiencies are identified, the Clerkship Director will develop a corrective plan with the
student and his supervising resident/faculty physicians.
Given the variability in patient admissions, it is likely that students will not personally care for a
patient with every recommended training problem. Students may obtain additional training
through participation in care of other patients on the teaching services, and by discussion of
patients during attending rounds and educational conferences, and through didactic lectures.
Students are expected to supplement their training through self-directed learning.
Students are expected to develop basic competence in the following areas:
• History Taking and Physical Examination
• Interpretation of Clinical Information
• Diagnostic Decision Making
• Therapeutic Decision Making
• Case Presentation
• Basic Procedures
Venous blood draw
Interpretation of basic chest radiograph findings
Interpretation of basic electrocardiogram findings
Observation of endoscopic procedure
Participate in cardiac resuscitation using Basic Cardiac Life Support skills
Microscopic examination of peripheral blood smear
Microscopic examination of sputum Gram stain
Observation of cardiac catheterization
• Basic Nutrition in Clinical Medicine
• Geriatric Care
• Coordination of Care and Team Work
• Communication and Relationships with Patients and Colleagues
o Including cultural competence
• Self-Directed Learning
• Bioethics of Care (Ethical Principles in Clinical Medicine)
Students are encouraged to participate in patient care of patients with the following problems.
Required patient encounters are noted in bold font.
• Patients Presenting with a Symptom, Sign, or Abnormal Test Result
o Abdominal Pain
o Altered Mental Status
o Back or Knee Pain
o Chest Pain
o Fluid, Electrolyte, and Acid Base Disorders
o Gastrointestinal Bleeding
o Upper Respiratory Complaints
• Patients Presenting with a Known Condition
o Acute Myocardial Infarction
o Acute Renal Failure and Chronic Kidney Disease
o Common Cancers
o COPD/Obstructive Airways Disease
o Diabetes Mellitus
o Coronary Artery Disease/Heart Failure
o HIV Infection
o Liver Disease
o Major Depression
o Nosocomial Infections
o Smoking Cessation
o Substance Abuse
o Venous Thromboembolism
Specific Clerkship Requirements
M3 students must see the following conditions/patient types over the course of the 8-week
1. 2 new acute conditions with the emphasis on diagnosis
2. 2 new acute conditions with the emphasis on treatment
3. 2 chronic conditions
4. 2 acute exacerbations of a chronic disease
5. 1 patient from a culture not their own
6. 1 patient over the age of 65 years
7. 1 patient with limited access to medical care
8. At a minimum, 1 patient with from each of the following categories. Note that students
are encouraged to obtain experience in all recommended patient training problems.
a. Congestive heart failure or coronary artery disease (includes HTN)
b. Diabetes mellitus (includes diabetic foot ulcer or other complications)
c. Shortness of breath
d. Fever or infection (includes pneumonia, UTI, sepsis, HIV, cellulitis)
e. Musculoskeletal pain (includes monoarthritic pain, tendonitis, bursitis, DJD, RA)
g. Abdominal pain or gastrointestinal bleed
h. Renal failure (chronic, acute, ESRD, nephrotic syndrome)
i. Electrolyte abnormality
j. Alcohol, drug or tobacco abuse
This handbook has been adopted from the Primer to the Internal Medicine Clerkship, 2nd
Ed., A Guide Produced by the Clerkship Directors in