Updated March 30, 2006

General Information
Outpatient Experience
Inpatient Experience
Subspecialty
MICU
Conferences, Grand Rounds, and Morning Report
Evaluation
Recommended Books
Recommendations for Success
Clerkship Information

General Information

The third-year Medicine rotation is twelve weeks. The clerkship is divided into 3 sections. Students spend two weeks in a Medical Intensive Care Unit (MICU), four weeks on general medicine wards, and four weeks on a subspecialty service. All students are assigned a two-week vacation period, though requests for specific dates may be granted based on need. Students on MICU or general wards will work at  University Hospital (UH) or the Veterans Administration Hospital (VA). Typically, students who are at the VA for MICU will be at University for their wards experience, and vice-versa. Subspecialty rotations are requested by students, and most students end up with their first or second choice. Participating subspecialties include gastroenterology, nephrology, cardiology, hematology/oncology, and infectious diseases. Each subspecialty differs greatly in hours and the number of hospitals they cover. Depending on your subspecialty, you may see patients at Norton or Jewish
Hospitals, or stay at University or the VA.

The number of patients on your general medicine and subspecialty services will most likely average 15, though it may be as many as 24 (after this number, you do not take more admissions on the wards). You will have far fewer patients for your MICU rotation. Overall, rotations at the VA tend to be slower than at U of L.

Some of the more common diseases/pathologies that students will see on the Medicine rotation include: diabetes, hypertension, hyperlipidemia, CAD/chest pain, COPD/asthma, CHF/pulmonary edema, pneumonia, abdominal pain, GI bleed, presyncope/syncope, cellulitis, and DVT/pulmonary embolism. You willl see a variety of chief complaints and admission diagnoses during your rotation.

Outpatient Experience

Inpatient Experience

A general medicine team consists of two third-year students, two interns, a resident, and a faculty physician. You may also have a fourth-year student on your team.   Unlike pediatrics, the census on your Medicine rotation will not vary much throughout the year.

Students spend 4 weeks either at UH or VA assigned to one of four teams: Red, White, Green and Purple. Each team is headed by one attending and consists of one upper level resident (PGY-2 or PGY-3), two interns, two third year students and one fourth year student. Student responsibilities include carrying a patient load of 2-3 patients, seeing them in the mornings before the interns, writing daily SOAP notes and presenting during morning rounds. Students are asked questions on rounds by the attending about their patient and the respective disease process. They may also have the opportunity to help with paracentesis, lumbar punctures, etc.

While on your general medicine rotation, you will admit patients during your call nights with the help of your intern and resident, and follow those patients throughout their hospital courses. All students are expected to carry 2 to 4 patients, though you may carry more if you and your resident agree you can handle the additional responsibility. Every morning, you should write a SOAP note for each patient and be prepared to update the team on your patients' progress. The amount of information your attending will expect you to give during your presentations is highly variable. It’s a good idea to ask your attending the type of information he or she would like you to present at the beginning of each rotation. Busy medicine attendings may only want quick problem-driven presentations, while MICU attendings will most likely want you to comment on the status of every organ system and give every lab value. Don’t be too hard on yourself if you get corrected several times during your first few presentations. Your attending will want to hear presentations in a way that corresponds with the format he or she uses for thinking through clinical problems. In the end, it all comes down to attending preference. After rounds your attending may want you to research a question that came up during rounds, or you may need to help your intern write orders on your patients. Your resident will be responsible for dismissing you after your work is done.

Wards call is a little more confusing than other services'. Call is still every fourth night, but if that night is on a weekday (considered Sunday through Thursday), you will only be required to admit patients from 7 AM to 9 PM the same day. A separate "night float" team admits patients and performs cross-cover duties overnight. This system does not operate on the weekends; Friday and Saturday call is 24-hours. When on weekday call, you may go home at 9 PM (or a little later if you‘re not finished with your work). When on weekend call, you spend the night in the call rooms. The amount of sleep you get will depend on your resident, your interest in medicine, and your census. Because fewer people are around at night, it may be your best chance to do a lumbar puncture or place a central line. Student pagers often do not work in the call rooms at U of L, so be sure to give your resident the direct number to your room before you go to bed. On your "post-call" day, students are generally dismissed after rounding and helping the interns with their patients. You will have four days off during your general wards month. These may be set up with your resident at the beginning of the rotation. On days you are not on call, you will generally get to go home by 3 PM, though this will also vary by census and attending.

Subspecialty Experience

During your subspecialty rotations, a fellow will most likely be on your team. Fellows have completed an internal medicine residency and are gaining additional training in a subspecialty. They are generally both knowledgeable and approachable. The makeup of your subspecialty team varies tremendously…cardiology teams tend to be walking herds, while an Infectious Disease team may only have 3 students, a fellow, and a faculty physician.

There is no evening call during your subspecialty month, and you will have one day off per week. Your time commitment and responsibilities will vary with your service and your interest in the field. Gastroenterology and Infectious Disease are typically the most demanding time-wise, but you will most likely work hard no matter what rotation you are on in subspecialty. Do not make the mistake of thinking that because there is no call you will have more time to study on subspecialty. You will actually find you have much more time during general wards, and the bulk of your studying should be done during this time. All subspecialties have an outpatient component that you will be required to attend. Unlike pediatrics, there is no separate outpatient portion of the rotation.

The following subspecialty rotations are available: 

1. Cardiology:
   
   The teams tend to be large.
   
   
2. Hematology/Oncology:
   
   One of the more popular subspecialty choices for students.
   
   
3. Nephrology:
   
   May spend some time at Jewish Hospital.
   
   
4. Infectious Disease:
   
   This is the busiest service but students learn an incredible amount.
   
   
5. Gastroenterology:
   
   Students are exposed to the clinical and procedural process at the hospitals and outpatient clinics. Students have a lot of independence on this consult service.

MICU

MICU teams are staffed similarly to inpatient wards teams during the day, but you will usually take night call with only one intern and one resident. Like subspecialty, a fellow will most likely be on your team. During the MICU rotation, call is every fourth night. You will begin call around 7 AM on your assigned day, and accept admissions until the following morning. You must be present at the hospital for the duration of your call, and call rooms are provided at both University and the VA. The post-call team (you, an intern, and a resident) leaves immediately after rounds, generally around noon. From past students' experiences, you can get a decent night’s sleep (5-6 hours) while on the MICU service. You have two days off during your two week rotation. On days that you are not on call, you will generally get to go home by 2 PM, though this will vary by census and attending. Working at the VA allows for more responsibilities and procedures including drawing arterial blood gases, doing EKGs, and venipuncture. Students learn to take care of critical patients and understand various life support equipment that isused, including respiratory ventilator settings.

Conferences, Grand Rounds, and Morning Report

Medicine has a variety of meetings and conferences you will be expected to attend:

1. Grand Rounds: A University of Louisville or visiting faculty member presents an update on a particular topic (e.g. fungal infections or smoking trends in Kentucky). Grand Rounds is held Thursdays from 8 to 9 AM in the Ambulatory Care Building (ACB) Auditorium across from the cafeteria. Attendance is mandatory and students from the VA have to drive to U of L.
   
   
2. Chief Residents' Conferences: Chief resident presents small-group sessions on chest X-ray, EKG, and ABG interpretation. These informal and friendly sessions are held Thursdays from 1:30 to 3 PM in the ACB Conference Room 1 for U of L students and Room 611 at the VA for VA students. These are also mandatory.
   
   
3. Didactics: U of L faculty present information on a broad subject (e.g. diabetes or anemia). In general these are pretty informative, but they will make you wonder how you ever survived six hour lecture marathons during your first two years. They are held Wednesdays in the ACB Conference Room 1 from 1:00 to 4:00 pm. Mandatory. Students from VA have to drive to U of L.
   
   
4. Meet the Professor Rounds: The director of the U of L Medicine Residency discusses cases presented by student volunteers. These sessions are very relaxed and informal, but once again, mandatory. They are held on select Mondays from noon to 1 PM.
   
   
5. Morning Report: A Chief resident leads a discussion of a case presentation by a resident. Students and interns are expected to ask questions to tease out the details of the case. These are "quasi-mandatory" (absence doesn't count against your grade). They are held Monday, Tuesday, and Friday from 8 to 9 AM in the ACB Conference Room 1 and the VA Conference Room. Students on subspecialty services are not required to attend morning report.

Evaluation

There is a NBME shelf exam at the conclusion of the course. The objective portion of your grade is based on your shelf exam (40%) and quizzes (10%). Quizzes are based on the material presented in lectures. They are put on Blackboard on Thursdays and must be completed by the following Monday at noon. There are four quizzes during the rotation, but you only have to complete three of them (the idea is to skip the one that occurs during your vacation). Some recommend doing the quiz during your vacation, giving you the option of skipping one later if you get busy. You will not be reminded to do them and they are easy to forget! The rest of your grade is determined by evaluations (30%) and participation (20%). Your participation grade is based on your attendance at grand rounds and chief resident’s conferences, so don’t miss them.

The grading system is Honors/Pass/Fail.

Recommended Books

Recommendations for Success

No matter what field you enter, you’ll need to know quite a bit of medicine. The attendings on medicine are knowledgeable and care about your learning. Take full advantage of their experience. Overall, most people enjoy their Medicine rotation, though the long rounds can be tedious. The best advice is to know everything about your patients. It’s okay not to know every pimping question (sometimes you'll not know any all day), but it’s not okay to fail to recognize important lab values, or not know that your patient has developed a new fever. If you can handle more than three patients, ask to take on more. If you admit a patient with ascites and fever, tell your resident you would like to perform the pericentesis. Help out your interns and residents with orders and discharge paperwork...if they are happy, you'll be happy, and you’ll all leave earlier. It takes a while to learn how to function as a member of a team, and some teams certainly gel more than others. By the time you have finished third year, you will be amazed at how much you have learned and how many new friends you have gained.

The breadth of medicine makes it challenging to study. The good news is the rotation is 12 weeks long, and for the most part you have sufficient time to study (and have a life) throughout. Case books are recommended to focus on more common conditions and serve as a good introduction to the clerkship and the types of problems you will see. Then, people tend to go through a review book, focusing on the more common diseases presented.

The bulk of students' grades is from clinical evaluation, so it is to your benefit to be on time, write proper H&P and SOAP notes, and present patients in an efficient fashion. Also, it is a good idea to read UpToDate articles on the patients' diseases and be prepared for any questions during morning rounds. The attendings, residents, and interns are extremly friendly and willing to help students in any way that they can, without pimping or being intimidating.

Shelf exams test you on common conditions…therefore, it is not necessary to know the molecular defect that causes paroxysmal nocturnal hemoglobinuria. Students who take medicine during the first semester tend to believe the shelf exam is the most difficult of the year, while those who take surgery during the first semester think the surgery shelf is more difficult. There is considerable overlap between the surgery and medicine shelf exams (hard as that may be to believe), and so you will be more prepared for whichever comes second.

In the weeks preceding the exam, focus on doing questions to increase your stamina and get you back into a test-taking mode. With so much time between tests, its easy to get out of practice. It doesn’t pay to cram for shelf exams. Most people agree that the most difficult part of the test is the massive amount of information presented in the question stems. You need to get a good night’s sleep to tackle them. As for all third year shelf exams, the question stems are extremely long. Make sure you give yourself enough time to finish. Read the last part of the question and the answers first, then search the stem for the pieces of information that allow you to quickly differentiate between the answer choices.

Clerkship Information