Medicine I Core Clerkship

Medicine Clerkships

­Clerkship Objectives and Expectations

Twelve Week Program
Students at the Beth Israel Deaconess Medical Center will be introduced to the whole range of experiences that internists encounter on both general medical wards and general medical and subspecialty ambulatory settings.

Eight Weeks on the Inpatient Services
The clerkship is designed so that students will acquire skills necessary to evaluate and manage common problems in internal medicine. To gain these skills, students will spend eight weeks on one of four general medicine firms, subspecialty services and twilight evening admitter service. A special effort will be made to give students a varied experience, and there will be flexibility in choosing admissions for student evaluation.

In addition, whenever possible, students will see patients first, with adequate time allocated to take complete histories, to perform complete physical exams, to discuss patients' problems with the intern and resident, to write complete admission notes, and to seek out information about patients' problems in relevant textbooks and peer-reviewed literature.

Four Weeks in the Ambulatory Setting
In addition to eight weeks on the wards, each student will spend four weeks in the ambulatory setting. During this component of the course, students will be paired with a primary care faculty continuity preceptor with whom the student will work two half-days per week.

Students will also rotate through several medical subspecialties (three half-day sessions each week), dermatology (one half-day sessions each week), and ophthalmology (one four-hour session per block). As much as possible in all of these sessions, the student will have the opportunity to perform problem-oriented history and physical exams, to review each encounter with a faculty preceptor, to develop a differential diagnosis, and to devise an evaluation and treatment plan.

This comprehensive, balanced experience should prepare students to handle medically diverse issues inside and outside the hospital setting, while enabling students to deal with subsequent clerkship rotations and ultimately internship.

Information and Skills Acquired During Clerkship
Students will be expected to:

  • Take a thorough history
  • Perform a detailed and accurate physical exam
  • Formulate a thoughtful differential diagnosis
  • Design a plan of evaluation of their patients' clinical problems
  • Develop skills in presenting their patients' problems lucidly to medical colleagues

It is hoped that these experiences will foster growth in each student's clinical judgment while consolidating development of sophisticated approaches to both simple and complex medical problems. By the end of the 12-week clerkship, students will be expected to possess a broad working knowledge and a thorough understanding of the pathophysiology and therapies of basic, common problems in internal medicine.

Emphasis on Total Care of the Patient
Great emphasis is placed on the total care of the patient. With this in mind, it is anticipated that students will acquire sensitivity to the whole spectrum of a patient's encounter with illness, including psychological as well as medical aspects of the patient's care.

Major Duties and Responsibilities

Inpatient Rotation
On inpatient rotation, students are considered an integral part of the medical team, working closely with one intern and under the supervision of the team resident and attending physician.

  • Students may pick up patients in the morning who were admitted by night float.
  • Students will work up new admissions during the Twilight Service as well as any new patients that come in during the day to the general medical or specialty teams. 
  • It is the student's duty and responsibility to work-up, evaluate, present, and follow their admitted patients daily.
  • The total patient load for each student at any given time should ideally number no less than two and no more than three to four patients.
  • Work-ups will be closely supervised by the team intern and resident. Students will present their patients in each instance to the Attending Physician.
  • Teaching is conducted at the bedside and in the conference room.
  • Students will have full responsibility for writing all orders and progress notes on their patients, scheduling tests, arranging consults, attending family meetings, and following their patients in as close a manner as possible with the intern.
  • When students are not available to carry out these responsibilities, students should be sure to review with their team results of patient evaluations and pending items for further follow-up.

Ambulatory Rotation
On ambulatory rotation, students will work closely with a faculty member in all sessions.

  • Students will see patients independently with their continuity preceptor, present each case, and write notes summarizing each patient encounter.
  • Primary goals include learning to obtain a focused history, physical exam, assessment and diagnostic plan in the time-limited ambulatory setting, as well as evaluating patients with undifferentiated complaints and formulating a differential diagnosis.
  • In all sessions, students will have the opportunity to review patients seen and to discuss assessments and management plans with their faculty preceptors.

Behavioral and Ethical Expectations
(e.g., confidentiality, discretion, patient interactions, attendance, dress code, etc.) Students are expected to be present at all scheduled sessions with preceptors and to be present at all scheduled student rounds and lectures. Promptness is appreciated. It is expected that the students will exercise careful judgment in their interactions with patients as well as their medical colleagues.

Expected Preparation for Clerkship

Suggested Texts for Review
The following texts should be considered when taking a “deep dive” into patients’ medical conditions and can be accessed through Countway Library. 

Harrison's Principles and Practice of Internal Medicine; Cecil and Loeb's Textbook of Internal Medicine; Branch's Office Practice of Medicine; Goroll's  Primary Care Medicine, Dubin's Introductory Textbook of Electrocardiography or Goldberger's Introductory Electrocardiography. 

Medical Equipment needed during the rotation:

  •  Stethoscope
  • Reflex hammer
  • Penlight

Teaching Modes Used During Rotation

Didactic Sessions for Medical Students Only
On the inpatient portion of the clerkship, students will attend sessions by Dr. Mark Zeidel, Department of Medicine Chair, Dr. Eileen Reynolds, DOM Vice-Chair, Dr. Anjala Tess, DOM Associate Vice-Chair, Dr. Chris Smith, DOM Associate Vice-Chair and Residency Director, and 3 EKG sessions by Dr. Ary Goldberger.

Inpatient Rotation
On inpatient rotation, students will meet weekly as a group with Dr. Anita Vanka and attend relevant Internal Medicine Residency conferences (i.e. Intern Report, M&M, and Grand Rounds). 

Ambulatory Rotation
On ambulatory rotation, students will meet one to two times a week as a group in sessions conducted by Dr. Amy Weinstein and other ambulatory faculty. Additionally on ambulatory rotation, students will attend dermatology and ophthalmology teaching sessions, organized centrally by HMS faculty. 

Didactic Conferences for Residents and Medical Students

Medical Housestaff and Students on Rotation
Two weekly lecture series, Primary Care Conference and Thorndike Rounds, are designed specifically for medical house staff and students on rotation. Both lecture series cover a broad spectrum of topics in internal medicine and other disciplines germane to the practicing internist. Invited speakers are BIDMC and other Harvard Medical School faculty who are considered experts in their fields.

Intern Report is held twice weekly during which cases are reviewed and discussed by the Chief Medical Residents with a focus on evidence-based medicine. Students are expected to attend during their inpatient rotation unless they have conflicting teaching sessions.

Department Conferences for Faculty, Residents and Medical Students
A weekly Firm Conference (conducted by ward Firm Chief) brings together hospital faculty, residents and medical students to discuss patient cases addressing challenging diagnostic, evaluative and medical management issues. Students may have the opportunity to present their own patient(s) cases during Firm Conference. 

Medical Grand Rounds
The department's weekly Medical Grand Rounds lectures cover a broad range of timely and clinically-important topics. Speakers are drawn from BIDMC, Harvard Medical School and other regional and national institutions. Along with named lectureships, Medical Grand Rounds includes the BIDMC-Annals of Internal Medicine “Beyond the Guidelines” series, which uses a case-based approach to address questions related to new clinical guidelines.

M&M (Morbidity and Mortality)
Morbidity and Mortality or M&M is an educational conference that takes place weekly on Tuesday mornings. The Chief Medical Residents review a recent case with medical errors, complications or unintended outcomes to improve the quality of care provided to patients at BIDMC.

Teaching Rounds
Students have dedicated student-only teaching attending (STA) rounds 3-4 afternoons/week during which case-based sessions, bedside observations of histories & physical exams, and physical exam diagnosis rounds are held.

Students join their teams for additional team-based teaching attending rounds in the afternoons twice a week, led by the team’s attending physician.

Once weekly, the Firm Chiefs conducts bedside "walk rounds" with the firm's junior and senior residents and medical students.

Ambulatory Preceptor Sessions
Faculty members in general medicine, subspecialty medicine, dermatology and ophthalmology precept students rotating through these various ambulatory settings.

Student-Directed Reading
To enhance understanding of subjects discussed at conferences and in teaching rounds, students are expected to read relevant online resources, texts and current peer-reviewed literature. In addition to reading materials suggested and/or distributed by residents and faculty, students will have unlimited access to literature search programs and various websites. The Shapiro Institute for Education and Research provides additional educational resources.

Student Presentations
On inpatient rotation, students will present their cases on work rounds, at STA sessions, and on occasion at Firm Conference. On ambulatory rotation, students will present several  cases daily, for students will be evaluating a number of patients during each outpatient session.

Expectations of Residents and Attendings as Teachers

Role of the Intern
Interns play an important teaching role in the following areas: They assist with teaching students how to write orders, arrange testings and consults, and find and interpret lab and study results. They discuss on a daily basis management issues relating to jointly managed patients. They read, correct, and countersign students' daily progress notes. And they contribute to case-related teaching that occurs on work rounds, Attending rounds, etc.

Role of the Resident
Residents review the expectations of the student on the ward service and set expectations that are unique to the service and to the resident's teaching style. Residents are expected to engage in case-based teaching surrounding each of the patients admitted by the student. This entails ensuring adequate data collection by the student; reviewing the student's understanding of each problem and the plan for work-up and management; reviewing the student's admission write-ups; "coaching" the student's case presentations, customized for various educational and conference settings; and assisting the student with development of a knowledge base.

Residents are also expected to provide immediate and on-going feedback, both positive and constructive.

Residents should at the very least meet with the student at the start of the educational relationship, in the middle and at the end of the resident's time with the student, to review expectations, progress, problem areas and plans for improvement.

Role of the Attending
Attendings are expected to meet separately with students twice weekly to hear case presentations, review write-ups, and provide feedback. It is the Attending's responsibility to provide mid-course, and end-of-rotation student feedback and evaluation.

Clerkship Organization

Number of students on rotation? 24 maximum; 4 minimum.

Do students work with partners? No. However, while on inpatient rotation, two students may be assigned to each Firm team (see below), with each student working with one of the two team's interns.

Do students work with a teaching resident? Yes, in weekly group sessions while on inpatient medicine.

Is there a centralized education office at the hospital? Yes.

What is the division of time among services? ( e.g., wards, emergency room, CCU, etc.)

Eight (8) weeks are spent on the medical wards, and four (4) weeks are spent in the ambulatory setting. All students spend the first 4 weeks of the clerkship on inpatient medicine. Thereafter, the student group divides in half, each half rotating on inpatient medicine or ambulatory medicine in either the 5th- through 8th- or the 9th- through 12th-week block of the course.

Required "on-call" schedule and duration of "on-call" at the hospital: There is no long call. Students are required to come in one weekend day per week. 

"Team" composition: 2 Interns and 1 Assistant Resident (either junior or senior) comprise the team, along with the supervising Attending Physician who is a Hospitalist. No more than 2 students will be assigned to a single team.  There are three Firm teams on each of the main inpatient medicine floors, Farr 2 and Farr 9.  

Evaluation

By? Interns, Residents, Attending Physicians, Ambulatory Continuity and Sub-Specialty Preceptors, and Clerkship Directors.

Criteria? (All of equal importance): Ability to do history and physical exam; ability to do case presentations; ability to do differential diagnosis and evaluation plan; fund of knowledge; and attitude, level of interest, and personal interactions.

Type of exams? Students are required to take the NBME Shelf exam during the last week of the clerkship. 

Formal feedback mechanism? Feedback is available to students at any time upon request from residents, attending physicians, and clerkship co-directors. Feedback is provided every week on the inpatient services on “Feedback Fridays.” In addition, feedback sessions are held mid-way through and at the end of each learning experience, with the attending physicians who have had direct responsibility for the student's learning. At mid- and end-of-clerkship, the Clerkship Directors meet with each student individually to give composite feedback received from all individuals with whom the student has worked (Interns, Residents, Attendings).

General Comments

At BIDMC, we are very interested in students learning and seeing a broad spectrum of internal medicine in a relaxed and enjoyable atmosphere conducive to education. From the house staff to the Chief of Medicine, the student clerkship has the highest priority, and every effort will be made to ensure that each individual is given the opportunity to thrive to the greatest extent possible.