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Primary Care/ Family Medicine/ Community Medicine

3rd Year IM Overview

As a third year medical student, you will have the opportunity to explore a career in Internal Medicine through your required Internal Medicine clerkship. As opposed to the Family Medicine rotation where there are many sites to choose from. The Internal Medicine rotation is done at LAC-USC for the vast majority of students, although a few students per rotation do theirs at Huntington Hospital in Pasadena.  The Internal Medicine rotation is entirely devoted to in-patient medical care, although students must learn about chronic conditions and how exacerbations of chronic disease result in hospitalization. The Medicine service gives students exposure to many cases of issues common in General Internal Medicine as well as sub-specialty care, and especially how a general internists must manage the care provided by several different teams of specialists.  Most patients receive follow-up care in the continuity clinic by the residents that care for them in the hospital if they have not already been seen previously in the continuity clinic. A major component to in-patient medical care is ensuring that patients have access to continuity of care and that their chronic conditions are addressed on discharge. The rotation exposes students to practicing general internists as well as “hospitalists,” who perform all of their clinical duties seeing general Internal Medicine patients in the hospital. Although hospitalists are not primary care physicians, working with them exposes students to the many practice models in General Internal Medicine.

HOW TO GET THE MOST OUT OF YOUR THIRD YEAR

As physicians who enter General Internal Medicine practice under the subset of primary care, your focus during your third year should be broad-based. Much of primary care is out-patient based and much of your third year is in-patient based. However, most general internists continue to round on their patients in the in-patient setting and some work as hospitalists and in intensive care units.

All internists need to know how to recognize the acuity of an illness that necessitates a hospitalization. After a patient is discharged from the hospital, their internist, family physicians, or other primary care provider must provide their post-hospitalization follow up care, surgical and pre-operative clearances and post operative wound care. Internists do many office based surgical procedures. Becoming comfortable with suturing and wound care is an important skill to learn on your hospital rotations. The many “common illnesses that bring patients into the hospital (diabetes, hypertension, coronary artery disease,etc.) are key illnesses to become very familiar with their diagnosis and management. Being attentive to these opportunities during your third year clerkships would be helpful.

As internists coordinate care for patients in the in-patient setting, they also are vital at coordinating care in the clinic as well.  They provide “the medical home for patients,” thus learning to work with the multiple specialists in a hospital is integral to this process.

INTERNAL MEDICINE CLERKSHIP
The Internal Medicine Clerkship is a 6 week in-patient, hospital experience at LAC-USC with an exception of 1-2 students who carry out their rotation at Huntington Hospital in Pasadena. Students work with a team of typically one resident, two interns, and one or two medical students who are all overseen by a member of the Department of Internal Medicine faculty.  Students are assigned patients and provide care through all stages of their hospitalization from admission to discharge.  Students at LAC-USC are given considerable responsibility for their patients, including writing notes, helping write orders, and calling consults along with any procedures that might be necessary. This experience allows students to learn how to work as a healthcare team as many times they assume responsibilities for others’ patients and vice versa. They learn the vital of an internist in coordinating care amongst several specialties that provide consults for their patients as well as all of the members of the health care staff, including nurses, physical therapists, nutritionists, pharmacists, and social workers.

On the first day of the rotation, after a brief orientation where students become familiar with the objectives and logistical aspects of the clerkship, students perform an OSCA (Observed Structured Clinical Assessment) to prepare them for their OSCE (Observed Structured Clinical Evaluation) at the end of the rotation which is a part of their final grade.  Students have weekly didactic sessions that include an ethics presentation which they must give during one of their weeks along with lectures in topics relevant to Internal Medicine. Third year students are paired with their resident and follow their schedule. The work day starts early in the morning and finishes with sign-outs to the night float residents. Students receive an average one day off per week.  On the rotation, besides their clinical duties, students are expected to attend morning report and noon conference where they have the opportunity to see case presentations from residents and lectures from attending.

INTERNAL MEDICINE RESIDENCY PROGRAMS

Internal Medicine residency programs are responsible for training physicians to be competent to practice all areas involved in General Internal Medicine with competency in most if not all its sub-specialties.  Programs have a wide variety of settings ranging from academic programs at major universities and teaching hospitals to independent community programs.  The type of practice setting that is right for each resident depends on their career goals, the amount of research they want to become involved in, and the types of patient populations they choose to serve.

All residency programs are now required to carry out one-third of their training in the ambulatory setting, thus the opportunity to experience medicine delivered in primary care practices is ample. Residents are also required to maintain a continuity clinic which they must attend at least once per week. This allows trainees with the opportunity to experience delivering healthcare where continuity of care is essential. Amongst the various Internal Medicine residencies, there is an ever-increasing number of programs that offer a primary care tract. This is either a subset of residents that apply to the traditional tract or is its own program with a separate NRMP match code.  These programs focus more on training internists to practice as general internists in the ambulatory setting. They typically have more time allotted for ambulatory rotations and require fewer sub-specialty rotations. These are becoming more popular because a greater number of residents who know they want to do primary care early on in their careers find these programs more beneficial to their long-term training.

For a full listing of residencies by region, please visit the Clerkship page.


–Overview written by Nicholas Arger, Class of 2011, IM