Internal Medicine (“Medicine”)

Your Real Responsibilities:
Nothing. You’re a medical student. Remember those red-shirted crew members on Star Trek? That’s kind of like you. Your only function is to walk around filling out the scene. Sometimes bad things will happen to you, sometimes you will provide comic relief, but mostly you will just fade into the background, indistinguishable from any other medical student.

Your Pretend Responsibilities:
Managing patients on the wards. Seeing patients in clinic and presenting them to your attendings and residents. Admitting and discharging patients under the supervision of your residents and learning to write the appropriate orders.

Things You Should learn:
Everything. Internal medicine (along with General Surgery) forms the backbone of the entire medical profession. It is medicine in its purest form complete with meticulous history-taking, a thorough physical exam, a comprehensive differential diagnosis, a sound plan with the appropriate testing, and either a definitive treatment or the appropriate referral. It is both traditional, as the internal medicine ethos would not be unfamiliar to the ancients, and cutting-edge, as new research is continuously incorporated into the profession.

So there is a lot to know. Rather than trying to list things, let me give you one of the only really useful mnemonics in medicine which is “VINDICATE.” I generally hate mnemonics but this one will let you systematically come up with a differential diagnosis from which further testing and treatment may be derived. The causes of every illness known to man are:

Vascular
Infection
Neoplasm (Cancer)
Drugs
Inflammatory/Idiopathic/Iatrogenic
Congenital
Autoimmune
Trauma
Endocrine/Metabolic

When you’re in a bind and staring at and acre or two of blank space on your note for your assessment and plan, just take a deep breath and remember VINDICATE.

Things That Will Suck:
Did I mention it was medicine? As bears shit in the woods, the Pope is Catholic, and death invariably follows taxes, medicine attendings love to round. And round and round and round, often well beyond the point where you care about anything but making it stop.

Rounding, for those of you who don’t know, involves visiting, as a group, every patient on your census to discuss their illness and the plan. Surgery rounds are sometimes of the variety, “Patient looks fine from door, let’s move on.” Medicine rounds, however, proceed at a glacial pace as every single aspect of the patient, his disease, his lab values, and his prognosis are discussed in excruciating detail. This is where you may have a 45-minute ad hoc lecture about a patient’s normal but slightly low sodium value and what it means for him. Then you will discuss the next patient’s potassium for half an hour.

Merck developed a probe that gave continuous readings of serum electrolytes but they had to take it off the market after internists started hanging themselves with their stethoscopes.

Not to mention that every possible cause of the patient’s symptoms, no matter how unlikely, will be trotted out like so much horseflesh to be poked, prodded, examined, and finally sent back to the corral. It is a good way to learn medicine, don’t get me wrong, but my feet hurt all the time on that rotation and I developed plantar fasciitis from standing up and walking for eight hours a day.

“Don’t they have anything better to do?” you ask. Well, no. This is what they do. Internal medicine is light on the procedures but heavy on the thinking.

Cool Things About the Rotation:
1. Morning report: Almost every program has a formal teaching session in the morning where a case is presented to the residents. It is usually in a question and answer format where the presenter starts with the presenting complaint and symptoms and the residents ask appropriate questions about the history, review of systems, physical exam and all the other elements of a good patient encounter. This leads to the creation of a differential diagnosis which is narrowed down to the most likely disease after which a short presentation on the final diagnosis is given. For my money, this is the best way to learn medicine. It’s interactive, it’s fun, and even the pimping is usually in good spirit.

2. The opportunity to rotate on sub-specialty services: I landed nephrology and cardiology (two weeks each) as my subspecialties during my two-month-long medicine rotation. Nephrology attendings, for their part, are like general medicine attendings on crystal meth, at least when it comes to their preoccupation with electrolytes and they are, as a class, perpetually exasperated that their medical students, most of who are just trying to survive, cannot identify garden-variety mixed acid-base disorders. Still, these kinds of rotations give you good exposure to the whole range of medicine.

3. Medicine is very cool. Internists have my deepest respect but it’s not something I wanted to do, what with my short attention span and poor memory.

Call:
Useless, like most medical student call. You’ll basically just follow your resident around as he grinds out admission after admission in the best cookie-cutter fashion. As there is no difference between an admission done at 8PM and one done at 3AM (except that at 3AM you are too tired to give a crap) there is no reason to lose sleep. You can learn all you need to know and still get a good night’s sleep except that your faculty is bound and determined that as they suffered, so shall you.

Slacking Potential:
Medium. Rounds don’t actually last all day. You may have a couple of hours to vanish and either take a nap or study. Generally, after formal rounds you have “work rounds” where your residents will go back to their patients and implement the plans discussed on rounds. Since you are not responsible for any aspect of patient care, your presence is not required and after you make yourself aware of what is going on with all the patients you are following, the day is pretty much your own unless until sign-out in the late afternoon. Like most inpatient rotations, expect early hours but not as early as OB/Gyn or surgery where they round early to get it out of the way so they can do their real work.

Miscellaneous:

A Typical Day on a Medicine Service
A Typical Day as a Medical Student Part 1
A Typical Day as a Medical Student Part 2