Clerkship Director: Dr. Krystal Renszel
Clerkship Length: 8 weeks
The Basics
Internal Medicine is one of the two EIGHT week clerkships! It’s broken into two blocks - four weeks of inpatient, four weeks of outpatient. The inpatient portion includes a week of nights, a week of cardiology, and two weeks of inpatient wards on resident teach teams. Outpatient includes a week of palliative medicine and three weeks of outpatient clinic including CIM and Women’s Health with afternoons in GI, nephrology, and/or pulmonology. You can also spend a week at the VA during the outpatient block depending on the schedule.
Assessments
Students must score greater or equal to the 10th percentile on the NBME exam (110 questions) in order to receive a pass. This is usually in the 60% correct range.
Point cutoffs (cumulative out of 100 possible points):
Honors: 90 points or above
High Pass: 65 -89 points
Pass: 45-64 points
Fail: cumulative < 45 points, failure to meet 10th percentile on NBME Shelf examination and/or failure in any domain of clinical performance as determined by Clerkship Director(s).
NBME Shelf Examination (25%, 25 points)
Honors performance, > 80th percentile rank (using 2020-2021 data), 25/25 points
High Pass performance 50-79th percentile rank, 20/25 points
Pass performance 10-49th percentile rank, 15/25 points
Fail performance, <10th percentile rank
Clinical assessment (75%, 75 points) – Goal is an average of 3.5 for Honors level clinical performance and maximum points
Calculate the mean score from all 9 EPAs and convert to percentage of points (ex. If your mean evaluator score is 3.2 out of goal of 3.5, this is 91.43%. Thus, you would get 69 points (i.e., 0.9143 x 75 points = 69 points)
Professionalism does not have a point value but is considered a foundational expectation. In addition to demonstrating professionalism in interpersonal interactions, completion of clerkship tasks in a timely manner is also a component of professional behavior. This includes:
CEX completion
Required Cases and Procedures
Conference attendance
EBM (AZ only)
Participation in the OSCE (Rochester only)
Clerkship Schedule Overview
The schedule they send out a few weeks in advance is quite detailed and hard to include as a screenshot! Note: There is an ethics session about halfway through. You do not need to attend if you are on nights. You can expect the following:
Inpatient Block (4 weeks)
Nights (1 week): You’ll work Monday thru Friday night. Sign out is at 7pm - you’re technically on the schedule until 7am but like most night shifts you usually get sent home early. Anywhere from 12am to 2am seems to be the theme. Just depends on the team you’re with and how the flow of overnight admits comes. The night team all the new admits and assign them to a teaching team. You typically will go down with a resident to get the initial H&P, and then you will write a note. You don’t need to present to an attending. Exceptation is to see one patient every night.
Inpatient Wards (2 weeks): Monday thru Saturday (they usually don’t keep you all day Saturday). 6am signout - usually you’ll get sent home around 4:30 unless your team is the late call team (one day per week) - and even then they’ll likely send you home early. Again fully dependent on the team. Max number of new admits per day is 2-3 per team. You will write progress notes for the patients that you are following (usually 1-3 patients), and an H&P for one new admit.
Cardiology (1 week): Monday thru Saturday. Start time is a little more variable - between 6 and 7 depending on your fellow. You’ll probably be there until around 5pm, give or take. You do not need to go to the internal medicine morning rounds. Rounding typically starts around 9, but is attending specific.
For inpatient wards, you will go to morning conference at 8:30 am with the residents. Sometimes there is a sim session that your residents will take you to. Rounding typically starts immediately after morning conference and goes till lunch (every attending does rounding differently). There is a noon conference most days with free lunch during the week! HIM Grand Rounds on Friday at 12 - they usually just do Zoom in the resident room. Afternoons are for busy work (calling specialties, writing up notes…). Teaching teams are open to take new admits all day until they hit their max. Max number of new admits per day is 2-3. At night, there is only one team working, and they take all new admits and assign them to AM teaching teams. The goal is to simply get patients situated, stabilized, and comfortable, more complex care occurs in the mornings with the Teach team.
Outpatient Block (4 weeks)
CIM Clinic (2-3 weeks): Community Internal Medicine clinic at Shea campus (on concourse level). You’ll be scheduled from 8-12 with a different provider each day (there’s obviously some repetition). Usually you are done around 11-11:30 am. 2 weeks if you’re at the VA, 3 weeks if you’re not. Paired with subspecialty afternoon half days. You will get 1-2 afternoons free. You need to do a CIX during these 2-3 weeks.
VA Clinic (0-1 weeks): 32nd St building. You’ll get an individual schedule with providers from the VA the week before. 8-12 with one doc, 1-5 (usually 4:30) with another. You may or may not have this week as part of your schedule. If you do, there are learning modules and an in-person fingerprinting process that needs to be completed several weeks before. It is annoying. Sorry. Appointments need to be made for fingerprinting and card pick-up, and you will need two forms of ID each time! Appointments are long. You will receive your schedule at least one week in advance (please reach out if you don’t). You are expected to see 2 patients in the AM and 2 patients in the PM. You are also expected to write notes (you will either use Word then email the preceptor or get access to VistaCPRS chart). Attendings evaluate you.
Palliative Medicine (1 week): Lots of variety in the schedule by day. Typically you have to be present in the workroom at 8 am, rounding starts at 9. They will try to send you home around 4 pm. Wednesday you will be at the Sherman home (start time is 8 am). The team is made up of a palliative fellow, a pain medicine fellow, a palliative attending, a social worker, and a charge nurse. This team doesn’t evaluate you.
Specialty Outpatient/Consult (1-3 weeks): With the CIM clinic weeks - this is your afternoon (or occasionally morning). Sometimes at Shea, sometimes at Mayo. 8-12 or 1-5. Attendings do not evaluate you.
Recipes for Success
Clinical Performance Evaluation
Internal Medicine is known to be one of the harder rotations, both because of the Shelf content and tougher schedule, as well as the expectations of you while on wards. Don’t be intimidated! You’ll spend the majority of your time with the residents who are always fantastic at helping you feel comfortable.
Pre-rounding and presentations: What you need to know from overnight events and pre-rounding changes based on what kind of patient you have (i.e. you 100% need to know I&Os for a heart failure patient, less so for someone there with a migraine). If you’re not sure, ask the resident, or pre-round with them. The residents are also usually down to help you practice a presentation before you give it in rounds. Rounding typically starts at 9, and if you are inpatient, you have hand-off at 6 am and morning conference at 8:30, so you can pre-round between these times.
The biggest trick for IM is to stay engaged as much as you can. If you don’t understand what’s going on, take it upon yourself to look the information up. If you aren’t sure what to do for the patient, use UptoDate or AskMayoExpert. Don’t tune out when it’s not your patient being discussed on rounds - they’ll often still ask a question then.
It is helpful to have an evidence-based article to back a finding/plan during your presentation (pubmed and open-evidence are good places to start).
Communicate with the whole team - check in with nursing, social work, case management, and pharmacy whenever they’re involved with the patient.
Offer to page specialties or services as needed.
BE RESPECTFUL. It can be really easy to lose professionalism when you’re working six days per week - remember that more than anything else being respectful to your team members and attendings makes the biggest difference.
I think it is helpful to ask residents or even attendings (particularly in the CIM) how they would like to hear a presentation. Some attendings are more formal than others.
Weekly Didactics
Morning report M, W, Th from 8-8:30. Usually cases. Mixed usefulness for medical students.
Noon conference M-Th… a huge variety of topics. The residents will tell you when/where. However, if there is a new admit, you might have to miss the noon conference.
Friday HIM Grand Rounds - usually via Zoom at 12pm on Friday.
Shelf Exam
The shelf exam consists of 110 multiple choice questions
Tier 1 → There are a TON of questions in UWorld for HIM. Do your best to get through as many as you can, and as always work through the incorrects if you have time. A lot of people suggest also doing the Ambulatory Medicine questions as they also cover topics on the Shelf.
Tier 2 → Practice NBME exams are super helpful! Best if done in the two weeks before the Shelf.
Tier 3 → Online MedEd if you have time. Anki is also a good tool for HIM with lots of small facts and exceptions to the rule.
Tier 4 → Emma Holiday Lecture (YouTube) - watch this in the few days prior to the exam for a high-yield quickshot overview. 2 hours.
Mehlman free high yield guides/anki can be helpful if you are looking to honor.
TEMPLATES
Linked templates below that you can print ahead of time and use for IM inpatient and outpatient.
Outpatient Template (for clinic)
I would print a handful of these for the week and fold in half to carry in my pockets. I would fill them out during precharting and prerounding. Then you just follow them and you read off to present during rounding.
If you need EPIC templates you can just look up my name (Vasilev, Dzhuliyan) under smartphrases and copy directly all my templates. You should only need 1) progress template for inpatient 2) admission template for inpatient 3) outpatient H&P. You can also use Isabella Reitz’s smart phrases (IRHIM-). I have made templates for all the departments that I rotated through during IM.
You can also check out the Mayo Rochester Clerkship Guide for more information.
Key Resources Quick Links
*most important resources are in red that you should do at minimum to pass
UWORLD
You know where to find that!
Question bank is roughly 1200 IM, 450 Ambulatory Medicine
Do as much as you can - but this is the one a lot of people don’t finish.
NBME Practice Exams
Online MedEd or Osmosis
Check their respective websites for the videos
Here is the Online MedEd PDF booklet that you can scan quickly for review
Mehlman free high yield guides/anki
Sample Study Schedule
To get through ALL of the questions (not necessary to do well on the Shelf):
Nights: 40 questions/day = 280 total
Inpatient x2: 30 questions/day = 210 per week x 2 = 420 total
Cardiology: 30 questions/day = 210 total
Outpatient x2: 35 questions/day = 245 per week x 2 = 490 total
This totals 1400 questions over 6 weeks. It’s TOUGH to accomplish this much - start ahead of the rotation if you can. If you stick to this schedule you’ll have two full weeks to do incorrect questions and/or review content.
Supplementary Clinical Content Pearls
Cardiology Pointers
Learn the different types of heart failure and the various management for each (i.e. HFpEF and HFrEF).
Be comfortable with different types of diuretics.
Review EKGs - this book is fantastic and a quick read. Copies in the library.
Review management of ACS and GDMT following an MI.
Dr. Fendandez loves statins-review how much cholesterol and LDL will drop (percentages and numbers!) when adding a statin, doubling the dose, and adding another cholesterol lowering medication on top of the statin. He loves asking about math.
Site Specific Information
VA Outpatient Clinic
You’ll get a schedule from Dr. Siddicky about a week before you start. You’ll be with a different doc AM/PM.
There’s no wifi in the building for phones/personal laptops. Download whatever you want to work on over lunch before you get there.
PACK A LUNCH. Trust me.
VA medicine is very different from Mayo medicine - this doesn’t mean it’s bad care (though sometimes it can be). Approach the week with a little extra patience and a thicker skin than usual and you’ll be fine.
Dress code is VERY casual business casual (girls a nice shirt and casual dress pants, guys khakis and a button down without a tie). Scrubs are also fine - but technically the orientation says business casual.
You’ll get a laptop and badge the morning that you start. You may or may not need to call for PIV exemption in advance - if so, they’ll email you.
Your PIV card will most likely not work, so you’re just going to have to follow people into the building without looking suspicious.
You are also supposed to park in the employee parking lot, but again your card won’t work. You can call security to let you in, but I parked on the street on 30th street and had no issues.
The VA EMR is very different than EPIC. You will need to call CAG helpline (1-855-673-4357) to request a 14-day PIV card exception.
The VA EMR is old and slow system, and just overall awful. There is no search function and no spell check.
Notes at the VA are very short and sweet, with not a lot of information. Once a note is in the EMR, you can’t make changes so look at the addendums at the bottom of the note.
To look up patients you will put the first letter of their last name + their assigned four digit code.
For the Pact Academic clinic, you can pull up the schedule by going to clinics->typing in phx 32st Pact Aca Res Ra2.
If you are told to write a note in the EMR, you will have to call (1-855-673-4357) to get a sign code (or April will send you one).
You will be on either the 3rd or 4th floor. When you get to a teamlet (pod) just ask a nurse or MA where your attending is.
Honestly, when I was there I saw maybe 1-2 patients the whole 8 hours I was there, and 3 of my attendings where on leave which was not communicated to me, so I was mostly sitting there regretting the decisions in my life.
End of Rotation Checklist
Log cases and procedures in MedHub
Senior Sages assignment
EBM within 2 weeks of end of clerkship
Palliative care post-survey
Mid-Clerkship evaluation
CEX during CIM
Ethics session survey
Last updated in June 2024 by Izzy Reitz.