If you’re not applying for a surgical residency, you might not choose to do an away rotation and that’s fine, but you will be required to at least complete a home sub-internship and a few elective rotations in order to graduate. Our goal is for this page to provide some advice on what it takes to do well on your internal medicine sub-internships and medicine-adjacent elective rotations.
Check out this page for general sub-internship advice.
An internal medicine elective is a 4 week, graded (H, HP, P, F) clinical rotation in primary care (community internal medicine, women’s health internal medicine), hospital internal medicine, or a subspecialty of internal medicine (ex. cardiology, pulmonology, endocrinology, gastroenterology, etc.). The expectations and responsibilities are higher in an elective compared to that of a 3rd year clerkship or selective. In a clerkship rotation, the expectations are for medical students to have a basic understanding of the material and to participate in performing patient care and consultations at a basic level. However, the expectations in electives are for medical students to perform at the level of a sub-intern or intern and perform patient care and consultations at a more advanced level. However, as discussed below, the responsibilities and expectations will differ depending on which elective you participate in.
The main goals of an elective are to:
Gain a better understanding of the daily routines of that specialty, including the common conditions they diagnose and treat
Gain a comprehensive and hands-on experience providing patient care in that specialty
Network with physicians, residents, and fellows if that specialty is one you are interested in or planning on pursuing as a career
Anyone interested in outpatient or inpatient internal medicine or a subspecialty of internal medicine
School administration will send out an email to fill out your desired schedule for the following year. In this schedule, you should include any and all electives you hope to do.
After you complete your core clerkships
Can do an elective either before or after a sub-I rotation
Highly recommend you understand the expectations/responsibilities of participating in a particular elective prior to signing up for it. If the expectations/responsibilities are similar to that of a sub-intern (where you are managing patients independently and expected to lead the majority of care for that patient), we would recommend completing your sub-internship prior to that elective
Before you start your elective:
Know the differential diagnoses for common complaints
Can’t miss diagnoses
Common clinical decision rules
Common treatments
Presentation skills
Ask yourself:
What interests me the most?
Where am I deficient or less strong?
During the Rotation:
Be on time
Be enthusiastic
Be prepared
Never lie
Own your patients
Ask questions
Interact with your team
Adhere with administrative requirements
Be humble
Have some fun!
Exercise, sleep, rest
Do something “local-ish” - great thing to ask residents/attendings!
Meet with faculty & residents
Interview with us
Request a Departmental SLOE
written by Nick Allen
Summary
The Community Internal Medicine elective is a 4 week long elective rotation in the outpatient setting that provides medical students with a broad variety of experiences relevant to primary care. You will spend the bulk of the rotation seeing primary care patients in the CIM clinic, very similar to the CIM portion of the Internal Medicine clerkship. Other experiences included in the rotation in the past have been travel clinic, integrative medicine, cardiac stress lab, pre-op clinic, and PM&R. Hours are generally 8 am - 5 pm Monday-Friday. I highly recommend this elective for those interested in primary care or those hoping to gain broad experience in the outpatient setting. Medical students have a lot of independence during the CIM part of this rotation and essentially have the same responsibilities as sub-interns/interns. During other parts of the rotation (travel clinic, stress lab, etc.), medical students are simply shadowing.
How to do well
During the CIM portion of the elective, find your preceptor in their office prior to the first patient of the day. Coordinate with them to decide which patients you will see for that half-day. Chart review on your patients and consider starting your note ahead of time to help with efficiency. Complete a thorough history and physical on each patient, remembering to discuss acute concerns, chronic conditions, and health maintenance. Consider pending orders. Find your preceptor in their office to present the patient, then see the patient together. Finish writing your note and prepare for the next patient.
In the shadowing portion of the elective (everything outside of CIM), the only expectation is that you pay attention, ask questions, and do your best to learn something from each patient.
Helpful resources: bugdrugdx.com
Sub-I experience recommended prior to this elective?
Not necessary
Outpatient, Inpatient, or Both
Outpatient
Preparation prior to elective
Review chronic disease management and USPSTF guidelines for preventive services.
Make sure you have a note template prepared for different types of primary care visits (complaint-based, annual exam, hospital follow-up, etc.)
No preparation is required for the specialty experiences as these are just shadowing.
Expectations for medical students
In the CIM clinic, you are expected to see 2-3 patients per half day from your preceptor’s schedule. You will write a note for each of these patients, similar to the CIM portion of the IM clerkship.
Depending on the preceptor, some may want you to pend orders
In other experiences outside of the CIM clinic, the only expectation is to pay attention and learn!
Patient Case Load
2-3 per half day
Common conditions
Diabetes
Hypertension
Hyperlipidemia
Obesity
MSK concerns
Disease prevention
Infectious disease (URIs, UTIs)
written by James Kim
Summary
The Cardiology Elective is a 4 week long rotation in the in-patient setting that allows exposure into common and complex cardiac conditions. You’ll be part of the Cardiology 1 team which consists of medical students, an IM resident, a cardiology fellow, and APP’s. You’ll share a work-room with the residents on 3W. Medical students have a good amount of autonomy, and are expected to follow patients which include pre-rounding, rounding and presenting, and writing notes. As a 4th year medical student, your notes will count and can be co-signed directly to the attending.
On Tuesdays, Thursdays, Saturdays, and Sundays, Cardiology 1 will be the admitting team, and thus the fellow will be paged throughout the day for consults. These consults can be distributed to any member of the team including APP’s and medical students as the fellow feels is appropriate. On the non-admitting days (M,W,F), Cardiology 2 will be the admitting team and Cardiology 1 will just be responsible for patients on their list. The hours were usually 7am-4pm, and your day will start at 7am by taking sign-out from the overnight team in the conference room. Be prepared with a printed out list for Cardiology 1 to take notes.
How to do well
Show up on time, with eagerness and enthusiasm to learn! Remember you are a medical student but can be very helpful to the team especially now that MS4 notes are billable and counted.
The patient load you are expected to carry will vary based on the size of the list but should be between 2-4 patients.
Before rounds, be sure to look through the telemetry of your patients and print out any concerning telemetry alarms using the Snipping tool and Microsoft Word.
Know the basics of ECG interpretation, pharmacologic management of common conditions to include heart block and ACS. Know the side effect profile of amiodarone, and know for which types of heart block a pacemaker is warranted.
This is a great source for ECG basics: EKG Library • LITFL • ECG Library Basics.
written by Aly Ishimoto
Summary
The gastroenterology elective is a 4 week long elective rotation in the inpatient setting that introduces medical students to a host of GI conditions. You will be working on the gastroenterology consult service with a team consisting of an attending, 2 fellows, 1-2 APPs, and 1-2 residents from 7 am - 5:30 pm Mondays-Fridays. I highly recommend this elective for those interested in gastroenterology as a career or those hoping to learn more about what gastroenterology entails. Medical students have limited independence on this rotation, and responsibilities are at the level of a 3rd-early 4th year medical student.
How to do well
Know when to ask for help, whether that is having a fellow or APP help you interpret imaging/labs or having a resident/fellow/APP review your management plan that you will present at rounds.
People are generally happy to walk you through something, so if you don’t know how to place common orders, have a question about a common procedure, just ask someone to walk you through it (at the appropriate time).
Recognize that you are sharing your patients with the resident/fellow. They are the main caretaker and will be the main GI contact for the patient so the primary service and other specialty services will be connecting with your resident/fellow. However, you can be helpful and update your resident/fellow about updates in diagnostic workup results or volunteer to reach out to the nurses/primary service.
Do your best to always clue in residents to new information/communication with other healthcare team members
Click the bell icon to turn on alerts for when labs/imaging reads are in the EMR so you’re notified immediately.
Que up orders for your resident/fellow if you know what they need.
Although medical student notes do NOT count on this elective (and residents/fellows are required to write a note for your shared patient), you are still required to write good quality notes. Attendings will use these notes to ensure you are doing well in the rotation and following your patient closely.
Be engaged during rounds, not just during your presentation of your patients but also during others’ presentations of their patients.
Ask questions appropriately during rounds or after pre-rounds.
Work well in a team. Collaborate and be respectful of your teammates. You will be spending several weeks in a row with the same fellows/APPs so it is best to get along with the entire GI team.
Show initiative and discuss trials or publications about different topics. Attendings love discussing the trials that led to the implementation of certain guidelines.
Volunteer to observe your patient’s endoscopy. Many of the patients on the GI hospital service require an endoscopy to take a biopsy, find the source of a GI bleed, or assess for masses, ulcers, etc. It shows initiative when you ask to observe your assigned patient’s endoscopy.
Sub-I experience recommended prior to this elective?
Not necessary
Outpatient, Inpatient, or Both
Inpatient
Preparation prior to elective
know the common GI conditions and how to diagnose/treat them
be aware of how an upper vs. lower GI bleed presents and the different etiologies of each
know the etiologies of dysphagia and how to take an H&P for dysphagia
know how to take an H&P for GI bleeds
understand the unique characteristics of melena and common mimics of melena (iron, bismuth, etc.)
know how to emergently care for GI bleeds (large bore IV with fluids, PPI, octreotide, colonoscopy vs upper endoscopy vs IR consult)
Expectations for medical students
be able to care for inpatient patients on the gastroenterology service with a supervising fellow/resident including seeing new consults, pre-rounding on all your patients, participating in rounding with the GI team, writing consult notes and progress notes (medical student notes actually do not count on this service so your assigned fellow/resident also needs to write a note), recommending management for your patients (endoscopy, medications, CT abdominal imaging, labs, etc.), interpreting results of diagnostic workup (labs, imaging, endoscopy results, pathology, etc.)
work in a team of APPs and fellows/residents
your assigned fellow/resident for that patient is the main caretaker. Your responsibility is to act as supplement caretaker for your patient so you can helpfully remind your fellow/resident about updates in the patient’s labs or imaging. Your fellow/resident usually places orders and reaches out to the endoscopy suite or primary service.
Patient Case Load
1-3
Common conditions
GI bleeds (upper vs. lower GI etiologies)
dysphagia (variety of etiologies)
peptic ulcer disease
IBD
cholecystitis
cholangitis
infectious vs noninfectious colitis (ischemic, microscopic, drug induced)
written by Aly Ishimoto
Summary
The pulmonology elective is a 4 week long elective rotation in the inpatient setting that introduces medical students to a host of pulmonary diseases and conditions. You will be working on the pulmonary consult service with a team consisting of an attending, a fellow, 1-2 APPs, and a resident from 7:30 am - 4:30 pm Monday-Friday. I highly recommend this elective for those interested in pulmonology/critical care or those hoping to learn more about what pulmonology entails. Medical students have a lot of independence on this rotation and essentially have the same responsibilities as sub-interns/interns.
How to do well
Know when to ask for help, whether that is having a fellow or APP place orders for your patient or helping you interpret imaging/labs, having a resident/fellow/APP review your management plan that you will present at rounds, or consulting other services for their expertise
Be engaged during rounds, not just during your presentation of your patients but also during others’ presentations of their patients.
Ask questions appropriately during rounds or after pre-rounds
Work well in a team. Collaborate and be respectful of your teammates. You will be spending several weeks in a row with the same teammates so it is best to get along with the other pulmonary providers.
Show initiative and discuss trials or publications about different topics. Attendings love discussing the trials that led to the implementation of certain guidelines (ex. TPA/DNAse trial for pleural infections)
Your note is the only note for your assigned patient so be ACCURATE and CLEAR. You are not sharing the patient with the fellow, resident, or APP. They will supervise you and can help guide you in your differential diagnosis and management plan. However, you are the main contact for the pulm team for your patient. Therefore, write good quality notes and ensure all points of the treatment plan are included in the note. If necessary, clarify any misunderstandings or points of confusion with the attending, fellow, or resident before writing it down.
Sub-I experience recommended prior to this elective?
Yes
Outpatient, Inpatient, or Both
Inpatient
Preparation prior to elective
have a basic understanding of what cryptogenic organizing pneumonia, NSIP, IPF, and hypersensitivity pneumonitis look like on CT chest imaging
have a basic understanding of how to diagnose and manage common pulmonary diseases
know how to perform a pulmonary focused H&P
understand when a bronchoscopy is recommended and what the contraindications are
have a basic understanding of the different types of supplemental oxygen and BIPAP/CPAP
Expectations for medical students
be able to care for inpatient patients on the pulmonary service independently including prerounding on new consults and acutely ill patients, participating in rounding with the pulmonary team, writing consult notes and progress notes, contacting the primary service regarding pulmonary recommendations, recommending management for your patients (bronchoscopy, medications, CT chest imaging, supplemental oxygen, labs, etc.), interpreting results of diagnostic workup (labs, imaging, bronchoscopy results, pathology, etc.)
you are the main pulmonary contact for your assigned patient. It is up to you to update your team and the primary service as needed.
work in a team of APPs and fellows to appropriately update them on your patients’ status/results of diagnostic workup and for any orders that need to be placed (bronchoscopy orders placed by pulmonary APPs/fellows)
Patient Case Load
2-6
Common conditions
Asthma
COPD
Pneumonia
Pulmonary hypertension
Respiratory failure
Lung malignancies
Interstitial lung disease
Pleural effusion
written by Nick Allen
Summary
The Endocrinology elective is a 4 week long elective rotation in the outpatient and inpatient setting. Medical students are primarily shadowing in the Endocrinology clinic and on the Endocrinology hospital service. One week is spent on the inpatient service, and three weeks are spent in the outpatient clinic. Hours are generally 8 am - 4 pm Monday-Friday, and shorter days are common. This is a great learning experience for those interested in improving their management of diabetes, thyroid conditions, osteoporosis, and other endocrine disorders. As this is a brand new elective, information is subject to change! Medical students are primarily shadowing during this rotation.
How to do well
In its current form, this is a very relaxed elective run by Dr. Bithika Thompson (Endocrinology Chair). Expectations are low but you should show up ready to learn and ask questions. This is a new elective and not all faculty are aware of the medical student role, so it helps to reach out to them beforehand to let them know you’ll be shadowing.
Sub-I experience recommended prior to this elective?
Not necessary
Outpatient, Inpatient, or Both
Both
Preparation prior to elective
No preparation is required, but review of diabetes and insulin management would be useful.
Expectations for medical students
Medical students are expected only to shadow during this rotation. Occasionally you will have a preceptor who isn’t familiar with the medical student role, and they may ask you to see patients/write notes.
Patient Case Load
Shadowing ~12 patients daily outpatient, ~20 patients daily inpatient
Common conditions
Diabetes (Type I and Type II)
Osteoporosis
Hypothyroidism and hyperthyroidism
Pituitary disease
written by Aly Ishimoto
Summary
The sleep medicine elective is a 4 week long elective rotation in the outpatient setting that introduces medical students to the basics of sleep medicine. You will be working one on one with a sleep medicine attending in their clinic from 7:30 am - 4:30 pm Mondays-Fridays. I highly recommend this elective for those interested in a sleep medicine fellowship or those hoping to learn more about what sleep medicine entails. Each sleep medicine attending does have a different style of how they like to take their sleep medicine histories so it is always best practice to copy their H&P template on their Epic smartphrases and use their template when gathering an H&P.
How to do well
Be aware of that specific attending’s H&P style. Their pattern of history taking often follows their template. In addition, when you write notes, it would be best to mirror how that attending prefers to format their notes.
Be engaged during patient presentations and ask questions appropriately during rounds or after pre-rounds
Work well in a team. Collaborate and be respectful of your teammates. You will be spending several weeks in a row with the same nurses, respiratory therapists, and attendings so it is best to get along with your team. The nurses who room your patients love friendly and respectful medical students. I often would walk to the nurses room to let them know ahead of time which patients I was seeing and they would take the initiative to let me know about changes in a patient’s schedule or any difficulties the nurses confronted while rooming the patient.
Show initiative and discuss trials or publications about different topics. Attendings in sleep medicine in particular love discussing new innovations in sleep medicine. Favorite topics include hyperbaric chambers, blue light therapy, Inspire surgery for OSA, etc.
Sub-I experience recommended prior to this elective?
Not necessary
Outpatient, Inpatient, or Both
Outpatient
Preparation prior to elective
understand the pathophysiology of obstructive sleep apnea
have a basic understanding of how CPAP is effective in treating sleep apnea
know the severity categories of OSA and which AHI corresponds to each category
understand how to diagnose sleep apnea
understand the differences between a home sleep apnea test and polysomnography and when to order each
understand how to diagnose RLS and how to treat it
understand the criteria for defining a hypopnea
have a basic understanding of what sleep disordered breathing looks like on overnight oximetry
know how to grade Mallampati/Friedman tongue position
Expectations for medical students
first week was shadowing. I observed how the sleep medicine attendings conducted H&Ps, performed physical exams, and reasoned through management plans. This is also an optimal time to learn how to interpret PSG/HSAT results from the attendings as they can walk you through the basics.
weeks 2-4 were applying what I learned to real patients. Expectations were to be able to see 1-3 patients per half day. For new patients, be able to conduct H&Ps in 20-30 minutes and present the patient to the attending with an appropriate management plan. Expectations for follow ups are to be able to interpret PSGs/HSAT results and recommend appropriate management. Be able to discuss the pathophysiology of OSA and CPAP as the gold standard for patients. Be able to write notes for the patients you see.
Patient Case Load
1-3 half day
Common conditions
sleep latency and sleep maintenance insomnia
obstructive sleep apnea
central sleep apnea
narcolepsy
REM sleep behavior disorder
restless leg syndrome
delayed sleep phase syndrome
written by Farha Deceus
Summary
Nephrology is a 4-week in-patient elective with the option to shadow the fellows on their out-patient continuity clinic half days. Hours are typically 7 am - 5 pm Monday - Friday. The general nephrology consult team consists of an attending (rotates weekly) and a fellow (rotates bi-weekly) +/- a PGY-2 internal medicine resident, shadowing M3, and APP trainee. The volume of patients on the list is highly variable based on season (up to 30-40 patients in the winter with snowbirds). This is an excellent option for anyone interested in internal medicine as you will need to be comfortable with the initial work-up and management of many of the conditions you will encounter during this elective. Medical students have a lot of independence on this rotation and can function up to sub-interns/interns.
How to do well
Fourth years rarely take this elective so faculty/fellows can be unfamiliar with your role and surprised you are spending 1 month on the service. This gives you the opportunity to function as a resident because that is the training level they are most familiar with. As long as you are enthusiatstic and diligent, they will give you the freedom to make meaningful decisions for your patients.
Faculty and fellows are very eager to teach and will focus on whatever topic you request! Come prepared with questions (ideally related to patients you are following) that you have read about and would like additional teaching on.
The fellows are very busy, so your note will be the only one in the chart for the patients you are assigned. Ask clarifynig questions as needed so the note is accurate. Also, message or call the primary team if there are new recommendations that require their attention.
Ask the fellow if pre-rounding will be necessary that week. If the list is especially busy, the team may prefer to table round and only physically see the sickest patients together or the attending and fellow may round separately for efficiency.
Commit to a diagnosis! Even if you are unsure, present your differential diagnosis but commit to an etiology for whatever you are being consulted for. Attendings would prefer you choose a reasonable diagnosis that you can provie evidence for than being wishy-washy while waiting for all the diagnostics to result. This helps them identify your content weaknesses and correct them before they become ingrained.
Sub-I experience recommended prior to this elective?
not necessary
Outpatient, Inpatient, or Both
Inpatient (with the opportunity to shadow fellows on their clinic half-days)
Preparation prior to elective
No preparation is required, but helpful to review:
Common Rx MOA and adverse effects (Antihypertensives, diuretics)
Etiologies/ management of AKI (pre-renal, etc.)
Na and K regulation
Fluids and indications
Dialysis modalities and contra/indications
Expectations for medical students
Increasing autonomy based on comfort. Can shadow for a few days with the expectation to eventually write consult and progress notes.
Patient Case Load
3-5 patients
Common conditions
AKI
Electrolyte disturbances
Hypertension
Glomerulonephritis
Hepatorenal and Cardiorenal syndrome
Kidney stones
written by Mylan Blomquist
Summary
This is a four-week elective in an inpatient setting. The hours are better than most inpatient services, and no weekends (7-8AM to 3-4PM in my experience). You will work with the solid tumor oncology team, including an attending (alternates each week), heme/onc fellow(s), rotating residents (usually TYs), and an oncology APP. This service only covers solid tumor consults (no malignant heme or bone marrow transplant). While this is primarily a consult service, they admit <5 patients per week for scheduled chemotherapy infusions if they are long in duration and require monitoring for toxicity. Note that there is limited diagnostic workup on this service. Most consults involve goals of care conversations and/or toxicities of treatment. Recommended for students interested in hospital internal medicine or oncology, but probably not the best exposure to the specialty of oncology, which primarily occurs on an outpatient basis.
How to do well:
NCCN guidelines!!! This is the secret. It is free to make an account and log in. These are the consensus guidelines where oncologists get their treatment plans and what can happen at each decision point (https://www.nccn.org/guidelines/category_1)
Patient interactions can be extremely emotionally charged on this service for different reasons. Make sure patients know who everyone on the team is. Don’t say/add extra things in the room unless you are “driving” the conversation and it is your patient.
Read up on what you haven’t heard of – goes without saying but there are a LOT of things that will be completely new and require some background reading.
Sub-I experience recommended prior to this elective?
Yes, medically and socially complex situations
Outpatient, Inpatient, or Both
Inpatient
Preparation prior to elective
You would look like a genius if you started out knowing how to look up guidelines on NCCN as mentioned above.
Understand how checkpoint inhibitors (like pembrolizumab and nivolumab) work and why toxicities happen. Knowing how BiTE therapy works and its toxicities also came up a few times.
No highly specific knowledge of any cancer or chemo drug needed going into it.
Expectations for medical students
They almost never get medical students, so this experience can be what you make it. I typically carried 1-2 patients per day and wrote consult and progress notes. I led goals of care discussions with families and educated on diagnoses if they were new during that hospitalization. I think the team would have found shadowing just as acceptable if I wasn’t comfortable. Some attendings really like to teach, but note most of them have clinic in the afternoons while on hospital service so they are not around a lot even if they do teach.
Patient Case Load
1-2 per day
Common conditions
small cell lung cancer (this is aggressive and one of the few things requiring initiation of inpatient chemo)
non-small cell lung cancer
pancreatic adenocarcinoma
breast cancer (all types)
renal cell carcinoma
brain metastases
soft tissue sarcomas (Ewings, synovial sarcoma)
immune checkpoint toxicity
written by Mylan Blomquist
Summary
This is a four-week elective in Rochester in the outpatient setting. The hours are approx 8AM-4PM, no weekends. You will be scheduled primarily with consultants in clinical genomics, but you will also have half days with genetic counselors and genetic counseling assistants to see their workflow. This is a great elective for anyone interested in pediatrics, OB/GYN, rare diseases, clinical genomics/genetics, or just interested in meeting some remarkable patients who are often eager to share their experience with rare disease (some are among single digit known cases in the world) and physical exam findings.
How to do well:
Look up cases as they come on NIH GeneReviews online. This is like UpToDate for medical geneticists. It will have the pathophysiology and the treatment guidelines for each gene/disease.
Sub-I experience recommended prior to this elective?
No, this could even be cool for an M1.
Outpatient, Inpatient, or Both
Outpatient
Preparation prior to elective
The cases are so rare/hard to predict that I found that it worked best to look up cases as they came. I hope you paid attention in biochemistry (but if you didn’t, this elective might help you brush up).
Understand a bit about gene sequencing. Whole genome vs. exome, the concept of panels and targeted sequencing
DON’T conflate NF1 and NF2 – they are two different diseases on two totally different genes. That was lost on me until this elective.
Expectations for medical students
Any trainee who is not a fellow (ie med students, peds residents) are not expected to write notes or place orders. I confirmed this with the fellows. Do not ask me why, just sit back and learn.
I volunteered to write notes in some circumstances (ie cases I really wanted to be involved with and learn from, in my case that was inherited cancer predispositions but choose your own adventure).
Patient Case Load
Shadowed for 1-4 patients per half day.
Common conditions
Marfan syndrome
muscular dystrophies
NF1
schwannomatosis (NF2)
osteogenesis imperfecta
galactosemia
trisomies
hereditary cancer predisposition syndromes - BRCA, Lynch, Li-Fraumeni