Internal Medicine Core - First Impression and the Mock CS Exam
Last week was the beginning of the 12 weeks of internal medicine (IM) core rotation. This rotation is one of the busier rotations of third year with time constraints and demands, and has already been filled with some amazing experiences. Internists are collectors of stories. There are so many different backgrounds of the patients, and some of them are very sick. Internists have to collect as much of the pertinent patient information as possible, sift through the details to ensure medical relevance, and hypothesize as to what is most and least likely plaguing the patient. This is true for a doctor in any specialty, but the internist is one specialist that has some of the broadest scope in terms of what they need to consider in their approach to the patient. My most relatable experience to IM is probably family medicine (FM), however I can sense a very different paradigm around the two disciplines. FM seems to involve more proactive and preventative medicine, whereas IM involves more reactive medicine and treating some of the sickest patients in our population. I really enjoy the thought processes involved in creating the differential, and the systematic approach via organ systems used in developing the differential.
The Schedule
The schedule for IM is different depending on the preceptor, and whether you are in an outpatient or inpatient setting.
For inpatient, some students might have to show up at 6:00 AM (or earlier if they need more time) to pre-round on their assigned patients before attending Morning Report where one of the new admits from the call shift is presented. Then, students will meet with their attendings and the residents for rounds, write progress notes or admission H&Ps depending on the patient, follow-up on patient's orders, and whatever else is needed to help support the team goals. Depending on if it is your inpatient service team's responsibility to stay for call that night, you may be at the hospital overnight or you might be done earlier in the day. I do not have my inpatient service (IMS group on your schedule) until my second month of the rotation so I cannot articulate the different schedules of inpatient quite yet but there are different days that revolve around the call shift. They're called long call, post call, short call, and no call days (and I believe they rotate in that order from what I've heard from other students but I could be completely wrong).
Outpatient is similar to other experiences that I have had so far, but one difference with this rotation is that my preceptor has his outpatient clinic hours and hospital admits. To me, this diversifies the day as we see patients in clinic from 9 to 5ish and then head to the hospital to round on admitted patients. I love having diversity in my day, not only in patient personalities but also practice settings (which is one reason why OBGYN is what I still really want to pursue). IM has its appeal by being everything I ever expected from traditional medicine with more. However, the practice focus of the IM is not what I envision for myself (and is probably answers a majority of my choice in discipline I want to pursue for matching in residency so no spoiler alerts quite yet).
The Studying
What a mess! This shelf exam is intended to cover everything in the body from an internal medicine approach. My impression is that I will be preparing myself as though my shelf exam is similar to taking STEP. There is a large volume of information to study (as the Becker resource alone has two volumes for Internal Medicine). This has been the first rotation where I have had to reassess my Cramfighter study plan based on the wide variety of resources I have access to and my judgement of the quality of the material. At present, I am reading Kaplan's USMLE Step 2 CK Internal Medicine lecture notes to supplement what I am going over with Doctors in Training lecture videos. I am also using my uWorld subscription to learn from the 1,300+ questions for internal medicine available in the qbank, and Becker GuideMD lectures for another pass through each organ system. One piece of advice I saw in my resource research for preparing for this shelf was to initially focus on the organ system you are studying for the questions that you are doing. This is helping me solidify the topics covered in the DIT videos, but is unlike my previous approach of doing random assortments of questions...I will likely follow this up in my post-shelf IM review post in 11 more weeks. Basically, plan early to create a study plan and stick to it if you are going to cover the information. I am not sure if I am being too 'type A' in preparing for this exam, but IM is one area where I want to be as well versed as possible as it will doubly prepare me for the USMLE Step 2 CK exam (which I will be registering for soon to take in April/May 2018).
Mock Step 2 Clinical Skills (CS) Exam
My school hosted a Mock USMLE Step 2 CS exam at Atlanta Medical Center where we used 15 minutes for H&P and 10 minutes to write note. After 3 patient encounters, we rotated back through the 3 rooms where we received 10 minutes of feedback per room from the Standardized Patients (SPs, who are Ross Jr. Faculty doctors that teach exam skills during IMF in Miramar). The experience was good overall for me to be able to gauge how prepared I am currently for an exam I intend to take in 4 to 5 months. I felt great about my performance, and was able to glean areas of opportunity to improve myself. One thing I plan to focus on in the next few months is practicing my physical exam skills avoiding unintended short-cuts I have begun to take (like only auscultating for a CVS or resp exam instead of also palpating or percussing).
One piece of feedback I have (which is not as negative as I first experienced it) is the feedback we received from the SPs was on the 'doom and gloom' side of criticism instead of being as constructive as it likely is intended to be. The exam has reported to be more rigorous starting 2018 in the grading schema to bolster the integrity of the exam in its intention of developing only the best and empathetic of doctors. My impression is that the SPs were erring on the intensive analysis of our performance, and some of the feedback seemed excessively nitpicky to an extent. Originally I took this as a negative because I felt great about my patient encounters yesterday, and as thought I did better than I expected and had improved when compared to my OSCE exam six months ago in IMF.
However, after the feedback I felt that I was no better at patient encounters than when we had our clinical patient experiences on island and had this impression that I may have regressed or something in my skills differential development. Most likely, the critical nature of the feedback led to some excessive negative internalization of my performance and is why I left the experience with an unsettled feeling. After some introspection regarding the mock exam, I realize that the subjectivity of the feedback is a great reflection of how our patient perspective of our performance sometimes does not mirror the internal sentiments we may have about our performance during an encounter. Today, I am thankful for the experience and the feedback has led me to plan for more focused preparation for the CS exam and has helped me realign my intermediate goals to prepare for my next round of Step exams. I think everyone benefits from staying humble, and analyzing one's self for areas of opportunity in how we can create better patient experiences.