I cannot believe I am saying this: I just finished my fourth rotation ¡Adios Internal Medicine! Sayonara Family Medicine. Goodbye Surgery. I’ll miss you pediatrics!  MS3 is going by extremely quickly and as hard as this year is – one of my favorite internal medicine residents told me it’s “a year that requires grit”– I’m a bit sad that things are winding down.

Before third year set off, I spent a lot of time reading the advice of medical bloggers and anonymous med-redditers. I found this advice extremely helpful and I just wanted to share how I approached each clerkship.

MS3 is extremely different from MS1 and MS2. There is a delicate balance between preparation for the wards/clinics and preparation for the end-rotation shelf. It’s hard for me to give concrete advice about how to strike that balance. Believe me, it will get easier with time. In this post, I’ll share what resources made internal medicine, family medicine, and surgery survivable.

If you’re looking for more advice, these are some pretty great places to check out as well.

• Bloggers: Ben White, Jenny W, and Bhuvani.
• Reddit: tigecycline, FawnLeibowitz, and hiaips.

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Internal Medicine at TUSOM: Internal Medicine is a 8 week rotation split into two weeks on sub-specialty (you get to choose between hematology/oncology – !!! – cardiology, nephrology, infectious disease, and gastroenterology) and six weeks on the wards. While on sub-specialty, you have guaranteed weekends off (woo!) but on the wards things are completely different. Sub-specialty is at Tulane Hospital (some complete cardiology at University Medical Center aka UMC) and wards work is at either Tulane or UMC. Tulane has Q4 call and so you’re on call every fourth day. It’s atypical for a MS3 to carry more than 4 patients at a time. Didactics for this rotation include: weekly clerkship school (2-3 hours), weekly grand rounds (1 hour), and afternoon report (resident-led case session, ~ 45 minutes). Outside of the shelf examination and evaluations, you’re also responsible for submitting H&Ps, and observation forms (physical exam, history taking, discussion of assessment and plan), and a practical exam (EKGs/X-rays and approach to clinical diagnosis).

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On the Wards: Internal Medicine was my first rotation. This is NOT an easy rotation to start with but I will say that subsequent rotations (particularly family medicine and surgery) were easier to approach given that I had already completed internal medicine.

• Presentations: I have serious stage fright. Presentations were what I feared the most prior to the start of clerkships. You quickly get so used to presenting that it is no longer a big deal. The IM presentation is all-encompassing / formal. It’s always a good idea to ask your attending if he/she has preferences in regard to your presentation. Here’s how I structured mine for new patients. SOAP notes are more casual and include subjective updates + objective information (vitals and physical exam – if there are changes), assessment and plan.
  • One-liner: Jane Doe is a XX year old female with past medical history significant for XX who presents with a chief complaint of XX.
  • History of Present Illness: The story (given chronologically). Pertinent ROS. Any recent and important illnesses. Course in the ED.
  • Review of Systems: All ROS otherwise negative aside from what was mentioned in the HPI.
  • Past Medical History & Past Surgical History
  • Home Medications
  • Allergies
  • Social History: Home environment (location / apartment or house or mobile home / who lives at home). Alcohol intake. Tobacco use. Illicit drug use.
  • Family History: Pertinent family history.
  • Vitals: Tmax, HR, RR, BP, O2 sat (on room air or otherwise specified)
  • Physical Exam: General, HEENT, Throat, Respiratory, Cardiovascular, Abdomen, Extremities / MSK, Skin, Neuro, Psych.
  • Labs / Studies
  • Assessment & Plan
• Patient Tracking: Organization is the key to success. I figured out a system in which I could use one sheet of paper to keep track of one patient for about a week. Prior to that, I used this medicine scutsheet to keep my information on my patients in one place. Print this out double sided!
• Resources: If you have time between when you pick up a patient and when you have to present, UptoDate is a great place to do some reading and to find some pearls to throw into your assessment & plan and to prepare for pimp questions. Pocket Medicine (aka the purple book) is the best starting point for your plan.
  • In the Whitecoat: Maxwell Quick Medical Reference, Pocket Medicine, Reflex Hammer, Penlight, Sketchy Medicine Cards, and Stethoscope.

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In the Library : This rotation is unarguably exhausting. This shelf is unarguably challenging. Although you’re going to be tired from long days in the hospital, it’s important to study regularly.

• Textbook: I quickly realized that there was no way that I could get through the textbook I selected as my primary source – Step-Up to Medicine – and so I made sure to read every section relevant to patients I had picked up (I made it through about 70% of the book).
• Questions: UWORLD. UWORLD. UWORLD. There are a ton of questions and it’s difficult to get through all of them (I certainly didn’t) but there’s no better way to prepare. I recommend going through by organ system and flipping into tutor mode.

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If I could repeat the clerkship: I enjoyed this clerkship a lot (I enjoy inpatient medicine) but I definitely learned quite a lot about what resources work and which ones are not worth my time. I was a prolific Firecracker user MS1-MS2 but I didn’t find it as helpful for MS3.

• SIMPLE: I tried OnlineMedEd and couldn’t bring myself to really enjoy it. SIMPLE is a series of clinical cases with a video component that is organized in a way that makes way more sense to me. If you find that OME isn’t your jam, check this out!
• Lippincott Q&A Medicine: I have always loved Lippincott’s questions and used multiple question books from the brand 1st and 2nd year. I didn’t realize that Lippincott’s had shelf material until my 4th rotation (whomp). This book is small enough to fit in your white coat pocket so it’s the study perfect aid when you have down time on the wards.
• NMS Medicine Casebook: As I mentioned before, I used Step-Up to Medicine as my textbook. Great book but more of a reference guide than a book that one can reasonably get through 1x let alone 2x. I used NMS Surgery Casebook on my surgery rotation and it really helped me gear up for “what is the next step” focused questions on shelf. I think the NMS Medicine Casebook could have helped made my preparation for the medicine shelf less stressful.

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Family Medicine at TUSOM: Family Medicine is a 6 week clerkship for us at Tulane. For those of us without children or pets, placement is almost guaranteed to be outside of New Orleans. I had the opportunity to work in Rayville, Louisiana (45 minutes outside of my hometown of Monroe).

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In the Clinic: Outpatient work is less formal compared to inpatient work. Things are a lot more casual and since it’s a one-on-one dynamic it really seems like casual tutelage, which I appreciated. Some preceptors will give you the opportunity to draw blood, give vaccinations, and do other small procedures. Take advantage of this!

• Presentations: Outpatient clinics are high volume so there is really no time for long-drawn out presentations. I asked my preceptor how he wanted me to structure presentations and he just told me to keep it concise… So here’s how I structured my presentations. This is a good rotation during which to learn how to present without relying heavily on written notes.
  • One-liner: Jane Doe is a XX year old female, (new or established) patient who has # concerns today.
  • Concern #1: The story (given chronologically) about the situation.
  • Concern #2: …
  • Home Medications: As per previous visits; I reviewed home medications and updated any changes in the EMR.
  • Vitals: Tmax, HR, RR, BP, O2 sat (on room air or otherwise specified)
  • Physical Exam: General, HEENT, Throat, Respiratory, Cardiovascular, Abdomen, Extremities / MSK, Skin, Neuro, Psych.
  • Assessment & Plan
• Patient Tracking: My preceptor had me write up the notes on the patients I saw and so I documented in the EMR as I spoke with the patients. For days when the EMR was down, I kept all of my notes on my patients in my WhiteCoat Clipboard. Such a lifesaver. 10/10 recommend.
• Resources: I kept Pocket Primary Care on hand so that I could quickly come up with a plan. I preferred Pocket Primary Care to Pocket Medicine on this rotation since there is a lot of information on management of diabetes and hypertension – common problems in a family medicine clinic.
  • In the Whitecoat: Maxwell Quick Medical Reference, Pocket Primary Care, Reflex Hammer, Penlight, and Stethoscope.

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In the Library : This shelf is notoriously difficult and that’s because there’s not a lot of information floating around regarding how to prepare and because the field of family medicine is so broad. There’s quite a bit of overlap with internal medicine in addition to some pediatrics and OB/GYN. I know…it’s a lot.

• Textbook: I think it’s extremely important to learn the USPSTF A and B recommendations. Know them cold! I also made sure to read the dermatology and
  • Case Files: Family Medicine: Comprehensive book but I came to realize that I’m just not a huge fan of the Case Files setup so I can’t really recommend it as a resource.
  • Crush Step 2: I read the OB, GYN, and Pediatrics sections in Crush Step 2.
• Questions: I primarily used the AAFP question bank. If you plan to use this question bank, make your account a week prior to the start of the rotation. You have to be approved prior to getting into the question bank.  I also did a lot of the USMLE Rx questions.

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If I could repeat the clerkship: I can’t say this enough but I wouldn’t have worked through the AAFP question bank. I found the musculoskeletal questions to be helpful but a lot of the material was just too random or out of scope for a shelf examination.

• fmCASES: I was still dabbling with OME at this time. fmCASES is similar to SIMPLE (for internal medicine). I think fmCASES could have been a good resource to break up questions and textbook reading.
• Exam Guru Family Medicine Shelf: Given that the family medicine shelf is relatively new, there aren’t a myriad of practice NBMEs. Exam Guru has received high praise for quality questions so if you’re looking for more practice, this could be a good starting point.
• UVA Family Medicine QBank: Excellent question bank that I didn’t get a chance to completely work through. I recommend this over AAFP.
• Swanson’s Family Medicine Review: A Problem-Oriented Approach: I honestly think the AAFP question bank is not worth the hype. Seriously. Believe me. I wish that I spent more time going through material in an organized way. I think Swanson’s could have easily replaced my combination of Case Files + Crush Step 2 + AAFP.

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Surgery at TUSOM: The surgery clerkship is 8 weeks for us at Tulane. There are a TON of sites for placement. Some at academic centers and some at private hospitals. I spent a month on general surgery in Thibodaux, Louisiana and a month on surgical oncology + general in New Orleans. It was really cool to see how life as a surgeon can vary depending on hospital affiliation. Aside from evaluations and the shelf, we had an OSCE, principles of surgery examination, H&Ps, and observed procedures.

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In the OR: I’ll be honest: it’s difficult to be useful on this rotation. There are minimal ways to be extremely useful in the OR and there aren’t a TON ton of opportunities to present/demonstrate your intelligence. It’s really important to remain engaged even if you’re like me and aren’t a huge fan of the OR.

• Presentations: Keep them brief and focused. I learned when I did outpatient surgery (two weeks before I started my surgical clerkship) that surgeons really appreciate a concise presentation. One of my attendings told me that a HPI should be 3 sentences MAX. For SOAP notes on post-operative patients, be sure to mention what post-op day (POD) you patient is (e.g. Jane Doe is a XX female status post (s/p) robotic colectomy POD #1).
  • One liner: Jane Doe is a XX year old female with past medical history significant for XX who presents with a chief complaint of XX.
  • History of Present Illness: 3 sentences or so.
  • Review of Systems: All ROS otherwise negative aside from what was mentioned in the HPI.
  • Past Medical History and Past Surgical History:  Note if the surgery is laparoscopic or open.
  • Home Medications: Report class of medications and give specific names only if requested.
  • Allergies
  • Social History: Report current or previous tobacco use.
  • Family History: Pertinent family history. +/- family anesthesia reaction
  • Vitals: Tmax, HR, RR, BP, O2 sat (on room air or otherwise specified)
  • Physical Exam: General, HEENT, Throat, Respiratory, Cardiovascular, Abdomen (pay attention to any previous incisions), Extremities / MSK, Skin, Neuro, Psych. — Report only positive findings. Always mention cardiovascular, respiratory, and abdomen.
  • Labs / Studies
  • Assessment & Plan
• Patient Tracking: Vitals (particularly I&Os) are really important to have on hand on each of your patients. I used the Surgery Pre-round Scutsheet to stay organized.
• Resources: Surgeons are notorious for pimp questions. I found Surgical Recall to be a good resource in order to get the basics down for procedures I hadn’t seen before. Keep in mind that Surgical Recall is not particularly high-yield for shelf.
  • In the Whitecoat: Maxwell Quick Medical Reference, Pocket Surgery, Reflex Hammer, Penlight, and Stethoscope.

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In the Library : The surgery shelf is basically a medicine shelf with more focus on GI.

• Textbook: I used two textbooks this rotation (they have a very different setup). I loved Surgery: A Case Based Clinical Review. Really systematic book organized by case presentation. I managed to read through the book 2X. I found it unnecessary to review any of my internal medicine notes because this book is so comprehensive. I can’t recommend it enough. I also used NMS Surgery Casebook because it is structured in a “what should you do next” fashion (and that’s how a lot of the shelf questions are structured). Dr. Pestana’s Surgery Notes: Top 180 Vignettes for the Surgical Wards are a really amazing quick review of the most common vignettes on the shelf. I’d recommend reading through it 2-3X. It’s really short!
• Questions: There are less than 200 questions on UWORLD and I felt as though the questions weren’t as similar to those on the shelf as compared to the ~250 questions in Surgery: A Case Based Clinical Review.

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If I could repeat the clerkship: That would be such a nightmare for me. I do not think I could survive another 8 weeks but here are a few resources I wish I knew about / utilized more.

• WISEMD: I took a peek at these the week of my shelf examination. If you wanna hear someone talk about surgical cases, this is definitely a good resource!
• Shelf-Life Surgery: I discovered the Shelf-Life series when I was on pediatrics and loved it! Given that there are so few UWORLD questions for surgery, this could have been a good resource.