Shelf Prep: Guide to the Internal Medicine Clerkship 

 
Note: This guide describes a typical clerkship rotation 
implemented by many US medical schools.   
Your experience may vary. 
 
 
Welcome to your Internal Medicine Clerkship!  
Your time on the Internal Medicine Clerkship will be split between managing 
the care of patients in an inpatient unit and seeing patients in an outpatient 
setting. When working in an outpatient department, you will see patients 
who are scheduled for appointments at the doctor’s office, either at a private 
practice, hospital specialty clinic, or at a resident clinic. The inpatient side is 
usually the most complex environment, and often involves a balancing act 
that can be difficult, but extremely rewarding. While working on an inpatient 
unit, you will be part of the “Medical Teaching Service,” which is composed of 
an attending, senior resident, interns and occasionally a clinical pharmacist. 

Your Role on the Medical Teaching Service 

A single medical teaching service will have up to 20 patients. You will be 
following and receiving most of your lessons of the day from the attending 
and senior resident. They both oversee the team, and do not have as many 
notes to write as the team interns. 
  
You will start by carrying 2-3 patients at a time, and advance to 5 or more 
by the end of your 3​rd​ year of medical school.​ Many of the patients you take 
on will have complex pathophysiologies and you are expected to know as 
much detail about them as possible, especially since you can spend more 
time with them than the interns or the senior resident. Your team will 
appreciate your involvement and you will uncover information that others 
may miss. This builds greater trust and reliability, which translates into better 
evaluations and impressive remarks that go into your MSPE (Medical Student 
Performance Evaluation) for residency applications. Yes, your MSPE is a 
direct “copy/paste” of the comments written by faculty and residents in your 
clerkship evaluations. 
  
Once you have established which patients are yours, make sure to regularly 
check on them.​ Ask your Resident/Attending what their expectations are for: 
● Updates 
● Whether or not your notes need to be signed prior to rounds 
● Performing H&Ps upon an assigned patient’s admission 
● Performing summaries when a patient you’re following is discharged 
Understanding expectations early on will help avoid any conflicts. With a 
focus on patient care, teaching may not always be accomplished, but remain 
tactfully curious and inquisitive. If your team is coding a patient, wait until the 
acute situation has resolved before asking your medical questions. This 
demonstrates maturity and respect toward your team.  
 
Utilize each patient as a multisystem learning opportunity.​ A geriatric 
patient who presents with acute or chronic heart failure may also have acute 
kidney injury, liver disease, venous insufficiency, hypercholesterolemia, and 
ethical dilemmas. Understanding the interplay between these complex 
processes can give you a much deeper understanding of the pathologies. 
 
To keep your thoughts organized, begin by considering the chief complaint 
and reported positives and negatives.​ This should help you build broad 
differential diagnoses, utilizing the patient’s social history and pertinent 
family history as additional support. Study the diagnostic criteria for each 
diagnosis and the typical development of the pathophysiology. Is it acute or 
chronic? Did it develop insidiously or suddenly? Does it normally occur in 
younger or older adults? The typical Shelf exam question cares about “what 
you do next” or the “best first step.” It will not usually ask you to troubleshoot 
the situation if the first step is unsuccessful. This thought process is reserved 
for residency and your Step 3 exam. A good rule of thumb with respect to 
management is to be conservative and avoid invasive testing when possible. 
 
What you may see in practice does NOT always correlate with exam 
answers and it’s important to recognize this for your success.​ Insurance 
coverage does have an impact on medical decision-making when cost is an 
issue to the patient. Hence, it is not always the “best” possible treatments 
that are selected. In other instances, we simplify and reduce pill burden on 
patients who would otherwise be non-compliant. This cuts out medications 
that are dosed more than once a day. Patient rapport and reliance are also 
significant drivers of medical decisions. For example, you may see a patient 
who is at high risk for TB and has been non-compliant with multiple “no 
shows”. You may want to consider a TB Quantiferon test instead of the 
Mantoux skin test, because Quantiferon does not require a return to clinic 
for results to be obtained. 
  
Shelf tip:​ For your exams, assume that all presented patients are covered 
with an all-inclusive insurance, do not have any issues with medication 
compliance (unless they develop adverse effects), and are reliable. 
 
Early on during your clerkship, create a study schedule.​ This will ensure you 
have reviewed each of the main internal medicine subspecialties before your 
final 1-2 weeks. View the videos and complete the questions offered in Shelf 
Prep along the way and consider taking the practice NBME Medicine exams 
2-4 weeks before your exam to assess for areas of weakness and allow time 
for more intensive review leading up to your exam, if needed.