1. Tips and Tricks for Internal Medicine and Family Medicine
Intro to Clinics
Tips and Tricks for Internal Medicine and Family Medicine

2. From Your Upper Classmen Friends
It all became worth it when…
“...When I had the chance to work with one of the best, most caring physicians that I encountered in medical school, following him from his solitary private practice to the hospital several times each day, where he cared for his patients’ both acute and chronic concerns and addressed their needs completely.”
“...When I got the chance to bring in the son of my patient with dementia, and ask him about how he was doing as a caregiver and what we could do for him. He told me no one had ever asked him that before.”

3. What should you buy? Essentials: USMLEWORLD!!! Step Up to Medicine
Kaplan Step 2CK Book
Pocket Medicine
Penlight / Stethoscope light
Pens, snacks (Clifbars, etc)
Case Files
Smart phone: Epocrates, some med calc software

4. What should you buy? Non-Essentials: Maxwell Cards Reflex Hammer
Pretest

5. What goes in all these pockets
Pocket Medicine
Maxwell Cards (if you want)
Reflex hammer (again, somewhat optional)
Papers: H&Ps, signout, articles
PDA
Penlight
Lots of pens
ABG kit, tape, etc (maybe…)

6. General Useful Shorthand

7. Advice: On Imaging

8. Computer Systems Coast: Check your team, call schedule, etc
Username: ahupuser; password ahupuser
Just type “coast” into the address bar of any Penn Comp
Penn Access Manager --> Link all your signons
Sunrise: All orders; most results --> be the first to know! Flag orders!
Signout: ask your interns/residents if they want you to update. Some do, some don’t. Ask first!
Epic
Medview
Extranet: Log onto Medview from Home
UpToDate from home

9. Sunrise
A good way to figure out what happened overnight if you don’t hear signout. You can see what orders were placed
Where you can see patients’ labs and studies. Cardiology studies (ECHOs), EEGs, and some special radiology may only be available on MedView
The Sign-Out: Don’t touch unless you’ve asked, but a great way to keep track of the patients overall clinical picture and To-Do list: CHECK OFTEN
These are where you can find vitals and other things like Is/Os
The MAR: where you can check what pills nursing has given, when the next scheduled dose is

10. More Sunrise
How to be in the know!

11. Computer Systems: Intranet

12. Structure of Team Attending Fellow (on sub-specialty services)
Resident
Two Interns (occasionally 1 intern + 1 sub-I)
You (with perhaps another 200 student)
Nurses
Other staff: Social worker, PT, OT, CNA (Certified Nursing Assistant), Case Manager, Floor clerk, Phlebotomist, etc

13. Typical Day Pre-Rounds: Rounds Work Time Call
Go see your patients, learn about o/n events, check vitals and lab --> get ready to present
Rounds
Work Time
Calling consults
Getting outside records (**ways to make your intern love you**)!
Call
Where you pick up patients and do H&Ps

14. Advice: On Vitals Bad: Vitals? What vitals?
Good:BP 134/86, HR 72, RR18  
Better:BP /75-92, HR 73-87, RR15-22  
Best: BP 120s-140s/70s-90s, HR 70s-90s.. You get the idea

15. Patient Presentations
Be methodical and thorough with history & exam
In order, same way every time, go back if needed
At least at the beginning, write it out (Type!)
Know everything, but only say what you actually think is important
Think about your assessment as a thesis (ie you think the patient has a pneumonia flare), include any aspects of the H&P, Labs, Imaging that support your thesis
Be prepared to answer other questions
Know the normal values for any labs you state
Follow-Up Presentations: SOAP

16. Topic Presentations
Start with a summary source: UpToDate, NEJM, American Family Physican
Be focused --> brevity is the soul of wit here more than ever
Make a handout, but say more than is on the handout
Incorporate actual evidence (use UpToDate or review)
End strong: Zinger, 3 take-away points

17. Your Greatest Fear … The Shelf!
Find your own studying style
Our basic suggestion: Read StepUp as quickly as possible --> familiarize yourself with the diseases, vocabulary, etc
Questions, Questions, Questions U SMLE!!!! Try to do all the questions, but there are a TON so don’t worry if you don’t do all, but definitely have that as your goal
Know: Common presenting symptoms, Best diagnostic tests, Treatment
Use Family Medicine time wisely

18. Attire
My basic approach: Never give anyone a reason to dislike you or judge you
Assume nothing: Wear nice clothes + white coat as baseline
For call days, ask your resident about scrubs
Cell Phone etiquette: People will assume you’re texting or goofing off.
Always on vibrate
Never use on rounds --> announce exceptions loudly

19. Feedback Ask for it from Attendings / Residents
Attendings like to be asked proactively for feedback, midway through your time with them
Residents are more likely to offer real, constructive feedback to help you improve
ASK SPECIFICS: ie, I’m really working on making my presentations concise and to the point, do you have any feedback for me on that or suggestions for how I could continue to improve? That way you can do something very concrete and they can say in their evals that you used feedback to improve!

20. Family Medicine
You will be placed at an outpatient practice… some will have residents, but in most you will work directly with the attending
Be ready to get thrown into seeing patients
Your H&Ps will be less thorough than in the hospital.
Be “problem” oriented and try to help the patient identify the biggest “problem”… Some will come in with many issues that you may not be able to address in one visit

21. Family Medicine: What to Review
Look over the last chapter in Step Up to Medicine before beginning the rotation
Know Framingham Risk calculation
Review musculoskeletal exams – knee, shoulder (will need this for the exam too)
Some practices will see more ob-gyn than others… if you feel like you are seeing a fair amount of OB, may be helpful to review the prenatal/postnatal care section of an OB-GYN book

22. Family Medicine Exam
One component is preforming a joint (shoulder or knee) exam on a standardized patient
The other component is a multiple choice test based on the computer modules you are required to do
The test is somewhat detail-oriented and less big- picture. Do not skip over the sections about cultural competency in the online cases… they can be tested (know the latino principals of respecto… etc)
Review all the guidelines presented in the online modules – like when to do pap smears, stress test, etc

23. Staying Sane Biggest challenges Tim’s Solution:
Schedule
Interpersonal work load
Not seeing your friends
Tim’s Solution:
Institutionalize time with those you care most about
Don’t let your empathy get fatigued! Taking an extra moment to listen to your patient is a good way to improve patient care, help your team, and make the experience more fulfilling for you!

24. Random Go to Intern Report --> good learning and good eating
When your resident tells you to leave, leave! ␣
Always be on time
Have fun

25. Advice: On Clinic Grades
The Three A’s:
Affability (enthusiasm for everything!)
Availability
Ability

26. Support Systems Suite 100: - JoMo, Barb, Helene
- Tutors set up through suite 100
Organized counseling:
- CAPS:
- Therapists in the community (Barb from Student Affairs can provide names and contact info)
- Paired mentoring: SNMA, LMSA, Elizabeth Blackwell, House mentors
Other people to turn to:
- Doctoring preceptors
- Advisory deans
- Clerkship directors (it’s really ok to talk to them!)
- Mentors you have connected with in pre-clinical years (through clinics, volunteering, etc)
- Friends and family outside of medicine

27. Supplemental Stuff UpToDate from Home
Access the hospital's Extranet at
Use your MedView username / password to log in
Create a bookmark on your home page for UpToDate
Click on the "+" that's on the far right side of the "Web Bookmarks" heading
Name your bookmark and put this URL in the URL spot:
Click on new bookmark that's now on your home page
Use UpToDate like you would from on campus
HUP OR Schedule:
Homepage: Left hand side, click on Departments-->Perioperative Services-->OR Schedule. The user name and password are both hupor

28. Supplemental Stuff
Bug Drug: UPHS guidelines for anti-microbial therapy
Pulse:
Phonebooks for each hospital
#s for Consult services
Lots of assorted resources, guidelines, forms
Phone #s to store in your cell
Hospital operator
General lab