Clerkship Objectives and Expectations
Twelve Week Program
Students at the Beth Israel Deaconess Medical Center will be introduced to
the whole range of experiences that internists encounter on both general
medical wards and general medical and subspecialty ambulatory settings.
Eight Weeks in One of Four General Medicine Firms
The clerkship is designed so that students will acquire skills necessary to
evaluate and manage common problems in internal medicine. To gain these
skills, students will spend eight weeks on one of four general medicine
firms, admitting patients on alternating long-call and short-call days. A
special effort will be made to give students a varied experience, and there
will be great flexibility in choosing admissions for student evaluation.
In addition whenever possible, students will see patients first, with
adequate time allocated to take complete histories, to perform complete
physical exams, to discuss patients' problems with intern and resident, to
write complete admission notes, and to seek out information about patients'
problems in relevant textbooks and peer-reviewed literature.
Four Weeks in the Ambulatory Setting
In addition to eight weeks on the wards, each student will spend four weeks
in the ambulatory setting. During this component of the course, students
will be paired with a primary care faculty preceptor. Each student will
have a continuity preceptor with whom the student will work two half-days
per week throughout the four-week block.
Students will also rotate through several medical subspecialties (three
half-day sessions each week), dermatology (one half-day sessions each
week), and ophthalmology (one four-hour session per block). As much as
possible in all of these sessions, the student will have the opportunity to
perform problem-oriented history and physical exams, to review each
encounter with a faculty preceptor, to develop a differential diagnosis,
and to devise an evaluation and treatment plan.
This comprehensive, balanced experience should prepare students to handle
medically diverse issues inside and outside the hospital setting, while
enabling students to deal with subsequent clerkship rotations and
Information and Skills Acquired During Clerkship
Students will be expected to:
Take a thorough history
Perform a detailed and accurate physical exam
Formulate a thoughtful differential diagnosis
Design a plan of evaluation of their patients' clinical problems
Develop skills in presenting their patients' problems lucidly to
It is hoped that these experiences will foster growth in each student's
clinical judgment while consolidating development of sophisticated
approaches to both simple and complex medical problems. By the end of the
12-week clerkship, students will be expected to possess a broad working
knowledge and a thorough understanding of the pathophysiology and therapies
of basic, common problems in internal medicine.
Emphasis on Total Care of the Patient
Great emphasis is placed on the total care of the patient. With this in
mind, it is anticipated that students will acquire sensitivity to the whole
spectrum of a patient's encounter with illness, including psychological as
well as medical aspects of the patient's care.
Major Duties and Responsibilities
On inpatient rotation, students are considered an integral part of the
Firm's medical team, working closely with one intern and a team resident
under the supervision of the ward's Firm Chief and/or Associate Firm Chief
and two Co-Attending Physicians.
Students take admissions with their assigned team on an
every-other-day alternating schedule of "long" and "short" calls.
Students remain in hospital until 11:00pm on "long call" days
(every fourth night).
Students may pick up patients in the morning who were admitted by
night float on the “short call” days.
It is the student's duty and responsibility to work-up, evaluate,
present, and follow their admitted patients daily.
The total patient load for each student at any given time should
ideally number no less than two and no more than five patients.
Work-ups will be closely supervised by the team intern and
resident. Students will present their patients in each instance to
the Attending Physician, and at times to the ward's Firm Chief or
Associate Firm Chief.
Teaching is conducted at the bedside and in the conference room.
Students will have full responsibility for writing all orders and
progress notes on their patients, scheduling tests, arranging
consults, attending family meetings, and following their patients
in as close a manner as possible with the intern.
When students are not available to carry out these
responsibilities, students should be sure to review with their team
results of patient evaluations and pending items for further
On ambulatory rotation, students will work closely with a faculty member in
Students will see patients independently with their continuity
preceptor, present each case, and write notes summarizing each
Primary goals include learning to obtain a focused history,
physical exam, assessment and diagnostic plan in the time-limited
ambulatory setting, as well as evaluating patients with
undifferentiated complaints and formulating a differential
In all sessions, students will have the opportunity to review
patients seen and to discuss assessments and management plans with
their faculty preceptors.
Behavioral and Ethical Expectations
(e.g., confidentiality, discretion, patient interactions, attendance, dress
code, etc.) Students are expected to be present at all scheduled sessions
with preceptors and to be present at all scheduled student rounds and
lectures. Promptness is appreciated. It is expected that the students will
exercise careful judgment in their interactions with patients as well as
their medical colleagues.
Expected Preparation for Clerkship
Suggested Texts for Review
Prior to Clerkship:
Introductory Textbook of Electrocardiography or Goldberger's
During the Rotation:
Harrison's Principles and Practice of Internal Medicine; Cecil and
Loeb's Textbook of Internal Medicine; Branch's Office Practice of Medicine; Goroll's Primary Care Medicine.
Books to Purchase:
See above (optional).
Instruments to Purchase:
Teaching Modes Used During Rotation
Didactic Sessions for Medical Students Only
In the first month of the 3-month clerkship, students will attend sessions
by Dr. Mark Zeidel, the Chair of the Department of Medicine, and 3 EKG
lectures by Dr. Ary Goldberger.
On inpatient rotation, students will meet weekly as a group with Dr. John
Danziger and weekly as a group with Teaching Residents.
On inpatient rotation, students will meet weekly as a group with Dr. John
Danziger and weekly as a group with Teaching Residents.
On ambulatory rotation, students will meet one to two times a week as a
group in sessions conducted by Dr. Amy Weinstein and other ambulatory
faculty. Additionally on ambulatory rotation, students will attend
dermatology and ophthalmology lectures, organized by Drs. Harley Haynes and
Didactic Conferences for Residents and Medical Students
Medical House staff and Students on Rotation
Two weekly lecture series, Primary Care Conference and Thorndike Rounds,
are designed specifically for medical house staff and students on rotation.
Both lecture series cover a broad spectrum of topics in internal medicine
and other disciplines germane to the practicing internist. Invited speakers
are BIDMC and other Harvard Medical School faculty who are considered
experts in their fields.
Junior and Senior Residents
Junior and senior residents attend "residents' report" daily, and interns
attend "interns' report" twice weekly. Cases are reviewed and discussed by
the Chief Medical Residents with a focus on evidence-based medicine.
Students are invited to attend interns' report.
Department Conferences for Faculty, Residents and Medical Students
A weekly Firm Conference (conducted by ward Firm Chiefs or Associate Firm
Chiefs) bring together hospital faculty, residents and medical students to
discuss patient cases addressing challenging diagnostic, evaluative and
medical management issues.
Medical Grand Rounds
The department's weekly Medical Grand Rounds lectures cover a broad range
of timely and clinically-important topics. Speakers are drawn from BIDMC,
Harvard Medical School and other regional and national institutions. Along
with named lectureships, Medical Grand Rounds includes the BIDMC-Annals of
Internal Medicine “Beyond the Guidelines” series, which uses a case-based
approach to address questions related to new clinical guidelines.
M&M (Morbidity and Mortality)
Morbidity and Mortality or M&M is an educational conference that takes
place weekly on Tuesday mornings. The Chief Medical Residents review a
recent case with medical errors, complications or unintended outcomes to
improve the quality of care provided to patients at BIDMC.
Two faculty members assigned to co-attend for one month on one of four
inpatient general medicine Firms conduct teaching rounds with the Firm's
medical students and house staff four times weekly and accompany the Firm's
teams on work rounds at the bedside once weekly. Separate medical student
sessions are scheduled with the teaching attendings three times weekly.
Once weekly, the Firm Chief or Associate Firm Chief conducts teaching
rounds with the Firm's medical students and house staff. Firm Chiefs and
Associate Firm Chiefs for the 4 general medical Firms are: Blumgart (Drs.
Wendy Stead and William Aird), Kurland (Drs. James Heffernan and John
Doweiko), Robinson (Drs. Robert Shmerling and John Butter), Tullis (Drs.
Sanjiv Chopra, Deepa Rangachari).
Once weekly, the Firm Chief or Associate Firm Chief conducts bedside "walk
rounds" with the firm's junior and senior residents and medical students.
Additional Conferences for Inpatient Medical Teams
Department of Radiology staff members conduct radiology conferences twice a
month during afternoon attending rounds. These conferences provide
important opportunities to review radiographic exams obtained on
hospitalized patients and to perform clinicoradiographic correlations.
Ambulatory Preceptor Sessions
Faculty members in general medicine, subspecialty medicine, dermatology and
ophthalmology precept students rotating through these various ambulatory
To enhance understanding of subjects discussed at conferences and in
teaching rounds, students are expected to read relevant textbooks and
current peer-reviewed literature. In addition to reading materials
suggested and/or distributed by residents and faculty, students will have
unlimited access to literature search programs and various internet web
sites. The Shapiro Institute for Education and Research provides additional
On inpatient rotation, students will present their cases on work rounds and
at radiology conferences daily, at co-attending rounds two to three times
weekly, and on occasion at Firm conference. On ambulatory rotation,
students will present many cases daily, for students will be evaluating a
number of patients during each outpatient session.
Expectations of Residents and Attendings as Teachers
Role of the Intern
Interns play an important teaching role in the following areas: They assist
with teaching students how to write orders, arrange testings and consults,
and find and interpret lab and study results. They discuss on a daily basis
management issues relating to jointly managed patients. They read, correct,
and countersign students' daily progress notes. And they contribute to
case-related teaching that occurs on work rounds, Attending rounds, etc.
Role of the Resident
Residents review the expectations of the student on the ward service and
set expectations that are unique to the service and to the resident's
teaching style. Residents are expected to engage in case-based teaching
surrounding each of the patients admitted by the student. This entails
ensuring adequate data collection by the student; reviewing the student's
understanding of each problem and the plan for work-up and management;
reviewing the student's admission write-ups; "coaching" the student's case
presentations, customized for various educational and conference settings;
and assisting the student with development of a knowledge base.
Residents are also expected to provide immediate and on-going feedback,
both good and bad.
Residents should meet at least with the student, in the middle and at the
end of the resident's time with the student, to review expectations,
progress, problem areas and plans for improvement.
Role of the Attending
Attendings are expected to meet separately with students twice weekly to
hear case presentations, review write-ups, and provide feedback. It is the
Attending's responsibility to provide mid-course, and end-of-rotation
student feedback and evaluation.
Number of students on rotation?
24 maximum; 4 minimum.
Do students work with partners?
No. However, while on inpatient rotation, two students may be assigned to
each Firm team (see below), with each student working with one of the two
Do students work with a teaching resident?
Yes, in weekly group sessions while on inpatient medicine.
Is there a centralized education office at the hospital?
What is the division of time among services?
( e.g., wards, emergency room, CCU, etc.)
Eight (8) weeks are spent on the medical wards (Firms), and four (4) weeks
are spent in the ambulatory setting. All students spend the first 4 weeks
of the clerkship on inpatient medicine. Thereafter, the student group
divides in half, each half rotating on inpatient medicine or ambulatory
medicine in either the 5th- through 8th- or the 9th- through 12th-week
block of the course.
Required "on-call" schedule and duration of "on-call" at the hospital:
Students are on-call, staying until the late evening every fourth night.
2 Interns and 1 Assistant Resident (either junior or senior) comprise the
"long-call" team. No more than 2 students will be assigned to a single
team. Since each general medicine Firm has two teams, no more than 4
medical students will be assigned to a single Firm. Each Firm has 2
Co-Attending Physicians, 1 Firm Chief, and 1 Associate Firm Chief.
Interns, Residents, Co-Attending Physicians, Firm Chief, Associate Firm
Chief, Ambulatory Continuity and Sub-Specialty Preceptors, and Clerkship
(All of equal importance): Ability to do history and physical exam; ability
to do case presentations; ability to do differential diagnosis and
evaluation plan; fund of knowledge; and attitude, level of interest, and
Type of exams?
A mid-course exercise is administered to students, generally on Monday of
the sixth week of the course. Using blue-books, students are asked to
outline their approach to evaluation and management of one or two cases
illustrating basic medical problems that arise in common practice.
Formal feedback mechanism?
Feedback is available to students at any time upon request from residents,
attending physicians, and clerkship co-directors. In addition, formal
sessions are held mid-way through each month and at the end of each month,
with students meeting with attending physicians who have had direct
responsibility for the student's learning. At mid- and end-course, the
clerkship co-directors meet in sessions with each student to give composite
feedback received from all individuals with whom the student has worked
(Interns, Residents, Attendings, Firm Chief and Associate Firm Chief).
At the Beth Israel Deaconess Medical Center, we are very interested in
students learning and seeing a broad spectrum of internal medicine in a
relaxed and enjoyable atmosphere conducive to education. From the house
staff to the Chief of Medicine, the student clerkship has the highest
priority, and every effort will be made to insure that each individual is
given the opportunity to thrive to the greatest extent possible.