Medicine

Students will be choosing between BMC and the VA as sites for the medicine rotation. If you are selected to rotate at BMC, your 12-week rotation will be divided into a 4 week block, a 3 week block and another 4 week block in that order, with one week vacation afterwards. Two of the blocks will be spent doing inpatient medicine while the third will be spent in an outpatient setting (i.e., CCHERS, ACC Clinics, Lowell VA, DOB Clinic, and Roger Williams in Rhode Island.)

The medicine rotation at HAC provides the student with exposure to a wide variety of disease entities. The patient population is ethnically quite diverse as well, representing many different cultures. Students are expected to pre-round on their patients at 7:00 AM and be ready for work rounds at 7:30 AM. Rounds generally last approximately 2 hours during which students present their patients and the resident conducts informal teaching sessions. These sessions can be valuable, and you will be surprised how much a good resident can teach you in 5 minutes. Be prepared for light pimping on your patients, but pay close attention because your resident may frequently turn to you and ask questions on another patient. Every morning at 9:30 AM the residents have morning report, and students are sometimes welcomed but rarely encouraged to attend. Many students felt they learned a lot from these sessions if they had the time to attend, but you time is better spent doing work for your patients, i.e. calling consults, writing notes. Attending rounds are usually on Monday, Wednesday, and Friday from 10:30AM-12:00 PM. The attendings at BMC are generally very good about teaching. Be prepared to present an interesting patient you recently admitted or to give a brief talk on a predetermined topic. This is an opportunity for you to shine. There are also twice-weekly clinical problem solving sessions, physical diagnosis rounds, and professor rounds that have now been integrated for students at both HAC and ENC. There are noon conferences (with food) every day that are shared by both sides, with the exception of Firm Conference on Wednesdays (still with food), and Interns Conference on Tuesday (ONLY for interns). If you have time and your work is done, you should go, but realize that these conferences (again with the exception of Firm Conference) are geared toward residents and interns.

Students do not take overnight call and take call with their teams. The teams admit three out of four days. Your particular hours depend on the patient volume, resident, and attending. Dr. Levin, the Clerkship Director at HAC, says that students should be able to leave weeknights by 6:00 or 6:30 p.m. and Saturdays by noon, but this is highly variable. Dr. Hershman insists that one weekend day off should be expected every weekend. So if your team is on call Sunday, you have Saturday off. If your team is not on call over the weekend, you should still expect to come in on one weekend morning to write notes on your patients, since notes need to be written on patients six days a week. Try to pick up at least one patient each time you are on call. Do not make the mistake of picking up four or five patients, just to impress the resident, because you will spend a lot of time filling out paperwork and not enough time learning about their particular conditions. Students at BMC are required to keep a log of their patients and to plot the natural history of a particular disease.

The exam in this rotation contributes little to your grade, but that does not mean you should not study for the exam. You need to balance your clinical responsibilities with your studying, but realize that nothing looks worse than having your resident or intern always having to wonder where you are.

The medicine clerkship at ENC is logistically very similar to that at HAC. One difference is the ancillary services. This means that when you are at ENC you will write orders for a blood draw; whereas at HAC you will actually have to fill out the paperwork, send it to the lab the night before and hope that it gets done (meaning that you often have to draw blood from patients yourself). However, you will become very skilled at venipuncture anyway. Dr. Hershman, the clerkship director at ENC, is superb and is strength of the clerkship at this site. There is no overnight call.

You will have two blocks of inpatient care and one block of outpatient care - Ambulatory Day Treatment Center at the VA (ADTC). In the ADTC, you will see one patient per day and present them at teaching rounds the next morning. There is free food on the wards. Overall, the strength of the VA is the fact that the patients are generally pretty sick, need lots of care, and you are integral part of the team. The patients also stay in the hospital much longer than at conventional hospitals, so you can see the course of their disease and treatment. Medicine is very much resident dependent and resident-run. If you have a resident who is interested in teaching and is well-organized, you will learn a lot. Dr. Caslowitz does a great job coordinating teaching sessions, and you should attend all of his sessions.

The patients at the VA are also generally good for students to work with because they are used to having students work on them and tend to be very patient and appreciative. Where else can you learn how to become a great phlebotomist and be proficient in doing prostate exams.

The experience at the VA was the best part of the internal medicine clerkship. Dr. Joel Caslowitz, who is the student coordinator at the VA, does an outstanding job teaching pathophysiology of many of the common disease processes. He meets with all of the students on M/W/F. On Monday, Dr. Caslowitz usually discusses a particular topic ranging from EKG interpretation to fluid and electrolyte balance. The Wednesday discussion is centered on several case studies. There are 2-3 case studies per discussion and focuses on one of the internal medicine subspecialties. There is also a case study discussion on Thursday that is conducted by one of the two chief residents assigned to the VA. On Fridays, one of the third year students will present a patient case encountered on the wards. The student assigned on that week will present the case and write the relevant problem list on the board. A discussion of the problem would follow. The learning curve for these discussions is very steep. Almost every student who has been assigned to the VA enjoyed these discussions and found the breadth and depth of Dr. Caslowitz’s knowledge to be quite impressive.

Do not be fooled into thinking that you will be spared going to the Lowell VA because you did the rest of your Medicine rotation at BMC. The absolute worst part of this experience is the commute (over the course of the month, you drive > 1000 miles…). Lowell is located 45-60 minutes away, somewhere North of Boston—which means that you will be going in the direction of traffic. The return trip is the worst, and I strongly advise finding an alternative to I-93 (explore Rt. 28).

There are some perks of this rotation. On your first day, you will find that you have your own office with its own exam table and supplies, phone, desk, and computer. The computer operates on the VA system. The schedule is pretty much 9-5, with mornings consisting of seeing established or follow-up patients on your own and presenting to one of the attendings, and afternoons consisting of seeing a new patient. The morning patients usually fit the profile of the standard VA patient, and your exam is geared toward their complaints: blood pressure, weight, diabetic feet, and prostate exams. Preventive care (safety, immunizations, smoking cessation, health maintenance) is emphasized. The afternoon patients are what made my days unbearable. They are new to the VA system, and usually want VA care so they can get their current medications for free. These patients require an extensive history and physical exam. If they are over forty, they also get an EKG and a rectal exam. All patients require bloodwork, which you obtain…however, these patients generally have good, easy veins. The afternoon patient usually arrives around 1 PM, and stays with him until 4 or 4:30 PM. The new patient was the second worst part of this rotation. You become SO tired of obtaining the H&P and then typing it up.

The director of this rotation is Dr. Kleinman, who is a BU grad. He is very nice, a good physician, and a good friend to his patients. Dr. Wolf is the director of the clinic, and his bedside manner is not as polished as Dr. Kleinman’s. He is also somewhat eccentric. The VA clinic is relatively new and very modern. All of the people who work there are very nice. The patients are generally very friendly and appreciative. However, they are still VA patients, and as a female, I got very tired of being mistaken for a nurse or nursing student (would a nurse ever have her finger up a patient’s…?). Also, this is your only taste of outpatient medicine, and a significant part of the general population (i.e. women) is missing.

One last thought: always remember to bring your lunch. There is no cafeteria in the clinic, and there aren’t too many places to eat nearby.

There are great things and not so great things about Roger Williams. First of all, practically everyone agrees that the experience there is what you make of it. The inpatient team is made up of one resident and one intern. There are six teams and two will have one medical student apiece. Therefore, you have no worries about competition and you are free to pick up whichever patients you want. Patients tend to be older and from nursing homes. The housestaff is very excited about teaching students. Dr. Macko is the coordinator of the rotation and he is very accessible and eager to help you. Dr. Macko runs the once-a-week EKG sessions that, for some students, made life a lot easier.

Roger Williams is in Rhode Island, you can stay in the nearby houses provided by the hospital.