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The Unofficial Clinical Clerkship Survival GuideUniversity of Louisville School of Medicine

Brought to you by the Class of 2016 Track Captains and the

Organization of Student Representatives (OSR)

AuthorsEric Kreps - General Information and Track Selection

Alexandra Healy - General Surgery

Eric Poulos - Internal Medicine

John Wehry - Neurology Anne Hayes - Elective

Chris Hamann - Obstetrics and Gynecology

Evan Rhea - Pediatrics

Gerald Cheadle - Family Medicine

Catey Harwell - Editor

Rudra Pampati - Editor

Allison M. Hunter - Editor

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Table Of Contents General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Parking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Food and Dining Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Scrubs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Evaluations and Shelf Exams . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Patient Tracking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Computer Access and Electronic Medical Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Prescription Writing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

White Coat Essentials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Professionalism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Third Year Track Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

8-week Clerkships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

6-week Clerkships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

General Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Internal Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Neurology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Elective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Obstetrics and Gynecology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Pediatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Family Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Values, Calculations, and Commonly Asked Topics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

General Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Internal Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Neurology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45


Pediatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Example Notes and Oral Presentations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

General Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Internal Medicine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Neurology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53


Pediatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Family Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

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The University of Louisville School of Medicine s Unofficial

Clinical Clerkship Survival Guide: General Information

By Eric Kreps

1

General Information

This section is entirely dedicated to the general information that spans all of your third year of medical school and is not

necessarily related to an individual clerkship. Topics include parking, on-campus free dining, attire, clerkship evaluations, shelf

exam, patient logs, etc. More specific information pertaining to each of the individual clerkships can be found under its own

section. Read at length or flip back for reference as questions arise!

Parking

University of Louisville Hospital

University Garage: If you have around $400 burning a hole in your pocket, go for renewing your parking pass to the

620 Garage, but keep in mind you may not be doing all of your rotations at University Hospital. This garage offers

1,711 parking spaces for faculty, staff, and students, and is ID card protected for safe access.

HSC Parking Office: 414 East Chestnut Street

Hours: 8:00am - 4:00 pm, Monday-Friday, Closed 1:00pm - 2:00pm for lunch

Phone: (502) 852-5111 Free Parking: Students often park along Muhammad Ali Blvd, starting at Clay St (in front of the 620 Garage) and

ending at Jackson St; there is also free street parking along S. Hancock, Marshall Street, and Clay St. Please be prudent

and keep safety in mind as you walk to and from your car during early morning and late night hours. On weekends,

there is free parking at the UL hospital garage (on the corner of S. Hancock and E. Madison St, next to the pedestrian

crosswalk). Metered parking is also available (most now payable by credit card). Metered spaces are free after 6PM

Monday – Saturday and all day Sunday.

Norton Hospital and Kosair Children’s Hospital:

Students get free parking at a lot adjacent to the L&N credit union (on the corner of

Chestnut St and 2nd

St) while on a rotation at these locations. Students on a rotation at

Kosair can obtain a pass for the hospital parking garage by going to the parking office on

the first floor of the Medical Towers South (the blue building on the right after you passNorton Hospital on the corner of Gray and Floyd Street, heading towards Broadway). Go

in the double doors that face Gray Street and go to the right, following signs directing

you to the Parking Office. Also, parking at Kosairs’s garage (214 Abraham Flexner Way )is

free on the weekends!

Jewish Hospital Garage:

Parking pass to the Jewish hospital garage (249 East Muhammad Ali Boulevard) can be obtained from the 5th

floor of the

Outpatient Care Center attached to the garage.

VA Hospital:

Parking is available in front of the VA Hospital. Good news: no passes needed! Bad news: many spaces are reserved for justpatients and the others fill up very quickly in the morning - it can be difficult to find a spot after 8:30AM! The best advice is

to get there early (before 7:50AM). You can park at the Ramada Inn on Zorn Avenue (numbered spots only) or at the

Lebanese American Supper Club parking lot off River Road behind the Ramada. A marked VA shuttle will arrive every 15 -

20 minutes to transport you to and from the VA Medical Center between 6:15AM and 6:00PM.

Escort Service: The UofL police department can pick you up from any on-campus location and escort you to your vehicle

within 4 blocks of campus if you call 502-852-6111. This is especially useful when it is late and you feel uncomfortable

walking to your car.

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Food and Dining Options

Eat for free! Each hospital has its own unique dining options, however this information covers the sustenance that is free of

charge only.

Jewish Hospital—Doctor’s lounge in the Rudd Heart and Lung center, 1st

floor. Serves continental breakfast, a full

lunch, as well as a soft drink and espresso machine. Don’t miss Taco Wednesd ays! Often, your resident will give you

their door code or let you in to get to the grub.

Norton Hospital—Doctor’s Lounge—2nd

floor Norton Hospital, across from escalators. A full breakfast and lunch are

served daily, with snacks available throughout the day. Relive your childhood dreams of chocolate milk with your

cereal. Badge access required, so have your resident let you in. Technically this is just for attendings, so opt to sit on

the couches and not at the tables if space is tight!

Kosair Hospital – Doctor’s Lounge – 1st

floor of Kosair’s; have your resident point it out, as it may be hidden. Your

badge should give you access to cereal, juice, fruit, peanut butter, crackers and a soda machine.

University Hospital—Although there are no meals provided, the pre-op doctors lounge does provide bagels and

donuts in the morning (they go quick!), as well as access to a soft drink machine (broken about 20% of the time). You

can almost always find at least peanut butter and crackers here or in pre-op when you are looking for quick food

between cases. While on inpatient wards, most patient floors have access to the nutrition room, stocked with milk,

ice cream, soda, peanut butter, and crackers.

Scrubs

In general, wearing scrubs is limited to time in the OR, on-call days for inpatient medicine and pediatrics, and on Labor and

Delivery during your OBGYN rotation. During L&D, it is recommended that you come to the hospital in business attire and

change into scrubs in the locker rooms (3rd

floor on L&D). It is always best to check with your resident teams about any dress

code for rounds. On Surgery, you should never wear scrubs to the Department of Surgery offices (2nd

floor ACB)—wear clinic

attire with your white coat. The location of scrubs will vary among locations and services, so check with your resident teams or

ask a nurse where you can find scrubs. Just a few pearls – be conservative with your scrubs; go a size up if you need to and

don’t be a hero. Ladies, small tops are hard to come by, so most prefer to wear a t-shirt or tank top underneath these oversized

scrub tops.

Evaluations and Shelf Exams

Evaluations:

The seemingly subjective evaluation of your clerkship performance is perhaps one of the most unique and important parts of

third year to understand. For the first time your grade depends not only on how well you study and perform on exams, but how

well you communicate, interact, and work as a member of a team. The intangibles of professionalism, emotional intelligence,

and reading social situations will come in handy. The mainstays of responsibility, hard work, and punctuality will serve you well,

so be on your best behavior and prepare to shine as you transition from the classroom to the clinic.

Clinical Evaluation of the Student:

Your student evaluation will be made up of one ungraded midclerkship evaluation and several graded clinical

evaluations.

First, you will be evaluated at the midpoint of each rotation (midclerkship evaluation). This consists of formal,

ungraded feedback from an attending using either a paper form or the tool on New Innovations (method is clerkship

specific). This is a way to gauge your performance before final graded evaluations, that way if there is significant room

for improvement, then you will have time to cover ground before it really counts!

The final evaluations at the end of the clerkship are graded and are the main component of your final clinical

evaluation grade. Keep in mind, that no matter how well you perform on your clinical evaluations, you cannot honor a

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clerkship without honoring the shelf exam. Both residents and attendings will evaluate you during each of your

rotations. You will be evaluated on the following:

Patient Care - Taking an effective history, physical exam skills, generating a differential diagnoses, creating a

problem list, generating a treatment plan

Medical Knowledge - Integration of basic sciences, application of clinical sciences) Interpersonal and Communication Skills - Spoken and written communication, oral presentation skills

Systems-Based Practice - Teamwork, skills in evidence-based medicine

Professionalism –Honor and integrity, responsibility and accountability, caring and compassion, and respect

Finally, your evaluator will have the opportunity to write “Overall Comments.” These comments will be the real meat

and potatoes of what appears in your Medical Student Performance Evaluation (MSPE) letter—a summary of your

overall clinical performance during each of your rotations as a third year. The MSPE letter is a large part of your

application for residency, so it is important that it reflects your true performance. These evaluations are completed

using New Innovations.

Evaluation pearls: Very rarely will a clinical evaluation keep a student from honoring—if you show up, work hard, and

are respectful, you should do just fine. If you are consistently not honoring because of your clinical evaluations (i.e.

honors on the shelf but not the clerkship), this is something worth talking about. Pediatrics tends to be a little more

difficult as their cutoff for clinical performance for honors is higher than most other clerkships.

Student Evaluation of the Rotation, Residents, and Attending:

Be sure to fill out your evaluations of the residents and attendings using New Innovations. You are often assigned

residents and attendings to evaluate at the end of your rotation-- constructive feedback (not overly negative) is

crucial to improving the experience for others. These evaluations are reviewed and can be used as a means for

positive change. Any serious issues or urgent concerns should be addressed sooner rather than later; utilize your

Track Captains, residents or anyone else you trust or to hear your concerns. Student mistreatment is taken very

seriously, so speak up should you feel uncertain or uncomfortable about an issue. Once the rotation ends, you will

receive an evaluation from Paul Klein to provide feedback on the rotation itself. This is a good time to offer up

suggestions to improve the way the clerkship operates (and it is anonymous!). Both the Clerkship Directors and the

Educational Policy Committee (EPC) review the survey results and comments to monitor the quality of the experience

and provide feedback for changes as needed.

Shelf Exams:

Each of the third-year clerkships concludes with a “shelf exam,” typically administered on the last morning of the clerkship. A

shelf exam is a clerkship-specific standardized test developed by the NBME that medical schools purchase to gauge how their

students perform on a national level. The exam is generally 2.5 hours long and consists of 100 questions. At the University of

Louisville, this exam is a generally a hefty portion of the final grade, ranging from 40-50%, depending on the clerkship, and is

graded on a curve with respect to percentiles. In order to receive honors for a clerkship you MUST receive a raw score

equivalent to the 75th

national percentile (which hovers around a raw score of 80-85/100) or above -- no exceptions. In essence,

you must honor the shelf to honor the rotation . A passing grade involves a raw score of greater than the 4th

percentile. If in the

course of your third year you fail a single shelf exam, you may retake that shelf exam. However, if you fail more than one shelf

exam, then you may have to remediate the entire course. While the school pays for you take the first shelf exam, if you fail a

shelf you will pay to retake the exam. Resources for each clerkship are listed under their respective sessions.

ONLINEMEDED.ORG has a series of free videos that review clerkship and NBME shelf content.

Patient Tracking

You are required to log each of your core clinical clerkships (with the exception of your time on Elective) in a “case log” located

on New-innovations. Each of the core clinical clerkships has a list of required clinical diagnoses that you must see or learn

about during the course of the rotation. New Innovations will allow you to log your patient with their corresponding diagnosis—

obviously not every patient fits the exact descriptors, so think big-picture if you do not f ind the exact diagnoses you are looking

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for. Students are now expected to log patients on a weekly basis. A portion of your grade will be dependent on your completion

of patient logs.

Though the process can seem tedious, it serves an important role: the New Innovations system allows the Office of Medical

Education and the accrediting body of all medical schools (LCME) to follow the type and number of patients you are seeing toensure comparability across all clinical sites (this is important for accreditation!). Also, make sure you have fulfilled the required

number of clinical diagnoses for each clerkship by running a “requirements summary” in New Innovations.

Computer Access and Electronic Medical Records

Pay close attention to your emails at the end of your second year, as you will be receiving log-in information for up to six

different electronic medical record (EMR) systems that you will need access to during your clerkship experience. These

systems include: Allscripts (UL outpatient), EPIC (Norton and Kosair), Cerner (Jewish Hospital), NetAccess (UL inpatient),

Synapse (UL imaging), and last but not least the infamous VA EMR system.

Both University systems, (Allscripts and NetAccess) can be accessed from your own computer/tablet through installation of the

Citrix receiver software on your device. Detailed instructions, including info on installation of Citrix, can be found from the

emails sent from the Office of Medical Education.

How to access EPIC and Allscripts from your home computer.

1. For Allscripts, the link is https://citrix.ulp.org

2. For EPIC, the link is https://myresources.nortonhealthcare.org

3. It may ask you to install some software. Let it.

4. Login with your respective ID and you should come to the familiar screen with the

links to "AHS - Live" or "Hyperspace PRD"

How to access EPIC and Allscripts from your iPad.

1. Go to the app store and download the free app called "Citrix Receiver".

2. After the app is installed go to the respective link (Allscripts = https://citrix.ulp.org,

EPIC = https://myresources.nortonhealthcare.org)

3. Sign in and select your respective EHR ("AHS - Live" or "Hyperspace PRD").

4. This will bring up a screen with a fi le asking how you want to open it. You should havea button that reads "Open with Receiver".

5. This should launch the app and bring you to the login screen.

One word of warning: the interface is a bit clunky and takes a few minutes to get

adjusted. It is more useful for reading notes and patient data than trying to write notes.

EMR System Help Contact Number

University: NetAccess, Synapse, Allscripts, Cerner (502) 588-0411

Norton and Kosair: EPIC (502)-629-8911

VA EMR Help Desk Extension – 55491

VA fingerprinting and ID services (502) 287-5983

University Hospital:

Inpatient: NetAccess (health information) and Synapse (Imaging)

Login information will be provided to you by email from Tonya Hockenbury ([email protected]), Administrative

Assistant from the Office for Medical Education. Accessed through myapps.ulh.org. IT help number 502-588-0411 for

problems with access (i.e. when your username and password expire for the 10th

time). NetAccess will provide you

with daily patient information, such as labs and ins/out, and some discharge summaries and operative reports.

However, at UL every patient also has a paper chart located on his or her respective hospital floor. Synapse is the

system used to access imaging, such as x-rays, CTs, and MRIs.

Outpatient: Allscripts

https://citrix.ulp.org/https://citrix.ulp.org/https://citrix.ulp.org/https://myresources.nortonhealthcare.org/https://myresources.nortonhealthcare.org/https://myresources.nortonhealthcare.org/https://citrix.ulp.org/https://citrix.ulp.org/https://citrix.ulp.org/https://myresources.nortonhealthcare.org/https://myresources.nortonhealthcare.org/https://myresources.nortonhealthcare.org/mailto:[email protected]:[email protected]:[email protected]:[email protected]://myresources.nortonhealthcare.org/https://citrix.ulp.org/https://myresources.nortonhealthcare.org/https://citrix.ulp.org/

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Login information will be issued through a sketchy “encrypted” email from Martin Kaelin ([email protected]) in

late June. Follow the directions to access your login information. The same email will include information on how to

install the Citrix receiver required to launch the EHR. Training for Allscripts is provided during orientation on

Blackboard. Again, the helpdesk number is 502-588-0411. Write it down. Save it. You will need it. This system

provides all notes from the outpatient experience, incorporating all outpatient providers from the UL network. It isoften slow and “crashes” more than you might consider reasonable, so be patient and help the clinic keep moving by

seeing patients and writing paper notes should technology issues arise.

University Wifi Access: In order to access the wifi at university hospital the following credentials are used

Network: guest

Username: wifiguest

Password: use the following format: yearmoguest (ie for December 2017, use 201712guest)

Norton and Kosair Hospital: EPIC

Everyone will be required to attend one 4-hour training session for formal EPIC training, held at Norton Hospital during the 3rd

year orientation week. At the time of training you will receive your login information and password, so make sure you WRITE

YOUR LOGIN INFO DOWN AT THE TIME OF TOUR TRAINING!

If you are unable able to get remote access to EPIC from your device (iPad or home computer), call the EPIC helpdesk at 502-629-8911. Having access at home makes it easier to ready about patients, however it is not very functional for writing notes or

anything other than information output. Once you get the remote access, you can log onto EPIC from

myresources.nortonhealthcare.org , then launch the secure connection from the Citrix receiver. As the sole source of patient

information for both Nortons and Kosairs, this system is the most comprehensive and should be the easiest to navigate.

Jewish Hospital: Cerner

Orientation will be provided at your specific site at Jewish Hospital; any login information will be provided to you prior to your

start date. The site to log on is webapps.catholichealth.net. Training videos can be found at http://www.chionecare.net/cerner-

physician-training-videos/. If you have any questions feel free to call the IT desk at 502-588-0411.

VA Hospital: The one and only

All students will be required to complete VA processing, as they will eventually rotate through the VA. If you are rotating at the

VA first, start this process 4 weeks prior to your start date. This process will be long and drawn out and something is bound to

go wrong-- be patient and plan ahead. Setting up your access to the VA EHR is a multi-step and complicated process, anddetailed instructions will be sent out via Tonya Hockenbury ([email protected]). The best advice is to start early (4 weeks

prior), call ahead to make sure the photo and fingerprinting system is working, and avoid the lunch hour.

There are just a few steps to this process:

1. Find the packet available on Blackboard and fill out the paperwork; fax one of the indicated forms to VAMC.

2. Go to VAMC, turn in the rest of the paperwork, get fingerprinted, and get pictures for your ID badge. Submit the necessary

paperwork (4 weeks prior to start date).

**The camera, finger print device, and web site are not reliable and are down frequently. If you want to make sure

that everything is up you can call Randy in the office where they take your photo and finger prints at 502-287-5983.

3. Complete online training modules

4. Return to VAMC, sign on to computer, get computer access, get email, and pick up your ID badge (cal l ahead to make sure it’s

ready!)

A key point is that even after you get everything set up at the VA computer system, after 90 days of inactivity your passwordwill expire, and you will need to call the national helpdesk (also in Tonya’s email) to have new access codes sent to you. VA Help

Desk Extension – 55491.

Prescription Writing

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One common task of medical students is writing out prescription medications by hand for practice, to then have the senior

resident sign. Some common abbreviations are used for the frequency of the medications, including QAM (morning), QHS

(nightly), Q4H (every 4 hours), Q8H (every 8 hours), BID (twice daily), or TID (three times daily). Also, some medications can be

“PRN” (as needed) for [a symptom]. Writing this out, say for administration of an antipyretic, would be “Q6H PRN fever.”

White Coat Essentials

One important aspect of third year is the application of your physical exam skills with respect to patient care. Particularly

critical for physical exam and note taking are your stethoscope, at least 2 pens, and a notepad. Your stethoscope bell can

double for a reflex hammer, but an actual reflex hammer and a pen light are recommended for your neurology rotation.

2 Pens (always have more than one—you are bound to lose one or your resident/attending will ask for a pen)

Small Notebook

Maxwell Quick Medical Reference (amazon.com for $6 or bookstore for $8)

Stethoscope

Reflex Hammer

Optional: Pocket Medicine (amazon.com for $20), iPad mini or other tablet

For Rounds, a foldable “White coat clipboard” (found on amazon.com) can be very handy for helping stay organized.

Professionalism

Overall, your third year will be a much different experience than your pre-clinical years, so prepare yourself for a fun and

exciting change! That being said, the amount of responsibility that the third year brings can initially be a shock, but with time it

will be a great transition to what you will be doing for the rest of your life!

With the transition to clinical work, the concept of professionalism and teamwork becomes even more crucial. You will be a

member of the patient care team, and you must keep in mind that you are representing not only the University of Louisville,

but also the medical profession. Always be mindful of your team as well as your peers. Avoid criticizing students openly to

others, and particularly in front of residents or attendings—they are now your colleagues and not just your classmates.

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If you notice repeat or gross lapses in professionalism by your peers, there are many resources at your disposal. Sometimes

professionalism issues call for tough conversations—if you feel comfortable and are in a position to have that talk, please do so.

If not, you can address professionalism concerns with your Track Captain and through the anonymous submission of an Early

Concern Note (ECN). Keep in mind that ECNs are confidential, low-stakes, and are only reviewed by the student-only Honor andProfessionalism Advocacy Council (HPAC). For more information, see: http://louisville.edu/medicine/studentaffairs/student-

services/hpac

To submit an ECN directly, see:

https://louisville.edu/medicine/acl_users/credentials_cookie_auth/require_login?came_from=http%3A//louisville.edu/medicin

e/studentaffairs/ecn

This is a valuable tool in preventing professionalism issues from reaching the point of being detrimental in a Dean’s letter (the

MSPE) and can go a long way in helping correct professionalism issues early.

http://louisville.edu/medicine/studentaffairs/student-services/hpachttp://louisville.edu/medicine/studentaffairs/student-services/hpachttp://louisville.edu/medicine/studentaffairs/student-services/hpachttp://louisville.edu/medicine/studentaffairs/student-services/hpachttps://louisville.edu/medicine/acl_users/credentials_cookie_auth/require_login?came_from=http%3A//louisville.edu/medicine/studentaffairs/ecnhttps://louisville.edu/medicine/acl_users/credentials_cookie_auth/require_login?came_from=http%3A//louisville.edu/medicine/studentaffairs/ecnhttps://louisville.edu/medicine/acl_users/credentials_cookie_auth/require_login?came_from=http%3A//louisville.edu/medicine/studentaffairs/ecnhttps://louisville.edu/medicine/acl_users/credentials_cookie_auth/require_login?came_from=http%3A//louisville.edu/medicine/studentaffairs/ecnhttps://louisville.edu/medicine/acl_users/credentials_cookie_auth/require_login?came_from=http%3A//louisville.edu/medicine/studentaffairs/ecnhttp://louisville.edu/medicine/studentaffairs/student-services/hpachttp://louisville.edu/medicine/studentaffairs/student-services/hpac

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Clinical Clerkship Survival Guide: Track Selection

By Eric Kreps

8

Third Year Track Selection

Your third year of medical school at ULSOM will consist of 7 core clerkships broken down into one semester of 8-week rotations

and one semester of 6-week rotations, starting in July and running through the following June. The 8-week rotations consists of

Surgery, Internal Medicine, Neurology (4wk)/Elective time (4wk), while the 6-week rotations include Family Medicine,

Obstetrics and Gynecology (OBGYN), Pediatrics, and Psychiatry. More detailed information pertaining to each of the 6 and 8-

week clerkships can be found as individual chapters in the Clerkship Survival Guide. The following information is meant to

provide you with an overview of the track selection process, as well as provide you with information that should be considered

as you begin to map your third year schedule.

Although the track selection process might at first seem to be a daunting task, it really is a very manageable process and will

provide you with a roadmap to your first clinical year as a medical student. You will be making your track selection using New-

Innovations, a web-based service that is used to manage the clerkship selection process in a way that makes organized, fair,

and efficient.

To select a “track” essentially means that you will be choosing the order in which you will experience each of the third yearclerkships. First, you must decide to schedule either the 8-week rotations (Surgery/Neuro 4wk-Elective 4wk/Internal Medicine)

or 6-week rotations (family med/OBGyn/Peds/Psych) first. When it comes to scheduling, be sure to take your career plans,

personal interests, and the seasons and into consideration. For example if you are sure that you are interested in Surgery, i t

might be wise to avoid scheduling that rotation first as you will likely be inexperienced. Also, coming off Internal Medicine in

early summer might have you better refreshed for Step 2, etc. Be sure to keep in mind the different experiences that you will

find on the clerkships given the time of year (example trauma season in warmer months for Surgery, RSV and flu season during

winter months for Pediatrics, etc.). Ultimately all students will complete each of the core clerkships, and some would argue that

timing and sequence does not matter. Seek out the advice from upper classmen and your advisor to make the decision that

works best for you!

After you determine the order of 6 vs. the 8-week rotations, you can then begin to consider the clerkship sequence and rank

your preferences for location/subspecialty for each rotation. There are several options to choose from, so read the following for

a VERY brief overview of each of the selections options you will find when using New Innovations (please look at each clerkship

within the packet for more details!).

8-week Clerkships:

Surgery

Jewish Hospital – Offers 4 weeks of general surgery, as well as 2 weeks of cardiothoracic surgery and transplant

surgery which most students find very interesting and enjoyable. A good balance of slow and busy, and usually

students find they have plenty of time to study. Call is at Jewish.

Kosair/VA – Kosair offers an abundance of cases that are far different from the other general surgery experiences,

and may appeal to those interested in pediatrics. Pediatric surgery questions are less numerous on both the shelf and

oral exam, but some students report being able to be more “hands on” as compared to other surgery rotations. VA

balances OR cases with time spent in clinic, and provides great exposure to bread-and-butter general surgery cases,

as well as exposure to thoracic and vascular cases. As with everything at the VA, things run a little slower but this

translates to a little more study time. Call is split between Kosair (while on Peds surgery) and UL Trauma (while on VA)

Norton Hospital – Comprised of 4 weeks of general surgery. Norton also houses the 2 week subspecialty optios of of

Colorectal Surgery, Surgical Oncology, and Vascular. This is a very busy service with a high patient volume, but the

exposure to numerous cases may appeal to those interested in surgery. Call is at Nortons.

UL Hospital – Includes 4 weeks of trauma surgery, which may appeal to those interested in surgery or ER. Students

will also be assigned to either 4 weeks of elective surgery, which students find as a good balance to trauma as they

have more time to study on elective, or 4 weeks of surgical oncology and vascular surgery, which are both busy and

interesting services that may appeal to students pursuing surgery. Call is with UL Trauma.

Madisonville – All 8 weeks are spent at Baptist Health in Madisonville, and students have a different lecture series

and call schedule. Most of the time is spent working directly with attendings, which may allow for more teaching

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moments and first-assists. Students that go to Madisonville all report a positive experience: call is home-call and you

have some weekends off; more didactic and committed study time; more hands-on with more time spend directly

with attendings only (1 UL resident spends time at this site at a time). If you are interested in pursuing surgery for

residency, however, this does prevent you from meeting and working with faculty members and residents involved

with the UL program.

Internal Medicine: 4 weeks on wards and 4 weeks on subspecialty, with the subspecialty month split between two

subspecialties (i.e. 2 weeks of Cards and 2 weeks of GI). Generally speaking, inpatient Internal Medicine wards tend to carry

primary patients, while most subspecialty services are consult services.

Wards (4 weeks) – Students are assigned to teams at either UL or the VA. As with most things at the VA, things tend to

run a little slower but hours are slightly shorter.

GI – Somewhat longer hours, but a great experience for those interested in the field and/or a more procedural

experience. You will see patients in the morning, observe procedures and see consults in the afternoon.

Cardiology - Both VA and UL involves seeing patients and writing notes. VA hours are slightly shorter, but all sites are

reportedly a great opportunity for those interested.

Pulmonary Consult –Generally a lighter patient load with moderate hours and plenty of study time.

Endocrinology - Service covers four different hospitals and students will be asked to attend rounds and see patient,

but generally will not write notes. Among the longest hours on medicine (8-6), but very rewarding and well-liked by al

students that understand the time commitment. Avoid scheduling this subspecialty close to shelf exam time for studypurposes.

Nephrology – Sites at Jewish, VA, and ULH. VA and ULH see lighter to moderate hours, while Jewish is among the

heaviest of the specialties in hours (7-7 many days). All the locations have been reported to be a good experience.

Infectious Diseases – Sites at Jewish and UL. Also Bone and Joint ID team available at both Jewish and UL. You will see

patients in the morning, round with and attending, and will stick around campus for consults in the afternoon. Some

services also have clinic in the afternoon at the VA.

Hematology/Oncology – Hours are extremely variable based on the attending and your team’s fellow/resident.

Clinic attendance is encouraged once a week. You will see patients in the morning or afternoon, depending on the

attending.

Neurology: 2 weeks on inpatient and 2 weeks on outpatient. You can rank your preferred locations in the electives.

Inpatient:

Jewish General - This is one of the busier services but provides students with a great opportunity to see a wide variety of

neurological diseases.

Child Neuro - This is one of the most demanding inpatient services for neurology, but students see a wide variety of very

unique cases and learn a tremendous amount from the faculty. Child neuro is split with one week on inpatient and one on

outpatient. You will work one weekend day, but this also counts as your “call” day for the rotation.

ULH Stroke - Hours vary with attendings and patient volume. In general, the start time is earlier than most services, but

students are finished in the afternoon.

ULH General - Hours are similar to ULH Stroke. Students are expected to see a patient and write a note but are not always

asked to present during rounds.

Outpatient:

Child Neuro - Hours are typically 8-4PM. Some attendings will have you see patients and write notes, while others will

have you shadow and be helpful to the resident. Child Neuro assignment is 2 weeks long with one week spent on inpatientand the other on outpatient.

Private Practice – You are assigned to work with a community neurologist with each experience varying based on your

attending. In general, however, the hours are reasonable and the neurologists you work with are very helpful.

HCOC-Outpatient Clinic- Located in the Healthcare Outpatient Care Building (HCOC). Students are paired with different

attendings each day. Students usually start around 8:30AM and finish around 4:00PM, depending on the patient load.

Elective: scheduled on a different basis, please look for emails from your leadership or Sherri Gary for scheduling information.

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6-week Clerkships:

Psychiatry:

Child Psych – Excellent hours, but one-on-one patient interaction can be limited due to the nature of the service. Students

are generally happy with their experience here and often more enjoyable for those interested in pediatrics.

Emergency Psych- and ACB – This rotation entails more dedicated hours, but the residents and attendings offer you

significant autonomy with a lot of patient contact. Pace can be hectic with patients that are potentially dangerous,

however security is always present and is a good environment for those that thrive in an ER environment. You will also get

this experience as part of your call assignment while on the psychiatry clerkship. The other half of this assignment is a

slower-paced outpatient experience at the ACB.

Norton Consult – This is a consultation serve for medical in-patients with concomitant psychiatric symptoms. This rotation

offers good hours (8 to 4/5), with excellent patient contact, lots of autonomy, and responsibility. Most students feel

integral in actual patient care as the attendings and residents on this service listen to your suggestions and even let you

put in orders.

Norton Inpatient Unit – Wide variety of diagnoses, excellent patient contact, with moderate autonomy.

ULH Inpatient Unit—Wide variety of illnesses and you are more likely to see those that are seriously ill as primary

admissions are made mainly through Emergency Psych. ULH Consult Service—This service sometimes has limited patient censuses, but this also gives you lots of opportunity to

study.

VA Inpatient/Outpatient – Hours consistently 8:00AM-4:30PM. This rotation offers significant autonomy with your own

patient load and one-on-one interaction with the attending. 5 weeks on inpatient VA-psych with 1 week on the inpatient

substance abuse treatment floor. You will present at Journal Club, write notes on your patients every day and will get used

to giving oral presentations.

Obstetrics and Gynecology:

2 weeks of private practice, 2 weeks of surgical subspecialty and 2 weeks of Labor and Delivery. The electives you may choose

are in the surgical subspecialty:

Gynecologic oncology—very interesting and demanding cases, but with significant hours and would be a good choice if

interested in surgery.

Benign gynecologic surgery—shorter hours than gyn/onc with more emphasis on hysterectomies and minimally-invasivesurgeries.

ODSU—outpatient surgery with short hours but less interesting/significant cases than the others. Will see procedures

including polyp removal and other procedures.

Urogynecology—procedures for pelvic organ prolapses and urinary incontinence. May work at several different hospitals,

but a very interesting experience.

Pediatrics:

Stonestreet Clinic: A lot of one-on-one time with attendings, where they emphasize patient interaction rather than EMR

proficiency. It is an off-campus site ( 20-30 min drive) and you will see a more rural patient population.

Eastern Parkway Clinic: Located at the Kosair Charities Building on Eastern Parkway. You will experience nearly one-on-

one student/attending time, with lots of individual teaching. However, there may not be as many patients to see (8-10 per

half day), and cases may be less acute. Many Spanish-speaking patients, and a great opportunity to utilize medical Spanish.

Children and Youth Clinic (C&Y): Located on campus, next to nursing building. Heavy patient load as this clinic recently

absorbed what was UL Broadway Pediatrics. Attendings are kind, helpful, and most interested in helping students learn

brief lectures Tuesday and Thursday morning. However there are several students assigned to this at the site at a time, so

time with each attending can be limited.

Family Medicine:

Both the Newburg and Cardinal Station clinics are very similar and just vary by physical location. You will spend 2 weeks at

either of the clinic sites, then 4 weeks at your AHEC site (scheduled separately; be sure to attend AHEC fair for locations.

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Clinical Clerkship Survival Guide: General Surgery

By Alexandra Healy

11

General Surgery

Welcome to surgery! It is easy to imagine this as a rotation you will spend al l of your time in the OR (and you will spend many

hours there), but there is much more to surgery than operating. You will also spend a good deal of your time seeing consults,

assessing whether or not the patient needs surgery, performing bedside procedures (central lines), and making sure your

patients recover well postoperatively.

Surgery generates most of its patients through either previous clinic visits when the surgery was planned months or weeks in

advance, such as for elective cases, or through inpatient consultations or the ER where the patient is scheduled for surgery in

the upcoming minutes, hours, or days. Prior to surgery the patient is taken to Pre-Op where consent is obtained and the

anesthesia team performs their assessment in preparation for sedation. Once ready for the OR, the patient is rolled back and

prepped for surgery. After surgery, the patient is taken to the PACU where they are monitored while waking from anesthesia,

and eventually transported to their hospital room for postoperative management on the floor. The surgery team then follows

the patient until ready for discharge and will subsequently schedule the patient for outpatient follow up appointments.

This rotation is a total of 8 weeks. You will spend 4 weeks on a general surgery or trauma service and 4 weeks on a subspecialty

service(s), sometimes further divided into 2-week services. The patient population is largely adult, however, you may manage

pediatric patients if you are assigned to Kosair Children’s Hospital pediatric surgery service. Some of the common diagnoses you

will encounter include bowel obstructions, hernias, appendicitis, and gallbladder disease. The learning curve for surgery is

steep. Not only will you be expected to know the diagnosis and indications for surgery, you will also likely be questioned on

complications, anatomy, imaging, etc. This is a fast-paced rotation with long hours, so be prepared to dive in and get your

hands dirty!

Length of Rotation: 8 weeks

Locations:

University of Louisville Hospital (ULH)

530 S. Jackson StLouisville, KY, 40202

Norton Hospital

200 E. Chestnut St.

Louisville, KY 40202

Jewish Hospital

200 Abraham Flexner Way


Kosair Children’s Hospital (KCH)

231 E. Chestnut StLouisville, KY 40202

VA Medical Center (VAMC)

800 Zorn Avenue


Baptist Health

900 Hospital Drive

Madisonville, KY 42431

Important Contacts:

Clerkship Director: Dr. Sheldon Bond

Pediatric [email protected]

(502)629-8630

Student Contact and Clerkship Coordinator:

Brenda Dawson

[email protected]

(502)852-5676

Department Chairman: Dr. Kelly McMasters

Surgical [email protected]

(502)852-5447

Residency Director: Dr. William Cheadle

General Surgery

[email protected]

(502)852-5675

mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]

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Didactics: All didactic sessions are required for this clerkship, and they take attendance very seriously! Always be prompt,

arriving 5-10 minutes before lectures begin. As with everything in surgery—if you are on time, you are late! Business attire with

your white coat for all lectures—do not wear scrubs to Grand Rounds or into the General Surgery Department offices (more on

attire later!)

Weekly Student Didactics: Wednesday 1:00-5:00PM

Location: Hagan Library, ACB 3rd

Floor in the General Surgery Department offices

Grand Rounds: Friday 7:00 – 10:00AM

Location: ACB Auditorium in the ACB Basement

** Grand Rounds is required even on post-call days. Drink lots of coffee these days!

Polk Rounds:

ULH - Monday 7:00-8:00AM

Location: SICU

**Mandatory for those on services at UL

VA – Tuesday 7:00 – 8:00AM

Location: SICU**Mandatory for all those on service at the VA

General Surgery Assignments

4-week rotations

Trauma Surgery (ULH) – Cares for patients that present to the ER and need urgent or emergent surgical

evaluation and management. You will be responding to Room 9’s (often Level I traumas!) and other consults in

the ER.

Elective Surgery (ULH) – The general surgery service at ULH.

General VA (VAMC) – The general surgery service at the VA. You will also have exposure to vascular and thoracic

cases.

Pediatric Surgery (KCH) – Cares for pediatric surgery patients at KHC. This is a very busy service, as you will

manage consults and trauma calls in addition to previously scheduled surgeries.

2-week rotations

Colorectal Surgery (Norton Hospital) – Manages patients needing surgery involving the colon or rectum. Offers a

great deal of exposure to colorectal cancer.

Vascular Surgery (Norton Hospital) – Manages patients with vascular diseases that need surgical repair. This

service offers abundant OR time, with cases such as amputations, fistulizations, AAA repairs, and

catheterizations.

Surgical Oncology (UL, Norton, and, Jewish Hospital) – Manages patients with cancerous tumors. This is a very

busy service, and you will see cases such as mastectomies, melanoma wide-local excisions, and Whipple

procedures.

Transplant Surgery (Jewish Hospital) – Manages patients undergoing lung, liver, or kidney transplants.

Thoracic Surgery (Jewish Hospital) – Cares for patients undergoing surgeries of the chest. Cases include

bronchoscopies and esophageal reconstructions.

Off-campus 8-week rotation: Madisonville (8 weeks, Baptist Health) – Comprised of a 4-week general surgery

rotation, and 2 2-week rotations in orthopedic and vascular surgery. You will see a wide variety of cases on this

rotation, and spend more time working directly with attendings.

Grades and Assignments

Clinical Evaluations – 30%

Quizzes – 20% (3 total)

Shelf Exam – 30%

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Oral Exam – 20%

Online Cases – Not graded, but part of LCME requirements

Surgical Technique Checklist – Must complete prior to end of rotation

Required Diagnoses/Patient Log – Must complete prior to end of rotation

Attire: Always wear business attire when entering the Department of Surgery (ACB, 2nd

Floor), Polk Rounds, or attending Grand

Rounds. This includes shirt and tie for men, knee-length dresses/skirts or pants for women. A general rule of thumb is to keep

an extra change of dress clothes in your car at all times, for instances when you forget you need to change into business attire

later in the day. Check with your team about clinic days and what attire is expected. On most other days you may wear scrubs

to the hospital. Each hospital has its own supply of scrubs, usually located in the locker room. If you are assigned to the VA you

will be given a ScrubX card and allowed to checkout two pairs of scrubs at a time. You must wear the VA scrubs on days you will

be scrubbing into surgery.

How to Shine: This is the most hands-on rotation you will have, and it’s important that you take advantage of it. Always be

willing and prepared to jump in and help. In the OR this means anticipating where you can be most useful, such as using the

suction to grab smoke at they use the Bovi, asking for the scissors as they begin to close, and transferring the patient to and

from the bed. Outside the OR this means running errands, putting on gloves when doing a bedside procedure, changing

dressings, etc. When in doubt, put on gloves so you are available for assistance should it be needed. In addition, confidence is

key. Always speak with confidence when you present or answer a question, even if you aren’t entirely sure of yourself. A fewother ways to shine –

Before the OR: There should be a student present in every case. Before surgeries begin each day, divide the

scheduled cases between you and the other students on your team and decide who is scrubbing in on what. Read up

on your patient, the surgeries you are scrubbing in on, and know the anatomy involved. Know your patient and know

why they are having surgery . Some surgeons ask—what’s the most important question of the day? The answer: Why

are we here? Read the HPI and look at any imaging the patient may have had. In addition, it may be helpful to get to

know the scrub team, the anesthesia team, and the other ancillary staff members that could make your life easier.

This is team- and location-dependent, but if you get to know the anesthesia resident well, and stay with your patient

from pre-op to the OR, they may be willing to teach you techniques like inserting IVs, induction, and intubation.

In the OR: Keep tabs on when your patient arrives to the OR. Pick out your gloves, and your resident’s gloves if you

know their size, and introduce yourself to the OR tech well before surgery. Also, write your name and year in medical

school on the dry erase board—it helps the staff identify who you are and your role immediately. Help the OR staff

with moving the patient to the table, positioning the patient, shaving body hair, applying betadine to the area being

operated on, etc. Always pay attention and be prepared to do your part during surgery. If you hear the attending or

resident ask for the retractor, be ready to hold it. If they begin to close, ask for the scissors and be ready to cut. After

surgery, help the OR staff transfer the patient back to the bed. Stay with the patient until they are delivered to the

PACU. The OR is like a dance—a lot goes unsaid and it’s up to you to anti cipate the pace, tone, and next move; predict

their needs, as well as when it is an appropriate time to ask questions or, arguably more important, when to stay

quiet. This finesse comes with time and close observation, but the keen student will catch on quickly as the rotation

progresses.

During Rounds: You should be seeing 2-4 patients each day. Show up early enough to see your patients (often around

5:00AM) and write notes on each of them. Your team rounding will be highly variable, based on your service and your

resident team. Surgery can be very hierarchical, so if you have a question, go to the first person ahead of you (i.e. ask

the intern before you go to the chief). There is a high volume of patients and very little time before surgery begins in

the morning. It is important that you take the initiative and jump in when the team gets to your patient. Make your

presentations succinct and present with confidence. Always have an assessment and plan for your patient.

On Call: Being on call means you are working from your report time to approximately 8:00 AM the next day –

generally more than 24 hours. Call nights can be exhausting, but it’s important that you don’t complain or make it

obvious that you want to go to sleep. Often it is just you and a resident working call night. In the event that you

become swamped, try to help out your resident. Respond to their pages if you can; get started on the H&Ps for

consults; ask for ways to be helpful. When all of the work is done, and there are no cases going, then it is okay to go

to the call room.

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On Trauma Service at UL: Your task as a student is making sure the patient-note templates are current with your

team’s list (Trauma 1 or Trauma 2). This means that you have a paper note with your patient’s sticker in the top right

corner, the HPI is current and accurate (include blanks for HD# and POD#), the medication list is updated, etc. You

should have these templates updated and ready for your pre-rounding team (generally the interns). Once they havecompleted their notes, the upper level will go over them, add their plan, and then you create the final day’s note

packet with enough copies for everyone on the team. You may be expected to pre-round and present 1-2 patients,

depending on which service you are assigned to and the expectations from your residents/attending. Just ask! Finally,

if you go to see a consult or room 9, grab a Trauma H&P and get started! The resident will ask the questions and

perform an exam; write as they talk. If you are on call, you can also get a template prepped and ready if you know the

patient is likely going to surgery/getting admitted. This will make the work easier in the mornings for those students

on the day shift. This can be a high-stress and busy service for the residents, so find ways to be helpful and they will

reciprocate by allowing you to be more hands on in the OR or with procedures.

The Oral Exam:

Surgery is the only rotation with an oral exam. The oral exam sounds terrifying, but most people leave feeling that it went much

better than expected. On the last Friday of your 8-week rotation, you will meet in the General Surgery Department (2nd

floor,

ACB) for your oral exam. The exam consists of 3-4 clinical scenarios that you will work through step-by-step, and be expected to

list differential diagnoses, interpret imaging results, state the next step in treatment, etc. You will have one or two surgeryattendings or residents proctoring your exam, and it will last 20-30 minutes.

This sounds extremely intimidating on the first day of your surgery rotation, but by the end of the eight weeks you

will be more than prepared. The last two lectures before the oral exam will be devoted to the “Gaar Sessions.” These are two

four-hour sessions where Dr. Gaar presents the 10-15 possible cases you may be given in your exam. He will work through each

case in an oral-exam format, and he will cover any and every question that you could possibly be asked in your exam. Old

manuscripts of the “Gaar Sessions” from previous years are circulating, and are very useful for studying.

Most Common Study Resources:

UWorld QBank (147 questions) – Shelf exam preparation.

Emma Rhamahi’s Review – A 2-hour review for the shelf exam.

o Video: http://atsvid.uthscsa.edu/Mediasite/Play/60089c931cca4bcabb76bf8f2c883b09

o Powerpoint:

http://som.uthscsa.edu/StudentAffairs/documents/High_Yield_Surgery_Compatible_Version.pdf – A quick

2-hour review for the shelf exam.

o ** Some students often review the Internal Medicine presentation as well; a lot of medicine shows up on

the General Surgery shelf, so look alive!

Dr. Pestana’s Surgery Notes – Read through this multiple times before the shelf exam.

Case Files Surgery –Lecture, quiz, and shelf exam preparation.

NMS Surgery – Quiz and shelf exam preparation.

Surgical Recall – More helpful for time spent in the hospital as it includes practical information as well as material you

may be pimped on. Also helpful for the oral exam.

Essentials of General Surgery by Peter Lawrence – Textbook that can be helpful to cover high-yield topics for

presentation, work-up, and surgical options. Directed toward high yield and big picture material.

Toronto Notes, General Surgery Section – bullet point information in dx and management of surgical diseases

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Clinical Clerkship Survival Guide: Internal Medicine

By Eric Poulos

15

Internal Medicine

Internal Medicine is a broad field composed of primary care internists and a variety of subspecialties that deal with adult

patients and their illnesses, most commonly in the inpatient setting but also outside the hospital in each of the Internal

Medicine subspecialty fields. Internal Medicine diagnoses are quite diverse, spanning every organ system. Some of the most

common include pneumonia, kidney disease, diabetes and metabolic diseases, hypertension and cardiac disease; the internist

functions as the primary care giver in the hospital for most of these patients. Some Internal Medicine teams are also consulted

by the surgical teams to co-manage complex patients before and after surgery.

Internal Medicine is an eight week clerkship organized into two four-week blocks: 4 weeks of general Internal

Medicine ward work and 4 weeks further subdivided into two separate Internal Medicine subspecialties. Both assignments

involve seeing new patient consults or admissions, writing a note, forming a differential diagnosis, constructing a plan with a

subsequent workup, and presenting that information to an attending and your resident team. During the rotation, students

attend weekly didactic sessions, daily Noon report, and weekly Grand Rounds. You will also be expected to complete two

graded clinical exercises called mini-CEX’s in addition to the midclerkship evaluation (ungraded) and your final clinical

evaluations.

Length of Rotation: 8 Weeks (4 weeks of general IM wards, 4 weeks divided into two subspecialties)

Locations:

University Hospital

530 S Jackson St


Jewish Hospital



Louisville VA Medical Center

800 Zorn AveLouisville, KY 40206

Important Contacts:

Clerkship Director: Dr. Kristan Milam

[email protected]

Clerkship Co-Director: Dr. Monalisa Tailor

(502) 852-3637

[email protected]

Student Contact: Missy Klotz

(502) 852-7945

[email protected]

Department Chairman: Dr. Jesse Roman

Dr. Roman’s Secretary: Ms. Sherry Hertel

[email protected]

Residency Director: Dr. Jennifer Kuch

[email protected]

Didactics: All medical student didactics are weekly and mandatory, regardless of your clerkship assignment location.

While on IM wards at either the VA or UL there is a daily Noon Conference that is also required. Grand Rounds is a

weekly requirement, though this is often broadcasted to the VA.

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he University of Louisville School of Medicine s Unofficial


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Weekly medical student didactics:

Thursdays, 12:00PM-2:30PM** Specific times may vary so check the schedule or ask your track captain.

These sessions include “Meet the Professor” rounds and teaching by the Chief residents over topics such as “Reading

EKGs”, “Reading Chest x-rays”, and “ABG interpretation/acid-base disorders” Location: Medicine Conference Room (ACB-3rd floor)

Noon Report (VA):

12:00PM – 1:00PM

Monday - Friday

Location: Room D010

Noon Report (UL):

12:00PM – 1:00PM

Mondays, Tuesdays, and Fridays

Location: ACB, Community Conference (basement)

Grand Rounds:

8:00AM – 9:00AM, Thursdays

Location: ACB auditorium (basement)

Grades and Assignments:

Clinical Evaluations – 40% (minimum of 70% to pass)

NBME Shelf Exam – 30% (Minimum of 4th

percentile to pass; actual raw score varies depending on the time of the

year. Like all other clerkships, you much honor the shelf to honor the clerkship, which is above the 75% percentile).

SIMPLE Online Cases – 15% (Completion of all 15 cases earns full credit)

http://www.med-u.org/simple or http://app.med-u.org/player/app/homepage.html

EKG Quiz – 5% (20 question quiz)

(2) Mini-CEX - Two clinical exercises graded by residents. . One mini-CEX will focus on medical interviewing skills and

the other mini-CEX will focus on physical examination. These exercises must be supervised by an attending, fellow,

or upper-level resident to meet the requirement. Does not count in overall grade, but must completed to pass.

Required Diagnoses/Patient Log: – Log your patients on New Innovations to complete required diagnoses

The Wards:

On wards, an Internal Medicine team is usually composed of one to two medical students, two interns and one upper level

resident. Each team is divided up by colors: White, Red, Green, and Purple. No team is harder or easier than the others, as your

workload is mostly dependent on your residents and your attending assignment. The upper level is responsible for admitting

patients, handling transfers from the ICU, managing consults, and overall organization of the team. The interns primarily serve

as the workhorses who place orders, make phone calls, and take pages. All members of the team will break up the patient list

and see each patient individually before the attending arrives. Often times the upper-level will see every patient on the list,

though the interns split the l ist to manage the details of the patients’ care. Occasionally a pharmacist and a teaching resident

will also round with the team.

As a medical student, the day begins anywhere between 5:30 – 7:00 AM with pre-rounding, where you will see the 1-3 patients

assigned to you by your team. This usually takes place before or concurrently with the interns. Keep in mind that your pre-

rounding time will vary based on your level of experience/efficiency, the number of patients you have, whether or not yourteam accepted Night Float patients that morning, and the overall expectations from your team. You will write your own note

(hand-written at UL and typed at the VA), forming your own differential diagnosis followed by a plan. Once you have given your

case some thought and constructed your plan, students should discuss their patients briefly with their residents, helping to

finalize the presentation and plan proposed to the attending. They like to see that you have thought about the case and

management plans before asking questions—it shows that you are taking ownership of your patient and you’re trying to

independently formulate a treatment plan based on your clinical assessment. Next, the attending arrives and begins to round,

which simply consists of a patient presentation, with students expected to present each patient they have seen that morning.

The expectations during rounds can vary dramatically between attendings, therefore asking a resident what a particular

http://www.med-u.org/simplehttp://www.med-u.org/simplehttp://app.med-u.org/player/app/homepage.htmlhttp://app.med-u.org/player/app/homepage.htmlhttp://app.med-u.org/player/app/homepage.htmlhttp://www.med-u.org/simple

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physician expects during the first few days is very important. After rounds, the team breaks off to place orders, make phone

calls to social services, or if they are on call, see patients needing attention in the emergency department.

Medical students are expected to work an average of 6 days per week with hours, usually ranging from 7:00AM to 4:00PM,

depending on your pre-rounding responsibilities, team’s patient load, and the overall working dynamics of your team. VAstudents tend to have shorter hours (usually end by 2) than ULH students (usually end anywhere between 2:00PM – 5:00PM).

Students are expected to take call from 7:00 AM until at least 7:00 PM every 4th

day with their team. During call, students will

see new patients in the emergency department and will be asked to conduct and write a full history physical, including a

differential diagnosis and plan. Your call days are a good time to knock out both your history taking and physical exam mini-

CEXs! Attire is mostly business casual with your white coat, however you are allowed to wear scrubs on your call days, p ost-call

days, and on the weekends. Finally, students on wards must attend Noon Report on Mondays, Tuesdays, and Fridays, which are

usually short case presentations that are didactic in nature. Be sure to sign in to get credit.

Subspecialty:

The available 2-week Internal Medicine subspecialty options are as follows:

Renal (Jewish, UL, VA)

UL Heme/Onc

General Infectious Disease (UL and VA)

Bone and Joint Infectious Disease (UL, VA)

UL Pulmonology

Cardiology (Jewish, UL, VA)

Endocrine (One service covers all hospitals)

UL Gastroenterology

Medicine Intensive Care Unit (UL, VA)

The subspecialty rotations are opportunities to explore the more specific fields of Internal Medicine (see l ist of available

subspecialties below). Each of these specialties share a similar team structure to wards, except the team is smaller, your upper

level is often a fellow, and many specialties do not admit their own patients, therefore acting only as a consult service to the

primary medicine team. Pre-rounding and rounding is similar to wards, though the focus is usually narrowed to only include

issues pertaining to that specialty. Most subspecialties will have both inpatient ward work and some clinic days. Clinic on some

services is mandatory (ID), while it can be optional for others (Endocrine, Heme/Onc). As always, clinic attire is business casual

with white coat.

The hours and work expectations seen on subspecialty depend not only on the site but also on the attending. In general, VA

rotations tend to be lighter than others, particularly on Cardiology and Renal. Infectious Disease at the VA and at University

tends to be a little longer and you will be asked to stay and wait for afternoon consults. Bone and Joint infectious Disease is

characteristically hit-or-miss but oftentimes works fewer hours than the general ID team. Hematology-Oncology can be a very

relaxed rotation or very time consuming, depending on the attending. The most difficult rotations have reportedly been Renal

at Jewish and Endocrine. Endocrine is a unique rotation in that students will cover all four major hospitals, often requiring

rounding at each location for a larger portion of the day than most other subspecialties. Students on this rotation do learn a lot

and have great experiences so long as you know what you’re in for! Renal at Jewish involves rounding twice, once during the

morning and once in the afternoon, leading to the longer hours. Despite the longer hours, students have said both are excellent

for learning their respective area.

As compared to ward work, the hours on subspecialty are often shorter. For this reason, some students will request ward work

first, leaving subspecialty for the last four weeks to pack in a little more studying. The exception is with Endocrine—be sure you

don’t have Endocrine scheduled during your last two weeks on IM, as it will interfere with studying for the shelf. Ultimately, half

of your track will do ward work followed by subspecialty or subspecialty then wards – some argue there is no real difference in

strategy, so don’t fret either way.

How to Shine: As with any third year rotation, attitude plays a huge role in success. Be willing to volunteer to write H&P’s, ask

your residents questions when they are free, offer to go medical-record hunting, and try to read the latest on Up-to-Date for

each topic so that you are prepared for discussion. Take extra time forming a differential diagnosis and be able to talk through

which diagnosis is more likely versus which are not and why. More so than many of your other rotations, the Internal Medicine

teams practice evidence based medicine, so whenever you can bring up new articles (print it out if you can!) or major clinical

trials on why things are conducted the way they are, that is something that will help prove you did look up information as it

related to your patient the night before. This is by no means a daily or even weekly requirement, but if you can find a tactful

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way to insert your review of the literature into the patient’s care, it can certainly take you a long way. Last, this is very much a

TEAM rotation—be a team player and find ways to be helpful along the way.

In terms of shelf preparation, start studying and do UWORLD questions IMMEDIATELY. There is too much information to begin

to master everything in 8 weeks, but it is possible to get a good grasp on most things with a consistent approach.

Most Common Study Resources:

World QBank (1359 questions) – Excellent example of questions, though the subjects tend to be VERY specific. Should

be your primary source of questions for the shelf. Start early, as this is the largest question section on the Qbank and

the shelf creeps up quicker than you think!

Step Up to Medicine – Best overall review for the shelf. Many students shoot to read this at least two times before

the shelf. This can also be very useful when studying for Step 2 CK.

Emma Rhamahi’s Review – This 2 hour video is a must; most people watch it during the last week of studying to

brush up on high-yield topics. You can speed up the video to make it shorter.

http://som.uthscsa.edu/StudentAffairs/documents/HighYieldInternalMedicinecompatibleversion.pdf

MKSAP questions – Not a great representation for the shelf, but the explanation are a great way to learn the

concepts and process of medicine. Consider this a secondary question resource.

Pocket Medicine (The Massachusetts General Hospital Handbook of Internal Medicine) Marc S. Sabatine; The

Washington Manual, Lippincott-Raven- Great resources for looking up quick information while on wards, but not a

great tool for studying for the shelf. Use as a quick reference guide.

NBME clinical mastery tests - Two 50 question tests that are $20 each. Best example of the questions faced on the

exam. Use more as a gauge of progress later on than as a study tool. Note: test 1 tends to be easier than the shelf,

while test 2 is more representative. Not often utilized by most students, but it can be a resource if you learn best by

example

http://som.uthscsa.edu/StudentAffairs/documents/HighYieldInternalMedicinecompatibleversion.pdfhttp://som.uthscsa.edu/StudentAffairs/documents/HighYieldInternalMedicinecompatibleversion.pdfhttp://som.uthscsa.edu/StudentAffairs/documents/HighYieldInternalMedicinecompatibleversion.pdf

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Clinical Clerkship Survival Guide: Neurology

By John Wehry

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Neurology

The field of Neurology encompasses a variable patient population and spans all ages, as well as inpatient and outpatientservices. Strokes, headaches, seizures, and altered mental status are among the most common diagnoses in inpatient

neurology; for each of these, identifying the underlying cause can drastically change the treatment options and prognosis for

the patient. In the outpatient setting, neurologists follow patients who tend to have a more chronic component to their disease

state. While diagnoses such as headaches and seizures are still common among outpatients, the role of the neurologist for

these patients is focused more on the ongoing treatment than the underlying cause with the best management commonly

achieved through long-term follow-up. As a student, you will experience neurology in both the inpatient and outpatient

environment, gaining an understanding of the variety of disease states that are most commonly encountered in the field. By the

end of the rotation, you will be a master of the ever-challenging neuro exam.

Length of Rotation: 4 weeks (2 weeks spent at two different locations, most commonly with 2 weeks of inpatient and 2 weeks

of outpatient).

Locations:

Inpatient:

University Hospital (Stroke, Inpatient)

530 S Jackson St


Jewish Hospital (General Consult Service)



Kosair Children’s Hospital (Pediatric)

231 E Chestnut St


Outpatient:

Louisville VA Medical Center

800 Zorn Ave, Louisville, KY 40206

Dr. Greg Smith’s Office: A505

Community Neurologists

Dr. Rukmaiah Bhupalam’s Office: 1169

Eastern Parkway Suite 1126

Dr. Michael Alt’s Office:

2934 Breckenridge Lane Suite #2


Children's Hospital Foundation Building601 S Floyd St, Suite 500


Important Contacts:

Clerkship Director: Michael A. Haboubi, DO

[email protected]

Student Contact: Connie Elgan

(502) 852-6328

[email protected]

Program Coordinator Asst: Dominique Hurt

(502) 852-8426

[email protected]

Department Chairman: Kerri Remmel, MD

(502) 852-6990

[email protected]

Didactics: All lectures for the Neurology rotation are held on orientation day. This is important to account for because it is mucheasier to put off studying through this short four-week rotation. Don’t underestimate the Neurology shelf —it is oftentimes one

of the more challenging shelf exams.

Grand Rounds: 8:00 - 9:00AM on Thursdays, located in the Nursing Building, however location may be subject to change. It is

required that students on the Health Sciences Campus attend Grand Rounds. Be sure to sign in! Those on outpatient service

with community neurologists are not required to attend Grand Rounds during those weeks.

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Clinical Clerkship Survival Guide: Neurology

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Clinical Neurology Assignments:

Logistics: This is a four-week rotation divided into two different two-week assignments that cover inpatient and outpatient

Neurology.

Dress: Business casual clothes and your white coat.

Hours: Generally , hours are 8:00AM - 5:00PM for most locations with weekends off (**Peds Neuro works 1 weekend)

Call: Every student will take in-house call one time during their inpatient rotationo UofL General Neurology call – from 4:00PM – 8:00PM on a weekday

Contact the resident that is on call to arrange a meeting place

o Kosair Pediatric Neurology call – weekend morning (~8:00AM until finished rounding)

Contact the resident or attending that is on call to setup the time and place to meet

Pediatric Neurology

This is a two-week experience with one week spent on the inpatient service and one week spent on the outpatient

service (clinic). Hours are usually 8:00AM – 5:00PM but may vary depending on the attending physician. Pediatric

Neurology inpatient hours are sometimes longer and it is required that you work one weekend, but the overall clinical

experience is one of the best.

Overall, this rotation is very popular with students given the patient population, wide variety of diagnoses, and the

high quality of the clinical faculty in Pediatric Neurology. Namely, Dr. Vinay Puri, Chief of Child Neurology and ViceChair of Neurology, is often cited as one of the major strengths of the rotation.

Contact: Miranda S. Der Ohanian, Pediatric Neurology Administrative Assistant

502-588-3673

[email protected]

Inpatient – The location for this assignment is Kosair Children’s Hospital. Of the inpatient locations, this can

be one of the most demanding of your time. However, students on this rotation have excellent experiences

and always praise the quality of the teaching by the faculty. Hours here are a little more demanding —

expect to arrive around 7:00AM to pre-round. You will write notes on all of your patients (usually 2-3 while

on service) using EPIC. The residents and NPs will give you a heads up on the time you will round the next

day. Be prepared to present your findings on the neuro exam. Don’t forget your penlight, reflex hammer,

and stethoscope. Both residents and attendings are most interested in helping you learn and perfect both

the neuro exam and the presentation of the neuro exam.

Outpatient – The location for this assignment is Kosair Children’s Foundation Building (the 5th

floor of the

Chase building across from Kosair). As a student you will see the patient and his/her parents before the

attending—sometimes with a resident and other times on your own. Be sure to get a thorough H&P for new

pati

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