The subinternship in Medicine provides a structured clinical
experience in the broad field of internal medicine and those specialty areas
necessary for the care of the medical
patient. It is designed to be a well supervised educational experience that
will serve to improve and build upon those cognitive and technical clinical
skills already attained
during the junior medicine clerkship. Through the subintern- ship, the student
will have the proper environment in which
to learn the clinical skills and attitudes essential to the practice of internal
medicine and the delivery of the highest quality patient care. The subintern
will fulfill clinical and academic responsibilities as an integral team member
of an inpatient medical service. Competencies that subinterns are expected to
attain by the end of the rotation are as follows:
1. The subintern workday begins at 7:15 A.M. At that time it is expected that the student will receive sign-outs from the night call intern or subintern, and evaluate his/her patients prior to work rounds.
2. The optimal patient load for a subintern will be between three and five patients. In rare circumstances as many as 6 patients might be managed successfully and this is the maximum allowed. Subinterns will take night call with their supervising PGY-2 or PGY-3 resident and should admit at least 1-2 patients on an on-call day.
3. A comprehensive history and physical examination, and assessment and plan, must be performed on all new patients the day of admission. The history and physical examination must be reviewed and signed by the supervising PGY-2 or PGY-3 resident.
4. Comprehensive on and off service notes are required for patients assigned to the subintern at the start of the rotation and on those patients remaining hospitalized at the conclusion of the student's rotation. These on and off service notes should include a brief history and physical examination and summary of the patient's hospital course as well as a comprehensive problem list and care plan.
5. All subinterns are responsible for writing daily problem-oriented progress
notes on all of their patients. These notes must be reviewed, critiqued, and
countersigned by the supervising resident (PGY-2 or PGY-3) or attending physician
daily.
The Medicine Subinternship program is offered at Hahnemann University Hospital,
Graduate Hospital, Allegheny General Hospital, Easton Hospital, Monmouth Medical
Center, Abington Memorial Hospital and Mercy Catholic Medical Center. Subinternship
responsibilities at these institutions will be essentially identical to those
outlined. Particular issues, such as the start of workday, required conferences,
and week-end rounding, are left to the discretion of each institution’s
assigned faculty subinternship director. Additionally, the affiliate subinternship
course directors will be responsible for scheduling night call implementing
the subinternship conference series as outlined in the following section for
their institution.
Dr. Allan Tunkel is the Subinternship Course Director.
The following physicians are the Subinternship Course Associate Directors at
each site:
All senior students during their subinternship in Medicine
are required to attend a special series of interactive workshops/conferences
covering the approach to the diagnosis and management of patients with the following
medical urgencies and emergencies:
These workshops/conferences will be given throughout the rotation at each clinical
site. Attendance is mandatory.
They will be built around a written case protocol which will
include a series of questions to be considered by the stu-
dents. These protocols will be distributed on the first day
of the rotation. The workshop/conference leader will engage the students in
an interactive exchange of pertinent material.
After participating in the senior student medicine sub- internship workshop/conferences, the participant should be able to:
1. Acute Renal Failure
a. define physiologic and pathologic parameters of oliguria, including urinary
indices of dehydration and acute tubular necrosis;
b. differentiate characteristics of non-oliguric from oliguric acute renal failure;
c. recognize similarities and differences between ischemic and toxic acute tubular
necrosis;
d. describe presenting features of acute glomerulo- nephritis and acute tubular
necrosis;
e. assess risk factors and prescribe prophylaxis for acute renal failure;
f. recognize complications of acute renal failure including acid-base, fluid,
and electrolyte disorders.
2. Gastrointestinal Hemorrhage
a. indicate the approach to the patient who presents with acute GI bleeding,
including the signs of massive or brisk bleeding that require urgent therapy;
b. interpret aspects of the physical examination and diagnostic studies that
provide clues to the volume and rapidity of the patient's bleeding;
c. assess the differential diagnosis of GI bleeding and the relative frequency
of the causes;
d. recognize the predisposing factors and important aspects of the history of
patients with GI bleeding;
e. determine the therapeutic options available for the management of variceal
bleeding and nonvariceal UGI bleeding;
f. correlate the factors that are associated with a poor prognosis in patients
with GI bleeding.
3. Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic Non-ketotic Coma
a. recognize predisposing factors for and clinical features of DKA;
b. interpret diagnostic tests needed for the diagnosis of DKA;
c. differentiate DKA from other causes of an anion-gap metabolic acidosis
d. determine treatment priorities for DKA;
e. recognize symptoms and signs of Hyperosmolar Hyper-glycemic Nonketotic Coma;
f. determine priorities for treatment of Hyperosmolar Hyperglycemic Nonketotic
Coma and how they differ from patients with DKA.
4. Acute Respiratory Distress
a. explain the risk factors for pulmonary embolism;
b. recognize the symptoms and signs of pulmonary embolism;
c. determine the diagnostic workup and treatment of patients with suspected
pulmonary embolism;
d. describe indications and treatment regimens for anticoagulant therapy and
emergency thrombolysis;
e. recognize the indications for prophylaxis for deep venous thrombosis;
f. identify the risk factors for an asthma exacerbation;
g. assess the severity of an asthma attack based on clinical presentation and
arterial blood gases;
h. identify the approaches to asthma management that can successfully impact
upon airway hyper-responsiveness;
i. recognize the importance of objective measurements of lung function in asthma
management;
j. recognize the importance of patient education and environmental control in
asthma management.
5. The Febrile Patient
a. describe the clinical manifestations, microbiologic etiologies, diagnostic
approach, and management of complicated community-acquired pneumonia;
b. recognize the pathogenesis, pathophysiology, and clinical approach to the
patient with sepsis and septic shock;
c. indicate the rational use of empiric and targeted anti-microbial therapy;
d. perform an assessment of the febrile hospitalized patient;
e. indicate the differences in microbiologic etiologies and management of various
nosocomial infections.
6. Chest Pain
a. assess the clinical distinguishing characteristics of unstable angina, acute
myocardial infarction, acute aortic dissection, and pericarditis;
b. indicate the importance of diagnosing outpatient causes of chest pain including
mitral valve prolapse, hypertrophic cardiomyopathy, costochondritis, and GI
related causes of chest discomfort;
c. employ diagnostic tests to differentiate between un- stable angina and myocardial
infarction;
d. recognize the indications for thrombolytic therapy and other modalities in
patients with suspected acute myocardial infarction;
e. describe those drugs which have been shown to decrease mortality in unstable
angina and acute myocardial infarction;
f. relate the management of malignant ventricular arrhythmias associated with
acute myocardial infarction;
7. Opportunistic Infection in AIDS
a. demonstrate an organized approach to the evaluation of symptoms in patients
with HIV infection;
b. generate a differential diagnosis, diagnostic approach, and management for
the patient with HIV infection who presents a new seizure or focal neurologic
deficit;
c. describe a systematic approach to the evaluation of a patient with HIV infection
who presents with shortness of breath including differential diagnosis, diagnostic
approach, and management;
d. understand the outpatient management of the HIV- infected patients;
e. comment on the approximate risk to a health care worker associated with a
needle stick injury.
8. Congestive Heart Failure
a. recognize symptoms and signs of CHF;
b. differentiate mechanisms and clinical presentations of diastolic versus systolic
dysfunction etiologies of congestive heart failure;
c. describe the indications and mechanisms of action of pharmacologic agents
used in treating congestive heart failure including: vasodilators, beta blockers,
diuretics, inotropic agents, nitrates, calcium channel blockers;
d. recognize causes of refractoriness to therapy and understand indications
for cardiac transplantation.
9. Hypertension
a. define malignant hypertension and distinguish hyper- tensive urgencies from
hypertensive emergencies;
b. describe the approach to the evaluation of hyper- tensive emergency;
c. recognize the various cardiac, CNS, ophthalmologic, and hematologic manifestations
of hypertensive emergency;
d. distinguish the various pharmacologic approaches for the management of hypertensive
emergency;
e. explain the need for and timing of conversion to oral therapy for hypertension.
10. Abdominal Pain
a. Describe the common causes of abdominal pain in the hospitalized patient;
b. Learn the procedures for evaluation of abdominal pain;
c. Development a management plan for patients with specific causes of abdominal
pain.
11. Altered Mental Status
a. Understand the common causes of delirium and coma;
b. Learn the appropriate diagnostic work-up in a patient with altered mental
status;
c. Develop a management plan for various causes of altered mental status;
d. Understand use of various environmental and pharmacologic interventions to
manage delirium.
12. Arrhythmias
a. Be able to recognize atrial and ventricular arrhythmias (specifically atrial
fibrillation and ventricular tachycardia);
b. Understand the emergent and non-emergent management of atrial fibrillation;
c. Understand the scenarios that lead to development of atrial and ventricular
arrhythmias;
d. Learn the diagnostic work-up for patients with arrhythmias;
e. Learn the need for anticoagulation in patient with specific arrhythmias;
f. Learn the pharmacology and side effects of medications commonly used to treat
arrhythmias.
Attendance by subinterns is required at designated morning reports, Grand Rounds
and conferences along with the residents of the Department of Medicine.
The student's clinical performance on the wards will be evaluated by both
the supervising resident and attending physician using the standard Drexel University
College of Medicine clinical evaluation form. The student will be evaluated
for: fund of knowledge, history taking, physical examination, clinical reasoning,
data synthesis, interpersonal and communication skills, use of diagnostic and
learning resources, technical skills, and professionalism. Furthermore, the
student's participation during the subinternship conference series and attendance
at morning report and other conferences will be integrated into the summary
evaluation prepared by the Course Associate Directors.
Midway through the subinternship, the clinical preceptors (attending and resident)
will discuss with the student his/
her progress, including recommendations for improvement. The course director
must be notified at this time if the
performance of the student is felt to be below expected or un-satisfactory.
The clinical preceptor will review the student's four week progress as subintern
and complete the Senior Student
Clinical Rotation Evaluation Report form including "form- ative" and
"summative" comments and recommendations.
The student will be asked to critique the course and must complete a confidential
evaluation form to include subinternship clinical service experience, subinternship
attending and resident teaching and oversight, and work- shop quality. These
forms will be on the web.
The preceptor evaluation forms will be completed by each site director must
be forwarded to Dr. Tunkel's office.
The student evaluation form must be turned in on the last day of the rotation
and will be forwarded to Dr. Tunkel’s office.
The standard textbooks of Medicine are recommended as references including:
Harrison's, Cecil, Stein, etc.
Relevant sections of these textbooks can be used in preparation for the conference/workshop
series. The
Washington Manual is recommended as a quick reference while working on the wards.
