DEPARTMENT OF MEDICINE

KECK SCHOOL OF MEDICINE

2020 Zonal Avenue, IRD Room 626

Los Angeles, CA 90033

Phone 323-409-6620 • Fax 323-226-2116

Internal Medicine Sub-Internship Clerkship Manual

Academic Year 2021-2022

Clerkship Faculty and Staff

Jeff Canceko, M.D.

Clerkship Director

323-409-6620

canceko@usc.edu

Matthew Johnson, M.D.

Associate Clerkship Director

323-409-6620

msjohnso@med.usc.edu

Sonya Earley, PA-C, M.A., CDCES

Medical Student Educator

Clinical Associate Professor

323-409-6620

earley@usc.edu

Angel Vallejo

Clerkship Coordinator

323-409-6620

medclerk@usc.edu

Department of Medicine Office Hours

8:30 am to 4:30 pm

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Table of Contents Introduction ................................................................................................................................................... 2

Internal Medicine Sub Internship Learning Objectives ................................................................................ 2

Internal Medicine Sub Internship Goals ....................................................................................................... 3

Clerkship Structure ....................................................................................................................................... 3

Clerkship Site Descriptions ........................................................................................................................... 3

Clinical Learning Activities .......................................................................................................................... 4

Curriculum .................................................................................................................................................... 4

Student Practice Profile (SPP)/Must-See Encounters ................................................................................... 6

Student Assessment ...................................................................................................................................... 7

HIPAA Privacy Regulations ......................................................................................................................... 8

Medical Student Time Requirements ............................................................................................................ 8

Wellness Day Policy ..................................................................................................................................... 8

Attendance Policy ......................................................................................................................................... 9

Professional Responsibilities and Behavior .................................................................................................. 9

Clerkship Evaluation ..................................................................................................................................... 9

Mistreatment ................................................................................................................................................. 9

Additional Information ................................................................................................................................. 9

Disability Services and Programs (DSP) .................................................................................................... 10

How to Deal with Urgent/Emergent Personal Issues .................................................................................. 10

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Introduction Welcome to the Internal Medicine Sub-Internship! We hope that you will find the following four weeks of

Internal Medicine experience both fun and educational.

Senior Medical Students will work directly with attending physicians and residents in the provision of

patient care in an inpatient, sub-internship experience. Your experience on the Internal Medicine Sub-

Internship will be directly proportional to the energy and interest that you invest. You must attend all

student lectures and conferences, be an integral member of your Medicine team, and perform in-depth

investigations and research about your patients’ medical problems. Students are expected to perform and

carry a patient load at a level nearly equivalent to that of an Internal Medicine Intern. The Internal Medicine

Sub-Internship is designed to prepare students for the challenge and rigors of internship.

We hope that you will enjoy this learning opportunity and will find gratifying the profound contributions

that you can make to your patients' care.

Please note that you are responsible for knowing and following the Keck School of Medicine Student

Policies.

Internal Medicine Sub Internship Learning Objectives In real or simulated clinical settings, students will:

1. Apply advanced basic-science and clinical knowledge to the clinical data and develop

comprehensive differential diagnoses.

2. Accurately gather information to develop prioritized differential diagnoses, and suggest evidence-

based diagnostic and review in real time treatment strategies for a resident and/or faculty

supervisor.

3. Write complete, concise, and evidence-based daily progress notes using the SOAP format.

4. Demonstrate proficiency in the care of patient’s common inpatient cross cover and emergency

scenarios.

5. Accurately describe the indications and contraindications for common procedures in internal

medicine

6. Accurately interpret common laboratory and diagnostic tests: EKG, CXR, UA, blood chemistries,

CBC, peripheral blood smear, ABG, cell counts and chemistries of spinal, pleural, joint or ascitic

fluids.

7. Design appropriate, evidence-based, cost-effective diagnostic and treatment strategies.

8. Perform concise, complete, and well-organized verbal case presentations.

9. Communicate effectively with patients and develop close and therapeutic medical student-patient

relationships with progressively increasing independence

10. Work effectively and harmoniously with colleagues, nursing staff, allied health personnel, and

physicians.

11. Appropriately incorporate ancillary services, community resources, and appropriate discharge

planning techniques to optimize patient care.

12. Demonstrate a commitment to caring for all patients, regardless of gender, race, socioeconomic

status, intellect, sexual orientation, ability to pay or cultural background.

13. Identify patients whose illnesses may put the community at risk.

14. Conduct a focused literature search, critically appraise the medical literature and apply best

evidence to the internal medicine problems encountered.

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Internal Medicine Sub Internship Goals A variety of presentations and experiential learning opportunities are designed to introduce the students to

the following topics/ skills under the supervision and guidance of residents and faculty:

1. Caring for diverse adult inpatients at a variety of clinical settings.

2. Admitting and cross covering patients.

3. Writing orders, prescriptions, and discharge summaries.

4. Effectively communicating with patients by:

a. Using lay terms appropriate to patient’s level of understanding.

b. Recognizing and managing denial and grief.

c. Communicating abnormal results and “bad news” to patients in a sensitive manner.

d. Discuss end of life issues with attention to patient’s wishes and needs.

e. Providing concise daily updates for patients and families regarding hospital course and

rationale for ongoing or new treatment plans.

5. Identifying alternatives in difficult ethical choices, analyze conflicting considerations and execute

a course of action that takes into account the ethical complexities.

6. Recognize the potential conflicts between patient expectations and medically appropriate care.

7. Applying the concepts surrounding advance directives in patient care activities.

8. Apply the concepts surrounding informed consent in patient care activities.

9. Preparing concise, evidence based, write-ups on clinical diagnoses

10. Conducting continual self-evaluation and life-long learning.

14. Recognizing the importance of systems – especially interprofessional collaboration in delivering

high quality patient care.

15. Adequately asses the limits of his/her medical knowledge in relation to the patient problems

encountered.

16. Actively incorporate formative feedback and evaluation into his/her daily practice.

Clerkship Structure During the Internal Medicine Sub-Internship, you will become a member of a team consisting of a faculty

attending, a resident, two interns, one to two 4th year students, and one to two 3rd year students. One of

the primary responsibilities of the resident is to teach and supervise medical students. Your resident will

select patients who are appropriate for you to manage and aid you in fulfilling the goals covered in the

Learning Objectives (see link above). It is important to remember that an attending or resident must

countersign all histories and physicals, orders, progress notes, and discharge summaries.

Wellness Day- On the second Friday of the Clerkship, students will have the afternoon off (1/2 day off) for

Wellness. It’s recommended to use this half-day for doctor appointments, studying, and to simply BE

WELL. At KSOM, student health and well-being are the highest priority.

Clerkship Site Descriptions Clerkship site descriptions can be viewed at the following website:

https://ksom.usc.edu/curriculum/year3/

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Clinical Learning Activities A. Schedule Overview

Time Schedule: Conference/Activity

6:30 – 7:00 am Pre-Rounds on Patients

7:00 – 8:00 am Work Rounds with Team

8:00 – 9:00 am Morning Report

9:00 – 11:00 am Teaching Rounds

12:00 – 1:00 pm Lunch

1:00 – 4:00 pm Discharge Planning & Management Rounds

1:00 – 4:00 pm Student Curriculum (TBD)

6:30 am – 6 pm Clerkship Work Schedule

Students are expected to admit patients on a daily basis. Students are expected to remain with their

residents daily from 6:30 am to 6 pm. You will return the next morning prepared to pre-round on

your patients. Remember that your supervising resident must countersign all of your work via

computer. You are relieved of all clinical responsibilities on the last Tuesday of the rotation at 6

pm.

B. Work Rounds - The team's established patients will be seen by the entire team. You should be

prepared to present your patients and discuss your findings with your resident. Work rounds

provides an opportunity to determine and implement the plans you wish to carry out for the day:

which lab studies need to be drawn, which diagnostic studies need to be scheduled, which lab

results need to be checked, which films or scans need to be reviewed, which consults need to be

called and which therapies to continue or change.

C. Teaching Rounds - All admissions and established patients with new problems will be reviewed

at the bedside by your attending faculty. During the last one-half hour of teaching rounds house

officers or medical students may give didactic presentations of medical topics relevant to the team’s

activities.

D. Sign Outs - It is imperative that you sign out your patients to the physician responsible for the care

of your patients when you are outside the hospital. You must communicate directly with this

physician in person. A sign out consists of the name and P.F. number of your patient, a brief

summary of the medical problems and present therapy, and an explanation of any procedures or

diagnostic studies you wish to be performed in your absence (such as serum glucose level in a

diabetic, a hematocrit in a bleeding patient, or a fever work up). Please do your sign outs in

conjunction with your residents.

E. Procedures - Your resident is expected to instruct and supervise you in any and all procedures you

may need to learn. Anyone who does not feel comfortable with a procedure (thoracentesis,

paracentesis, central line replacements, etc.) should express their discomfort.

Curriculum Attendances at all sessions are mandatory unless otherwise stated.

A. Syllabus and Text – There is no required text book, however, a great reference text is Andreoli and

Carpenter’s Cecil Essentials of Medicine 10th Edition. E-book available through Norris Medical

Library. Requires USC network connection. Link: http://web-

app.usc.edu/e_resources/hsl/gateways/30681.php (click on “Access this resource”).

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B. Student Afternoon Report – Two Weekday Afternoons, IPT Conference Room (see calendar). These

sessions are designed to invite student participation in a problem-solving approach to clinical case

presentations. Each session, medical students will be chosen to make case presentations and provide

supporting laboratory and test results. Internal Medicine faculty will guide a process intended to hone

one’s skill at synthesizing historical, physical and laboratory data, establishing differential diagnoses,

as well as, diagnostic and treatment strategies. Students are assigned to present.

C. Patient Care Workshops – Students are divided into two groups where they will be given typical

cross cover and emergency scenarios. As a group, students will work through various scenarios.

Workshops will be run by Internal Medicine Hospitalist Faculty.

• Workshop Topics Include:

o Seizures

o Dyspnea

o Fever

o SIRS/Sepsis

o Abdominal Pain

o Chest Pain

o Tachycardia

o Altered Mental Status

o IV Fluid Management

D. Pain Management –Palliative Care faculty review various approaches to pain management.

E. Morning Report – (Student Attendance is Mandatory) Monday and Thursday, 8:00-9:00 am,

Inpatient Tower-Conference Room B or Virtual. Residents present and discuss cases recently admitted

to the Internal Medicine Service. This is an excellent conference for observing clinical problem

solving. Wide arrays of medical problems are discussed and faculty representatives from the

Department of Medicine are present for expert advice.

F. Faculty Mentor Rounds – (Timing at the discretion of the faculty attending.) The team’s attending

spends 1-2 hours per week with the medical students reviewing clinically based topics. Topics include

medical documentation, physical examination, critical thinking and patient management.

G. Medical Grand Rounds – (Student Attendance Highly Recommended) Fridays, 12:00-1:00 pm,

Inpatient Tower – Conference Room B Senior residents, under the guidance of faculty mentors,

present interesting Internal Medicine cases with didactic overviews.

H. Evidence Based Write Ups- During the clerkship, each student will submit two evidence based

write-ups for review by the faculty attending. Both write-ups are due simultaneously, in duplicate,

the Third Monday of the rotation. One copy of each write-up is to be submitted to the MSE and

Coordinator or Clerkship office, IRD 626. The duplicate copy is presented at your mentor session.

Both write ups should be typed and include evidenced based summaries including references.

Students who present for the Student Afternoon Reports can submit that PowerPoint as one of the

required write-ups. Please see the attached Sample Write-Ups located in your Orientation packet for

the required format.

I. Clinical Inquiry and Simple Cases (CI)- The CI features aspects of the Case Based Curriculum used

at Keck School of Medicine (KSOM). You will have a computerized quiz based on your workshops

worth 15% of your grade.

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Student Practice Profile (SPP)/Must-See Encounters SPP/“MUST SEE” encounters of the student's interaction with assigned patients. The rationale for the

timely completion of patient encounters is twofold. In addition to providing the student with a readily

accessible patient profile, it enables the faculty to review the number, complexity and breadth of clinical

experiences the student is afforded during the clerkship. The patient encounter format is concise and allows

the student to describe relevant patient findings reflected through the history, physical examination,

assessment and plan. All SPP/ Must See encounters DO NOT REQUIRE A SUMMARY!

The data that are collected and aggregated provide a representation of the patient population and clinical

sites which allows the faculty to evaluate and revise the clinical experience as it relates to the core

curriculum objectives and competencies. In addition, students and faculty are able to track learners’

experiences with the encounter of the SPP, and to assure that patient encounters are equivalent across sites.

During the four week clerkship, students should have the opportunity to care for actual patients that meet

the criteria of the SPP/“MUST SEE” encounters. However, if an actual patient encounter with a particular

diagnosis or symptom has not been available, the clerkship MSE will assist the student by identifying a

patient or an alternative experience at another site, or the student may be asked to complete a simulated or

alternative experience, e.g., a “virtual” (paper or web-based) case, a lecture or case discussion, a problem-

based learning case, etc. The student will document this alternative encounter on MedOASIS according to

the instructions given to you by the MSE.

During the clerkship, you will be required to enter an encounter for each of the Student Practice Profile

(SPP) encounters, also known as “MUST SEE” encounters.

Requirement Checklist:

1. Chest Pain

2. Pain Management

3. Fever of Unknown Origin

4. Renal Failure

5. Dyspnea

You will log all encounters in MedOASIS based on your admissions. In the encounters, you can enter up

to three (3) of the SPP/“MUST SEE” diagnoses per patient within those encounters. Just simply check off

on the drop down diagnosis menu. This will mean that you only have 2 SPP entries remaining to include in

your other admissions. Nearly all “MUST SEE” encounters are viewed in some form during the clerkship.

If, however, you are not able to see an actual patient for any of the SPP/“MUST SEE” encounters, please

talk to the MSE. You will be able to use an alternative (virtual, lecture, workshop cases, etc.) encounters.

Ideally, all encounters should be ACTUAL patients.

The MedOASIS application can be accessed via a web browser at http://mymedweb.usc.edu. Please click

on an overview of the required checklist. For technical questions, please contact Raymond Lam at 442-

2156 or email at chiyuila@med.usc.edu.

Note: Students must have all of their patient encounters completed on MedOASIS no later than 5:00

pm on the third (3rd) Friday of the rotation. The Medical Student Educator will review the patient

encounters and determine if the submissions are adequate. All clerkship evaluations (program,

attendings, and residents) must be entered on MedOASIS no later than 5:00 pm the final Thursday

of the rotation.

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Student Assessment Final examinations are administered by this Clerkship.

A. Nationally Standardized Subject Exam

B. Clinical Inquiry Quiz (CIQ)

The Subject Exam is administered on the last Friday of each rotation and is coordinated by the Assessment,

Evaluation, and Reporting Office.

Evaluation and Grading

The following components contribute to each individual's grade:

1. Written evaluations from faculty attendings and residents

Note: It is the policy of the Department, that students shall address any

concerns regarding evaluations to the Clerkship office. Students are

NOT permitted to contact their medicine team attending, senior or junior

house officers regarding any evaluations.

60% of grade

2. Nationally Standardized Subject Exam 25% of grade

3. Clinical Inquiry Quiz 15% of grade

4. Other Satisfactory Completion of:

• Mid-Clerkship Feedback Form (due on 3rd Monday) ✓

• All SPP/Must See Encounters Entered in MedOASIS (due on 3rd

Friday)

✓

• Two Evidence Based Write-Ups (due on 3rd Monday) ✓

Note: If applicable, the narrative portion of the final clerkship evaluation will indicate any of the above

requirements not met.

The final clerkship grade is determined by your composite score and the following grades are possible:

Overall Score cut off for

each grade

Minimum NBME Subject

Exam Score for each grade

Internal Medicine

Sub Internship Honors 90+

62 High Pass 73-89

Pass 67-72

Fail 66 or below

Passing the Clerkship: To receive a passing grade (Pass, High Pass, or Honor) for the clerkship,

students must demonstrate minimum competence based on their 1) overall clerkship performance; 2) the

NBME subject exam performance; and 3) the absence of unprofessional behaviors as outlined in the

student handbook.

1. Students who do not pass the NBME subject exam on their first attempt will be ineligible for

Honors.

2. Students who pass the retake exam (second attempt) will receive their original clerkship grade of

Pass (P) or High Pass (HP) on their transcript for that clerkship. If their original grade is H, their

final clerkship grade will be downgraded to an HP.

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3. Students who fail the retake exam (second attempt) will continue to have a grade of Incomplete

(I) noted on their transcript for that clerkship and will be required to sit for a second retake (third

attempt) of the NBME subject exam.

4. Students who pass the second retake exam (third attempt) will receive a grade of “Pass” for the

clerkship. They are ineligible for a grade of HP or Honors.

5. Students who fail the second retake exam (third attempt) will receive a grade of “Fail” (F) for the

clerkship and must repeat the clerkship.

Fail: A grade of fail may be given in the following situations: 1) failure to demonstrate minimum

competence based on overall clerkship performance, 2) any unprofessional behavior as outlined in the

student handbook, 3) failure to resolve a grade of incomplete.

Incomplete: Not a final grade, but a designation that is used if a student has been excused from meeting a

clerkship deadline.

• Grades of “Incomplete” will be assigned to any student who does not complete any required

component of the clerkship.

• Grades of “Incomplete” will be assigned to any student who has not yet achieve the minimum

score set for passing the clerkship on their NBME Subject Exam.

HIPAA Privacy Regulations Please note that HIPAA privacy regulations are in effect at all times in all clinical settings. Individual

practitioners (including medical students) are held personally responsible for violations of HIPAA

regulations which may result in financial and other penalties. You have previously completed a HIPAA

training on Trojan Learn and have access to the training modules if you wish to review them. You can also

find additional information by visiting https://ooc.usc.edu/data-privacy/health-information/hipaa-privacy-

regulations/

Medical Student Time Requirements In general, students on their Internal Medicine clerkship work Monday-Saturday, in an inpatient setting,

with no required call responsibilities. Students are expected to work in the hospital with their team

members- medical students, Interns, Residents, and faculty members six days per week (often, students

work 60 + hrs/week). Because students are placed at a wide variety of practice sites with varying business

hours, students should understand and accept that their work schedules will vary, although every student

will be working full-time.

Student hours include the following limits: a maximum of 28 hours in the hospital over one period and a

maximum of 80 hours per week averaged over four weeks. Students receive at least one day off per week

(pre-set off day). Please review the Medical Student Time Requirements Policy for more comprehensive

information.

http://medweb.usc.edu/policies/medical_student_time_requirements_for_clinical_and_educational_activit

ies.html

Wellness Day Policy Wellness days are mandatory and are incorporated into clerkship schedules to provide students with an

opportunity to attend to their personal wellbeing. Students are released from clinical duties one full day for

each 6-week clerkship and 1/2 day for each 4-week clerkship. The timing of wellness days are electronically

posted and communicated by the clerkships.

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Attendance Policy It is the responsibility of the student to notify the proper individuals (Medical Student Educator, Attending,

Senior Resident) of absences in case of personal emergencies and unforeseen events. Please review the

KSOM Attendance Policy for more detail.

http://medweb.usc.edu/policies/attendance_and_absence_request.html

Professional Responsibilities and Behavior Unique to the Family Medicine Clerkship is the opportunity for you to be an ambassador and exemplary

representative of KSOM and USC to other cities and institutions across CA and the U.S. Promoting a

positive image of KSOM ensures that we continue to recruit and maintain outstanding preceptors who

kindly open their practices to USC students and also benefits you directly with residency applications and

eventual practice.

Please refer to http://medweb.usc.edu/policies/guidebooks/medical_student_teaching.html#one for more

detail.

Clerkship Evaluation We rely on your thoughtful and constructive feedback to continually improve our clerkship.

Please complete the following to meet clerkship expectations:

1. Submit Orientation week Evaluations on MedOasis by the end of the week. If you did not attend

more than ½ of a particular session, please check the “N/A” box.

2. Preceptor/Site Evaluation

3. Director/MSE Evaluation

4. Clerkship Evaluation

Completing the evaluations is expected and part of your professional responsibilities. Pease refer to the

http://medweb.usc.edu/policies/.

Mistreatment KSOM is committed to creating a positive learning environment. Students are encouraged to report

instances of disrespect that “unreasonably interferes with the learning process”. Please review

http://medweb.usc.edu/policies/mistreatment_and_professional_behavior.html for more information on

mistreatment policies and the mechanisms by which you can report mistreatment.

Consistency of Evaluations and Grading within Internal Medicine Sub-Internship

Criteria for Resident and/or Faculty Supervisors Eligibility: All residents and attendings that are the

supervisors of record for at least 1 [calendar] week (typically 6 days, 1 day off).

Minimum number of Supervisor Evaluations Required to Generate the Final Grade: One attending.

Additional Information A. MedOASIS Documentation of SPP/Must See Encounters:

Medical Student Documentation of Patient Encounters using mymedweb.usc.edu:

"MedOASIS" is a highly specialized information system used throughout the four year medical

school curriculum. In addition to course materials, class schedules, web-based educational programs

and interactive links, patient encounters and clerkship evaluations are accessed through the system.

10

If you would like to review a sample on how to input a patient encounter, please review a web-casted

segment at:

http://keckmedia.usc.edu/mediasite/Viewer/?peid=a79d58bf64b046d88afaa2a8628f14a3

For complete instructions on entering SPP/MUST SEE encounters on MedOASIS, please refer to the

document entitled “Clinical Experience Portfolio User Instructions” on MedOASIS, listed under

Clerkship Learning Resources. You may also wish to view the Introduction to Clinical Experience

Portfolio Instructional Video located at the same site. Please use the patient’s diagnosis as the “alias”

for the encounter entry. This will allow easier tracking of your MUST SEE encounters throughout

the clerkship.

There is an example of a comprehensive patient encounter (Attachment B) online at:

http://medweb.usc.edu/site/clerkships/clerkship_general_resources.htm under the sub group listed

as: “Clinical Experience Portfolio User Instructions for Medicine I.” Please contact Raymond Lam

at (323) 442-2156 or e-mail him at chiyuila@med.usc.edu with any technical questions.

Note: In order for clerkship faculty to have adequate time to review SPP encounters, students

must have all of their patient encounters completed on MedOASIS no later than 5:00 pm on

Friday of week 3 of the rotation. Points will be deducted from your clerkship grade if this

deadline is not met. All clerkship evaluations must be entered on MedOASIS no later than

5:00 pm the final Thursday of the rotation.

B. Internal Medicine Sub-I lectures can be found in the Blackboard course and in the webcast

link: http://keckmedia.usc.edu/Mediasite/Catalog/Full/e14052deb3d0480ca6b0bf19262901c421

C. Information about Clinical Affiliates

Disability Services and Programs (DSP) Disability Services and Programs provides support services and accommodations necessary to enable

students with disabilities to develop their maximum potential by making their education accessible, while

having the dignity to work independently.

DSP Services Include:

• Assistance in providing readers, scribes, note-takers and/or interpreters.

• Special accommodations for test taking needs.

• Assistance with architectural barriers.

• Assistance in obtaining books and supplies from the University Bookstore.

• Information regarding accessible seating at USC sporting events.

• Auxiliary aid equipment loans.

• Assistive Technology.

• Support for individual needs that are unique to a student’s disability.

If you have any questions regarding these services, please feel free to contact us at (213) 740-0776.

Link: https://dsp.usc.edu/

How to Deal with Urgent/Emergent Personal Issues Link: http://medweb.usc.edu/students/