What you will do:

This rotation split between the inpatient and outpatient settings will be under the supervision of an internal medicine physician with years of experience as an educator as a faculty member at the Florida International University College of Medicine. Although no longer part of the faculty, this physician remains active in the teaching and mentoring of international medical students and graduates.

Your day will start at 6 AM in the physician’s office where you will meet with the attending to go over new hospital admissions. On a typical day, this physician will receive 17-20 new patients on the service. Each student will be assigned several new patients to see and evaluate.

At approximately 6:30 AM, you will start prerounds. During this time, you will be responsible for taking the history and performing the exam in your assigned patients. Rotators will also find it useful to acquire relevant information from discussions with the nursing staff regarding overnight events, orders that have been placed, and consults that have been completed. Following your patient encounter, you will develop your assessment and plan and prepare to present the case to the attending.

These cases will be presented to the attending during teaching rounds which typically start at 8 AM and end at 11 AM. During these rounds, you will accompany the preceptor and other students to the ICU, CCU, Step-Down Unit, and medical wards. Please note that this attending prefers that you present your cases in the patient’s room at the bedside. After the patient is presented, the attending will ask you questions for clarification and to stimulate discussion among the team. The team will then see the patient to confirm the findings from your evaluation and finalize the day’s diagnostic and treatment plan.

Of note, while these new admissions may have been worked up by other providers (e.g., emergency department), this attending strongly believes that students should not be overly influenced by admitting diagnoses. In other words, this preceptor will expect you to not be biased by another doctor’s evaluation and assessment. Therefore, the preceptor will not give you access to all the information in the patient’s chart. Instead, you will be given a brief summary of the patient’s situation as the starting point for your own evaluation. This approach will allow you to form your own conclusions regarding the diagnosis and workup and help prevent you from making a common diagnostic error in medicine known as premature closure. Premature closure is defined by Dr. Croskerry of Dalhousie University as the following:

Premature closure: is a powerful bias accounting for a high proportion of missed diagnoses. It is the tendency to apply premature closure to the decision-making process, accepting a diagnosis before it has been fully verified. The consequences of the bias are reflected in the maxim ‘when the diagnosis is made, the thinking stops’.

Following teaching rounds, you will return to the physician’s office where you will work on your note writing. The emphasis will be on writing an accurate and thorough history and physical exam. Your documentation will be reviewed and edited by the preceptor and then added to the EMR. Please note that you will not be directly entering patient information into the Citrix EMR. As you are working on your notes, the attending may ask you questions about the patient’s conditions and what you feel is the next step in the evaluation and management.

Several times per week, a student on the team will deliver a 15-minute PowerPoint topic presentation. Once the topic is selected, all students are expected to read about it so that they can maximize their learning from the talk. Students will be expected to ask the speaker questions to further their knowledge and understanding.

During your experience, you will learn the following U.S. medical practices under the preceptor’s supervision:

• Taking patient histories under supervision.

• Performing exams under the physician's supervision.

• Presenting patients.

• Writing notes

• Researching the literature to answer clinical questions at the point of care.

• Educating patients under supervision.

• Giving talks to the team.

• Spending time with other healthcare professionals to understand their roles and responsibilities.

Of note, 60-70% of patients are Spanish speakers. For rotators who do not speak Spanish, taking the history when there is a language barrier present may be challenging. However, as you will encounter non-English-speaking patients frequently as a trainee in US-based residency programs, this rotation will help you discover strategies to more effectively communicate with patients when language barriers are present (e.g., family members, bilingual staff members, mobile translation apps). In addition, this will be an opportunity for non-Spanish-speaking rotators to practice their medical Spanish.