- Read this document.
- Put the clerkship website on your iPAD desktop. Go to the Yale Web Clips Service, or you can go directly to the clerkship website and put a link on your desktop.
- Be sure you have installed key medical applications on your iPad and/or other mobile devices, such as Micromedex and U-Central. These can be put on your hard drive for access without an internet connection.
- If your site has Yale network connectivity, you can access Cushing/Whitney Library resources online. Put on your desktop some of the information resources described below.
- If your site is not on the Yale network, you have three options.
- If the site has WiFi, access the Cushing/Whitney Medical by VPN and the iPAD will work just like you were on site at Yale. Instructions for configuring iPhone/iPad for Yale VPN
- If the site does not have WiFi, download and install the resources listed below (such as U-Central and Micromedex) to your iPad.
- Alternatively if the site does not have WiFi, consider purchasing a 3-G data plan for your iPAD for the month (from AT&T). Then, you can access the Yale Intranet via VPN.
- Consider purchasing one of the paper-based point-of-care resources for primary care listed below
To provide clerkship students for a model for managing knowledge needs in internal medicine, we asked senior clinicians and clinician/educators in the Department of Internal Medicine at Yale to describe how they keep up. Here is a distillation of what they said.
For point-of-care rapid access to information
- Go online to Up-To-Date through the Cushing/Whitney Medical Library website, especially for management advice
- Consult another library resource if needed. For example, the "Clinicians" portal on the main library website (ACP PIER, Clinical Evidence, Cochrane, etc.). Micromedex (full Web version) for drug information. A subspecialty textbook in the "e-book" section of the library website.
- Talk to colleagues when other resources fail or questions remain - in the lab, in the pharmacy, in clinical departments.
To research a clinical question in more detail
- Cecil's is helpful for Pathophysiology, etc.
- Consult a subspecialty textbook
- Medline search
- Create an Autoalert search on Medline (Ovid or PubMed) to receive regular updates via email on your topic
To keep up to date generally
- A key is to manage information efficiently and with routines. Develop a paced approach to avoid becoming overwhelmed.
- Every faculty member plans for a little general reading almost every day (i.e., reading not intended to answer a specific pre-formed question). The major source for this reading is journals.
- Every faculty member scans several journals as they come out and reads complete articles selectively. Here is a list of most popular journals: Annals of Internal Medicine, Archives of Internal Medicine, BMJ, JAMA, Lancet, The New England Journal of Medicine and their major subspecialty journal(s). Most faculty members receive some of their journal(s) in print form (especially The New England Journal of Medicine). Most faculty members have tables of contents sent to them for other journals as they are published. They scan the articles for those they want to review in detail.
- Purchase and read review books as needed (e.g., Lippincott's Clinical Pharmacology Textbook).
- Attend Grand Rounds each Thursday (not everyone does this)
- Attend subspecialty rounds
- Attend one or two specialty society meetings each year
- Re-certify in the specialty as needed (this requires lots of study at 10 year intervals)
- Teach and write (the teacher always learns more than the students)
- The Medical Knowledge Self Assessment Program from the American College of Medicine is a favorite way to review. It comprises about 10 slim volumes. Faculty get CME credit for answering questions.
Reading during the clerkship has four goals, which are to assure students:
- Are able to answer timely questions at the point of care.
- Gain deeper knowledge of specific conditions. This deeper knowledge is needed to support advanced skill in patient counseling and management.
- Gain broad working knowledge of the domain of internal medicine. Students need this broad knowledge so that their minds are primed to seek or recognize symptoms and signs that support clinical diagnosis and to consider potential therapies for confirmed disease. It is a truism that a clinician will miss the diagnosis he or she does not recognize.
- Develop effective skills for building and replenishing their knowledge in medicine.
Rather than proscribe specific readings, the approach in this clerkship is to provide you with strategies for accessing information at the point of care to answer timely questions, building broad knowledge of general internal medicine, and gaining deeper knowledge when needed. This approach may be applied to other disciplines.
To access information at the point of care to answer timely questions, we suggest you confirm you have access to on-line or downloaded resources from the Harvey Cushing /John Hay Whitney Medical Library. Some sites (e.g., the Primary Care Center at Yale, Yale Health Services, and selected computers at the West Haven Veterans Administration Medical Center) are on the Yale network.
If your site is not on the Yale network, but the site has WiFi, you can connect your iPAD to the Yale Library using a VPN connection. If the site does not have WiFi, you can
- activate the 3G connection on your iPAD prior to your clerkship (about $20 for one month through At&T); or
- download selected resources to your iPAD prior to going to your site. At minimum, we suggest UCentral, Micromedex or Epocrates, MedCalc or QX Calculate
In addition to electronic resources, we suggest you purchase one of the books listed below to carry with you.
To gain deeper knowledge on specific topics, formulate your questions as clearly and specifically as possible. Options to access information include:
- Start with a general source such as Up-To-Date or another textbook;
- Go next, if needed, to more detailed information, such as a subspecialty textbook, Cochrane reviews, Medline search for latest reviews and original articles, or ask a librarian for help identifying source information;
- Go to Access Medicine on the Cushing/Whitney Library Website. It has Harrisons and many other textbooks. This may be the single, most useful collection of textbooks available to us.
In general, it is always good to go to more than one source. This helps to identify controversies in the field and avoid error that may occur by acceptance of unsupported opinions or misleading research.
To build broad knowledge and maintain awareness of important new developments in general internal medicine, we suggest (a suggestion which applies to every year in medical school, every clerkship, the rest of your life) that you:
- Plan to do some general reading (i.e., reading that is not targeted at a specific clinical question) most days;
- Scan at least one, preferably more, major medical journals as they are published. The major general medical journals are British Medical Journal, JAMA, Lancet, The New England Journal of Medicine;
- Scan at least one major journal in your the field of General Internal Medicine (American Journal of Medicine, Annals of Internal Medicine, Archives of internal Medicine;
- To read efficiently at your stage, in each of these journals, read each of the case-based presentations in detail (e.g., case records of the Massachusetts General Hospital in the NEJM or "clinical crossroads" in JAMA). Then consider reading the review articles in entirety (e.g., "In The Clinic" series in the Annals of Internal Medicine). Also, read at least the abstract and introduction of the other original research articles (read the full article in areas that interest you;
Here is how some senior internists at Yale do their journal scanning.
- Have paper copies of the journals delivered to home or office (caveat: this is an expensive option that is not practical for most medical students)
- Sign up to have the table of contents from selected journals emailed to you each week
- Every major journal provides this service free
- Use the UCentral "Medline Journals" function to give you updated access to table of contents (to customize your list of UCentral journals, log into your UCentral account through the link on the Medical Library's mobile page)
To carry with you
- A quick reference for differential diagnosis of symptoms, such as Wasson common symptom guide (RC69 C65 2009), Field Guide to Clinical Diagnosis (RC71 S63 2007), and Symptom to Diagnosis, an evidence-based guide (2nd edition, McGraw Hill Medical)
- Your iPAD with the following on your desktop: U-Central (this has some quick references, such as Harrison's Manual of Medicine); Micromedex or Epocrates; AHRQ ePSS (preventive care guidelines/recommendations); and a medical calculator (e.g., MedCalc or Qx Calculate)
- Information on these and other applications are on the Medical Library's Mobile Device Application page
To read cover to cover during the clerkship
- MKSAP for students
- The articles listed as recommended reading for each case conference
To consult for brief topic overviews as needed
- Primary Care Medicine (Goroll) (available online and the Reserve Room)
- Principles of Ambulatory Medicine (Barker, et al) (available in the Reserve Room)
- Up to date
- Step up to Medicine
To consult for deeper understanding
- Well-edited textbooks: pharmacology text and subspecialty fields
- Current reviews from well-edited general medicine journals (Lancet, BMJ, NEJM, Annals of Internal Medicine, American Journal of Medicine, Archives of Internal Medicine
- Original papers - identify from Medline?
- Cochrane Collaboration
- Cushing/Hay Medical Library "clinicians" portal
One condensed textbook of Ambulatory Care Internal Medicine:
- Alguire PC, CDIM, ACP Internal Medicine-Essentials for Clerkship Students 2007-2008. ISBN 9781934465134. Price $44.95.
- Griffith C, Hoellein A, First Exposure to Internal Medicine: Hospital Medicine. ISBN 0-071459014. Price $36.85.
- Abramson JS, Alper EJ, Caruso JW, et al. MKSAP 4 for Students. Philadelphia, American College of Physicians - American Society of Internal Medicine, 2008. ISBN 9781934465035. Price $49.45. (Available at Yale Coop Medical Bookstore)
- One symptom-based quick diagnosis evaluation and treatment:
- Wasson JH, Walsh BT, Labrecque MC, Sox HC, Pantell R. The Common Symptom Guide. Fifth Edition. New York, McGraw-Hill Inc, 2002. ISBN 0-07137765-4. Price $42.25.
- Stern SD, Cifu AS, Ahkorn D Symptom to Diagnosis-An Evidence-Based Guide. ISBN 9780071496131. Price $24.98.
- Smith DS, Field Guild to Bedside Diagnosis. Second Edition, Philadelphia, Lipincott Williams & Wilkins, 2006. ISBN 0-781781655. Price $50.00.
- Sellers RH Differential Diagnosis of Common Complaints. ISBN 9781416029069. Price $40.05.
- One book on interviewing:
- Billings JA, Stoeckle JD. The Clinical Encounter. A Guide to the Medical Interview and Case Presentation. St. Louis, Mosby Inc, 1999. ISBN 0-815113749. Price $32.00
- Smith RC, Patient-Centered Interviewing - An Evidenced-Based Method. ISBN 0-781732794. Price $39.95.
- Wilson, J., Laine, C., Goldmann, F., Sox, H. In the Clinic: Alcohol Use.Annals of Internal Medicine, ITC-3, March 2009. PMID 19258556. Price - free.
- Clerkship Directors in Internal Medicine, Primer to the Internal Medicine Clerkship, December 2004. Download at IM.org/publications. Price - free.
- Barker LR, Burton JR, Zieve PD, Principles of Ambulatory Medicine. Seventh Edition. Baltimore, Williams & Wilkins 2006. ISBN 9780683303520. Price $90.00.
- Up-to-date (see Cushing Library site).
- Newble D, Cannon R., A Handbook for Medical Teachers (4 th Revised Edition). Dordrecht; Boston, Kluwer Academic, 2001. ISBN 0-792370929. Price $71.97.
- OVID (Available at Yale Library Site)
- Cochrane Database
- Best Evidence
- Micromedex (Pharmacy Database Available at Yale Library Site)