Welcome to Internal Medicine! It is a privilege to have you on our team, teach you and care for patients alongside you.

This is a brief guide meant to orient new clinical clerks to the internal medicine clinical teaching unit (CTU). It isn’t meant to supersede the rotation objectives as set out by your program, but it’s meant to provide some clarification about your role and help you feel more confident, rooted in my own struggles during my first days on CTU.

The strengths of the CTU as a rotation are the same as its challenges: you are given an immense amount of independence in the management of the patients assigned to you as a medical student. Many medical students appreciate this about CTU, citing it as “the first time they felt like a doctor.” This also means you are expected to get a handle on the patients assigned to you quickly and understand how to manage their illness(es) and support their recovery, including how hospital and social systems contribute to (or hamper) this.

CTU is actually two jobs: in the days, you will be taking care of patients admitted to Medicine wards and managing their medical issues, by seeing the patients every day (referred to as “rounding” on them), ordering and interpreting lab tests and imaging, performing physical exam maneuvers, and integrating all of this in the clinical context of the patient’s presentation.

In the nights when you are on call, you (or, often, the resident on your team) is responsible for the entire list of patients assigned to your medical team, as well as admitting new patients from the emergency room to your team. This role will be detailed leader below.

CTU Structure

The CTU team contains a staff physician who oversees the team, a senior medical resident (SMR; second year of residency in Internal Medicine or higher), a number of junior medical residents, including first year internal medicine residents and a mix of first and second year “off-service” (non-IM) residents, physician extenders (physician assistants/nurse practitioners), and you, the clinical clerk, of which there may be one or two.

Guiding Principles of Daytime CTU

The biggest consideration when managing patients on CTU, and a question you must ask yourself daily when caring for them, is “why is this patient still in the hospital, and what can I do to get them out?” There are generally three reasons a patient is admitted:

  1. They have a medical condition being actively managed (that is, they’re too sick to go home)
  2. They have deconditioned while in hospital to the point that they can’t get around home safely
  3. They don’t have a safe place to go back to (ie, home/retirement home may not be safe for them anymore), called dispositions issues. (Patients with dispo issues will sometimes be designated as “ALC,” or alternate level of care. Occasionally, they will be transferred to an ALC offload team. While still under your care, your senior will tell you how many times to see them, but generally three times a week.)

Issue number 1 is our bread and butter, and what you will be spending most of your time on. You will also be spending lots of time on 2. and 3., handled primarily by physiotherapists (PT) and social workers (SW), respectively. Internal medicine is a team sport. If you have a question about your patient’s ability to ambulate or where they are going next, ask the PT/SW assigned to your patient. Never make promises to patients about where they will be discharged to.

For every patient, every day: why are they in hospital, and what can I do to change that/these issues?

CTU Schedule

8-9 am Morning teaching Please attend! Called “morning report,” often will go over an interesting case
9-10 am Running the list Splitting the list with the team (assigning patients to each team member), discussing plans for the patients and any issues from overnight
10 am -2 pm Rounding Review your patients’ charts, and go to see them and see how they’re doing.
12-1 pm Lunchtime teaching Often, there will be teaching at lunch. Please attend! Sometimes food is provided!
2-4 pm Running the list Afternoon meeting with your team, where you discuss how all of the patients on the service are doing.
4 pm+ Wrapping up Ensure any loose ends are addressed. Any orders or notes that need to be co-signed by your residents? Does a patient need to be seen again?

A Typical CTU Day

Start each day with a comprehensive review of the patient's chart. At this time, you can begin writing your progress note for the day. This process should include checking for new notes, especially those from consulted services, and a brief review of overnight nursing notes. It's worth noting that feedback from a prior day’s consultation might only appear on the subsequent day, necessitating prompt action. Review vitals. Is your patient’s blood pressure OK? Tachycardic? Review patient labs. Many patients will have labs ordered daily, making it essential to regularly order and review CBCs and electrolytes as the situation demands.

Review the microbiology, imaging and cardiology tabs every day. Under microbiology, updated antibiotic susceptibility might result. This is a great opportunity to suggest changing the antibiotic to your team. Look at the ECGs yourself. Even though a cardiologist will review it, you should always review them yourself, both for your own learning, but also to see if something might have been overlooked. Do not trust the computer readouts from the ECGs.

For a structured daily patient assessment, consider creating a daily worksheet for each patient; mine is linked here.