Internal Medicine Electives and Selectives

Attendance: Students may not take time off on the start date but must attend check-in and system orientation with Visiting Student Affairs. See the attendance policy for details.

Location: CRMH

Available: August  – June

Duration: 2 or 4 weeks, starting any Monday and ending Friday

Number of students per rotation: 1

Prerequisites: Letter of Intent from IM Chair/Advisor validating applicant's intent to pursue residency in IM

Overview: Students will be paired with an IM faculty member and see patients at Carilion Clinic Internal Medicine, Riverside. Students will be exposed to a wide array of patients with diseases and conditions typically seen in an outpatient setting, such as diabetes, hypertension and chronic lung disease. Students will learn to do a focused history and physical exam pertinent to the patient’s reason for being seen. Students will then report their findings to the attending physician and together formulate a management plan for the patient. The preceptor is the ambulatory faculty attending and the location is the outpatient clinic.

The student will become progressively proficient and knowledgeable in the following:

1. Obtaining and reporting an accurate, focused history and physical appropriate to the patient
2. Setting priorities in developing management plans to address the patient’s most critical problems first
3. Proposing a course of management for common diseases encountered in the patients they evaluate
4. Choosing testing and medicines consistent with cost constraints patients face
5. Incorporating recommendations for adult health maintenance
6. Recognizing and managing the interaction between the social setting, patients and illness, particularly in regard to the chronic disease mode
7. Articulating symptoms and historical details, pertinent physical findings, differential diagnoses, initial diagnostic approach, initial treatment and relevant patient education

Attendance: Students may not take time off on the start date but must attend check-in and system orientation with Visiting Student Affairs. See the attendance policy for details.

Location: CRMH

Available: August – June

Duration: 4 weeks, starting any Monday and ending Friday

Number of students per rotation: 1

Prerequisites: Letter of Intent from IM Chair/Advisor validating applicant's intent to pursue residency in IM

Overview: The student will be introduced to a diverse population of individuals with a wide variety of infectious diseases, while further developing skills of history taking, physical examination, critical thinking and knowledge of infections and antimicrobial medications and becoming competent and confident in the diagnosis and management of these diseases.

The student will become progressively proficient and knowledgeable in the following:

1. Taking a history for possible infectious diseases
2. Identifying the signs and physical findings of general and specific infections
3. Developing a differential diagnosis and prioritizing the list based on the history, physical examination, baseline laboratory results, imaging studies and knowledge of the epidemiology of infectious diseases
4. Working comfortably with the microbiology laboratory
5. Analyzing the interpretation of susceptibility testing
6. Discussing the advantages and disadvantages of serological testing
7. Describing the mechanism of action, dosing and adverse events of antimicrobial agents
8. Accurately interpreting gram stains

Attendance: Students may not take time off on the start date but must attend check-in and system orientation with Visiting Student Affairs. See the attendance policy for details.

Location: Carilion Clinic Dermatology - Riverside 1

Available: August – June

Duration: 4 weeks, starting any Monday and ending Friday

Number of students per rotation: 1

Prerequisites: N/A

Overview: The elective consists of dermatology outpatient clinics at Carilion's Riverside complex and consults at Carilion Roanoke Memorial Hospital. The student will do patient chart reviews, history taking and physical examinations. In consultation with the attending physician, the student will develop a differential diagnosis, plan the diagnostic evaluation and design a management plan for the patient’s skin disease.

The student will become progressively proficient and knowledgeable in the following:

1. Taking a focused history for skin diseases
2. Listing the signs and physical findings to look for in general and in certain specific skin diseases
3. Accurately using the terms for describing the morphology of basic skin lesions
4. Developing a differential diagnosis based on morphologic diagnosis, and prioritizing the list, based on the history, physical examination, laboratory results and knowledge of the epidemiology of skin diseases
5. Describing Mohs micrographic surgery and the workings of a Mohs laboratory
6. Discussing the interpretation of skin biopsies
7. Performing cryotherapy, shave and punch biopsies
8. Identifying the mechanism of action, dosing and adverse events of topical therapeutics and phototherapy as well as systemic and biologic drugs used in dermatology
9. Accurately interpreting KOH prep

Attendance: Students may not take time off on the start date but must attend check-in and system orientation with Visiting Student Affairs. See the attendance policy for details.

Location: CRMH

Available: August  – June

Duration: 2 or 4 weeks, starting any Monday and ending Friday

Number of students per rotation: 1

Prerequisites: Letter of Intent from IM Chair/Advisor validating applicant's intent to pursue residency in IM

Overview: This elective is intended to expose medical students to a wide variety of acute and sub-acute medical pathologies and to enable them to provide physiologic support for patients who have suffered acute catastrophic insult. Students will gain experience in coordinating the management of critically ill patients with multiple healthcare professionals and will apply evidence-based concepts to diagnosis, care, and outcome prediction of critically ill patients.

The student will become progressively proficient and knowledgeable in the following:

1. Managing daily exam during rounds, explaining the impact of mechanical ventilation, sedation and paralysis; outcome prediction; and incorporating laboratory and radiographic data
2. Explaining the physiology, differential diagnosis, and therapy of different kinds of shock; the use of fluid resuscitation and vasoactive agents
3. Explaining the underlying pathophysiologic components of acute respiratory failure, hypoxemia, methods of monitoring oxygenation in the ICU setting
4. Describing the indications and limitations of non-invasive ventilation techniques for patients with acute respiratory failure, endotracheal intubation and assisted ventilation, positive pressure ventilation on hemodymanics
5. Listing the different types of breath delivered by mechanical ventilators, recognizing and interpreting alarms and complications associated with positive pressure and ventilation
6. Discussing indications of HFOV and applications in therapy of severe refractory respiratory failure
7. Recognizing common acid-base disturbances, the compensatory changes associated with them, and the underlying etiologies; describing the use of anion and osmolar gaps in determining etiology of acid-base disturbances and their treatment.
8. Recognizing common fluid and electrolyte disorders and their consequences
9. Describing the side effects of medications commonly used in the critical care setting and list their antidotes, indications, contraindications and side effects
10. Explaining the rational use of blood and blood products in the ICU, including the indications and contraindications of RBC, platelets and FFP transfusion
11. Describing basic methods used to assess nutritional status and the impact of critical illness on the patient’s nutritional requirements
12. Performing nasotracheal and oral intubation, arterial catheters, central venous lines, arterial puncture, lumbar puncture, thoracenteses, cardioversion, temporary pacemaker insertion, transcutaneous pacing, and pulmonary artery catheters, sterile insertion of radial and femoral arterial catheters

Attendance: Students may not take time off on the start date but must attend check-in and system orientation with Visiting Student Affairs. See the attendance policy for details.

Location: CRMH

Available: August  – June

Duration: 2 weeks, starting any Monday and ending Friday

Number of students per rotation: 1

Prerequisites: N/A

Overview: The medical student will see a diverse population with a wide variety of serious illnesses in order for the students to demonstrate an understanding of the management of medical problems in the specialty area of palliative medicine.

The student will become progressively proficient and knowledgeable in the following:

1. Discussing the current state of dying in the U.S.
2. Identifying psychological, social and spiritual issues of palliative care patients and their families
3. Discussing the management of symptoms utilizing various pharmacologic and non-pharmacologic modalities, pharmacodynamics and pharmacokinetics of commonly used agents
4. Facilitating ventilator withdrawal
5. Managing common complications including neuro-psychiatric co-morbidities at EOL
6. Facilitating complex discussions about goals of care and symptom management with patients and families in a structured environment
7. Utilizing comprehensive interdisciplinary assessment of the patient and family
8. Facilitating communication between different disciplines within the palliative care team
9. Developing a care plan based on the identified and expressed values, goals and needs of the patient and family facilitated by professional guidance and decision making support
10. Assessing and managing pain and symptoms based on best available evidence including equianalgesic dosing
11. Discussing the impact of life-limiting disease on the family system resources
12. Performing physician spiritual assessment
13. Analyzing cultural implications of life-limiting illness
14. Identifying the signs and symptoms of impending death that can be communicated and managed

Attendance: Students may not take time off on the start date but must attend check-in and system orientation with Visiting Student Affairs. See the attendance policy for details.

Location: CRMH

Available: August  – June

Duration: 2 weeks, starting any Monday and ending Friday

Number of students per rotation: 1

Prerequisites: 

• Letter of Intent from IM Chair/Advisor validating applicant's intent to pursue residency in IM or Pathology
• An affiliation agreement between the Carilion Clinic, applicant's school and Dominion Pathology is required for accepted candidates 

Overview: Physicians routinely rely on tissue diagnoses and clinical laboratory tests to guide patient care. The student will learn the role of anatomic pathology and clinical laboratory medicine in the multidisciplinary care of patients. This course aims to provide a deeper understanding of tissue testing and clinical laboratory test utilization, and of how specimens should be submitted. Specifically, every physician needs to know where laboratory tests are performed, limitations, and what pathologists and other laboratory professionals need in order to provide the most meaningful report results for their patients and how to develop a differential diagnosis. Such needs include sample size, adequacy, quality, fixative and proper type to fit each specific test, as well as knowing what pertinent information should be provided. In this manner, the medical student will know the importance of proper test utilization for which they ultimately one day may be responsible to interpret in the context of the patient’s clinical history, radiologic studies and physical findings. The medical student will also learn how to best consult pathologists and other laboratory medicine professionals, and discover an amazing resource for collaborative patient care. System cost savings due to decreased laboratory overutilization and improved interdepartmental communication is the goal.

The student will become progressively proficient and knowledgeable in the following:

1. Describe anatomic pathology and clinical laboratory medicine.
2. Summarize the role of anatomic pathology and clinical laboratory medicine in the multidisciplinary care of patients. This includes diagnosis, prognosis and strategies for treatment, including personalized cancer therapy based on ancillary tissue and/or laboratory test results.
3. Develop an understanding of the kinds of errors a submitting physician (Family Medicine physician or practitioner, surgeon, oncologist, radiologist, etc.) can make when taking and submitting a specimen and the dire consequences that may result.
4. Develop a differential pathologic diagnosis based on clinical history, radiologic studies and gross and microscopic findings of patient specimens.
5. Describe the requirements for tissue submitted to anatomic pathology for diagnosis.
6. Demonstrate the proper use of clinical laboratory tests, including sensitivity and specificity, to prevent test overutilization.
7. Appreciate the proper use and limitations of molecular, cytogenetic, flow cytometric and other ancillary tests. Anticipate how future contributions of both molecular and proteomic research might change the use of clinical and anatomic pathology laboratories.

Students applying to any research, medicine or surgical subspecialty are expected to greatly benefit from an elective in anatomic and clinical pathology.  

Laboratory medicine touches all patients in any health care facility. Clinical laboratory tests and anatomic specimens submitted for diagnosis remain the bedrock to clinical decision making and for optimized patient care. This is especially true for oncology, surgery and any complicated medicine patient. However, laboratory tests also impact the routine evaluation of well-person checkups. Clinical and anatomic pathology are critical to integrated, multidisciplinary patient care and translational research.

The course will be offered at the 9000 level as an elective option to students who have successfully completed the third year of the medical curriculum. Students are expected to bring knowledge gained from the third-year core clerkships into assessment and management in patient care. Students will improve their knowledge and skills in understanding the role of anatomic and clinical pathology and how those labs can be utilized in collaborative patient care.

Attendance: Students may not take time off on the start date but must attend check-in and system orientation with Visiting Student Affairs. See the attendance policy for details.

Location: CRCH 7th Floor Rehab

Available: August  – June

Duration: 2 or 4 weeks, starting any Monday and ending Friday

Number of students per rotation: 1

Prerequisites: Letter of Intent from IM Chair/Advisor validating your intent to pursue residency in IM/PM&R

Overview: The student will learn how to assist individuals who have permanent impairments (paralysis, sensory loss, cognitive dysfunction, alteration of consciousness, decreased endurance, etc.) in identifying their remaining abilities and developing them to their maximum potential. There is a strong emphasis on the team approach, with communication as the vital link between team members, most importantly the patient and the patient's family. We will focus on issues that the students will be likely to see in their primary practices. Students will participate in daily rounds, attend weekly conferences to discuss his/her patients with the team, complete admission histories, physical exams and consults.

The student will become progressively proficient and knowledgeable in the following:

1. Performing a physical exam on a patient with a spinal cord injury including completing an ASIA exam
2. Recognizing the signs and symptoms of autonomic dysreflexia
3. Recognizing signs and symptoms of dysautonmia
4. Recognizing signs and symptoms of mild TBI
5. Recognizing agitation in a patient with TBI
6. Identifying spasticity and outline a treatment plan to treat spasticity in either a patient with TBI or SCI
7. Determining a patient’s appropriateness for inpatient rehabilitation by determining if the patient has appropriate goals for acute rehabilitation services, determining barriers to a successful discharge from the hospital environment and determining social and family factors that may impact successful rehabilitation and discharge to home
8. Listing and defining conditions, medications and treatments within the field

Attendance: Students may not take time off on the start date but must attend check-in and system orientation with Visiting Student Affairs. See the attendance policy for details.

Location: CRMH and Carilion Clinic Pulmonary and Sleep Medicine - Roanoke

Available: August  – June

Duration: 2 or 4 weeks, starting any Monday and ending Friday

Number of students per rotation: 1

Prerequisites: Letter of Intent from IM Chair/Advisor validating applicant's intent to pursue residency in IM

Overview: Students will be involved in consulting on patients with pulmonary diseases in the inpatient unit and evaluating patients in the outpatient clinic. The student will do the patient’s chart review, history taking and physical examination. From this information and the integration of physiopathological principles, the medical student will develop a differential diagnosis, learn how to prioritize this and propose a treatment plan.

The student will become progressively proficient and knowledgeable in the following:

1. Mastering the physical examination skills related to the evaluation of pulmonary diseases
2. Identifying the presenting signs and symptoms of patients with respiratory problems
3. Identifying variables that allow differentiating varied disorders of other systems causing similar “respiratory” symptoms
4. Acquiring skills to develop a focused differential diagnosis, and prioritize the alternatives in order of importance
5. Identify indications for pulmonary function testing and interpreting the results
6. Discussing available technological diagnostic and treatment advances and determining how to use these judiciously
7. Discussing the impact of respiratory disorders in a patient’s quality of life

Attendance:  Students may not take time off on the start date but must attend check-in and system orientation with Visiting Student Affairs.  See the attendance policy for details.

Location:  Carilion Clinic Rheumatology ; Riverside 3

Available:  August – June

Duration: 4 weeks, starting any Monday and ending Friday

Number of students per rotation: 1

Prerequisites: 

• Letter of Intent from IM Chair/Advisor validating applicant's intent to pursue residency in IM
• Successful completion of third-year IM clerkship
• Interest in Palliative Medicine

Overview: The medical student will see a diverse population with a wide variety of serious illnesses so that they can demonstrate a comprehensive understanding of Palliative Medicine in the inpatient setting.

The student will become progressively proficient and knowledgeable in the following:

1. Discuss the current state of dying in the U.S.
2. Understand the difference between palliative medicine and hospice as well as insurance as it relates to the hospice benefit (HSS)
3. Identify psychological, social, and spiritual issues of palliative care patients and their families
4. Discuss the management of pain utilizing various pharmacologic and non-pharmacologic modalities, pharmacodynamics, and pharmacokinetics of commonly used agents
5. Discuss the management of non-pain symptoms utilizing various pharmacologic and non-pharmacologic modalities, pharmacodynamics, and pharmacokinetics of commonly used agents
6. Facilitate ventilator withdrawal
7. Manage common complications including neuro-psychiatric co-morbidities at EOL
8. Facilitate complex discussions about goals of care and symptom management with patients and families in a structured environment
9. Utilize comprehensive interdisciplinary team in care of the patient and family and facilitate communication between different disciplines within the palliative care team (HSS)
10. Develop a care plan based on the identified and expressed values, goals and needs of the patient and family facilitated by professional guidance and decision-making support (HSS)
11. Discuss the impact of life-limiting disease on the family system resources (HSS)
12. Perform physician spiritual assessment
13. Analyze cultural implications of life-limiting illness (HSS)
14. Identify the signs and symptoms of impending death
15. Explore common ethical and legal challenges healthcare professionals face in caring for patients at end of life (HSS)

This elective will consist of consulting on patients who are hospitalized with serious illnesses.  The medical student will do the patient’s chart review, history taking, and physical examination.  From this information, the student will be able to synthesize information to develop an interdisciplinary plan of care incorporating palliative care principles for the patient and family that address comprehensive views of suffering.