Chapter 1
How to Study This Book
Allan R. Tunkel MD, PhD, MACP and Jessica L. Israel MD
Patients on the inpatient medicine services run the gamut of complaints that may require not only care by primary care physicians but also involvement of a number of specialty services—some within internal medicine such as cardiology, nephrology, or infectious diseases, and others from a variety of non–internal medicine specialties (e.g., surgery). Furthermore, the majority of the medical care of adult patients now occurs primarily in the outpatient setting, and coordination of ambulatory care and preventive medicine fall within the purview of the general internist. Based on the shift of care to the outpatient setting, most Internal Medicine Clerkships and Internal Medicine Residencies include significant time in the ambulatory setting.
This book is not meant to be an exhaustive approach to all aspects of Internal Medicine. Rather, the book serves as a framework to introduce students and residents to patient care utilizing a competency-based approach. Information surrounding each patient’s diagnosis, or consideration of additional aspects of clinical presentation, diagnosis, and management, should be supplemented by the reading of standard internal medicine textbooks (such as Andreoli and Carpenter’s Cecil Essentials of Medicine, 8e). It is also critically important that students and residents utilize the principles of self-directed learning to ensure that they develop the attitudes and skills to learn medicine for the rest of their careers.
STRUCTURE OF THE BOOK
The book begins with several introductory chapters that provide an overview into the organizational structure, consideration of the principles surrounding the Accreditation Council for Graduate Medical Education (ACGME) competencies, and “Tips for the Medicine Clerkship.” These are followed by 58 case-based chapters that are divided into the following 11 sections:
Renal Diseases and Electrolyte Disorders
Gastrointestinal and Liver Diseases
Within each section are individual chapters in which disease states are considered based on symptoms or syndromes, or abnormal laboratory findings, to assist the reader in considering a broad range of possibilities based on a patient’s clinical presentation. In some sections there are also teaching visuals on specific topics: interpretation of electrocardiograms, chest radiographs, and peripheral blood smears; and coronary angiography and colonoscopy.
CHAPTER ELEMENTS AND VERTICAL READS
Each chapter begins with a representative Case that includes the pertinent aspects of the patient’s subjective complaints and physical examination findings; some data are also provided if pertinent to consideration of a Differential Diagnosis (generally four to eight likely conditions to consider, but only the more common entities and not an exhaustive list). The next paragraph, termed Speaking Intelligently, sums up the clinical overview in language that is representative of a physician speaking to a colleague. This is followed by Patient Care, consisting of bulleted sections on History, Physical Examination, and Tests for Consideration; each section includes pertinent information that may assist the student and resident in consideration of a specific diagnosis. A section on Imaging Considerations (if applicable) follows. In these latter sections, the reimbursements for specific diagnostic tests and imaging modalities are provided. These are taken from the Medicare payments listed in the Clinical Diagnostic Laboratory Fee Schedule and the Ambulatory Payment Classification for 2012, and are provided only to give guidance to the reader in considering cost and reimbursement when ordering specific diagnostic tests; exact amounts are subject to multiple variables and will likely change in the future. The listed reimbursements do not include payments to physicians. For readers who have acquainted themselves with the other volumes in the series, you will note that the listed costs are different than those in this volume; in the other books, the authors and editors provided best estimates gleaned from difficult-to-obtain hospital charges. This discrepancy highlights the great variability in charges, as well as differences in reimbursements for tests and procedures from Medicare and commercial payers.
The Clinical Entities section then takes each of the more common, but not all, disease states listed as part of the Differential Diagnosis and reviews pertinent information on pathogenesis and pathophysiology, clinical features, diagnosis, and management. Unusual diagnoses are considered in the Zebra Zone.
Each chapter has a section on Practice-Based Learning and Improvement, which presents and critiques an important publication from the literature. For the student and resident, this illustrates how clinical trials have been designed to evaluate clinical questions and how evidence-based medicine has been utilized to change medical practice.
Finally, there are sections on Interpersonal and Communication Skills, Professionalism, and Systems-Based Practice. These three sections begin with an important principle in each competency that relates to the patient’s clinical situation or diagnosis. Across chapters these competencies can be organized into a “vertical read” to allow the reader to develop a complete understanding of these competencies as they pertain to the Medicine Clerkship and during the Internal Medicine Residency; these vertical reads are available online at http://www.studentconsult.com. In addition, suggested websites for most chapters are available online on Student Consult.
We are optimistic that this competency-based approach to learning internal medicine will be productive for you on the clerkship or during your residency, and will prepare you for a successful career in the discipline of your choice.
