Excelling in Clinical Rotations: Your Guide to EM-IM Success

Understanding EM-IM Combined Training and Why Your Rotations Matter

Emergency Medicine-Internal Medicine (EM IM combined) programs attract students who enjoy acuity, complexity, and continuity of care. These five-year combined residencies train you to stabilize crashing patients in the emergency department and manage them longitudinally on the wards or in clinic. Doing well on your EM and IM clinical rotations—especially in third year rotations and early fourth year—directly impacts your competitiveness.

Program directors in emergency medicine internal medicine are looking for applicants who can:

• Function effectively on both high-acuity ED shifts and structured inpatient services
• Demonstrate adaptability, resilience, and strong clinical reasoning
• Communicate clearly with patients, families, nursing, and consultants
• Show maturity and insight into why EM-IM specifically fits their goals

Your clerkship performance serves as a preview of how you’ll function as an intern. This guide breaks down concrete, day-to-day clinical rotations tips that will help you excel on EM, IM, and EM-IM-specific rotations—and translate those experiences into a stronger residency application.

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Foundations of Clerkship Success: Mindset and Professionalism

Before focusing on EM vs. IM specifics, you need a strong foundation in professionalism and clinical habits that transcend any specialty.

Adopt the Right Mindset

Treat every shift and call as:

• A working interview: Residents and attendings may later write your letters or interview you.
• A learning contract: You’re responsible for deliberate improvement each week.
• A team sport: Your value is measured partly by how much easier you make life for the team.

Ask yourself at the end of every shift:

1. What did I add to patient care today?
2. What did I learn that I didn’t know yesterday?
3. How did I make the team’s work easier?

Professional Behaviors That Stand Out

No matter the rotation, certain behaviors consistently separate top students:

• Reliability

  • Arrive 10–15 minutes early; never be the last one ready to start.
  • Follow up on every task you accept (calls, labs, notes, consults) and close the loop.
  • If you make a mistake, own it early and transparently.

• Work Ethic with Boundaries

  • Volunteer for extra tasks when appropriate, but respect residents’ judgment if they send you home.
  • Use downtime to read about your patients, not scroll on your phone.

• Humility and Growth Mindset

  • When you don’t know, say, “I’m not sure, but here’s how I’d look it up / think about it.”
  • When corrected, respond with, “Thank you—that helps. I’ll adjust my approach.”

• Respect and Team Awareness

  • Learn everyone’s name: nurses, techs, clerks, security.
  • Ask nurses, “Is there anything I can do to help with this patient?”—simple offers go a long way.

Your professionalism “brand” from third year rotations will often precede you via informal comments and formal evaluations. Protect that brand.

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Excelling on Emergency Medicine Rotations: Performance in the Pit

Emergency medicine internal medicine applicants must show they can thrive in the fast-paced, uncertain ED environment. Here’s how to shine.

Core Expectations in the ED

Your goals in EM rotations:

1. Rapidly assess patients and identify sick vs. not sick.
2. Formulate focused, prioritized differential diagnoses.
3. Propose concrete diagnostic and management plans.
4. Communicate clearly and concisely—verbally and in documentation.
5. Show comfort with uncertainty and frequent task switching.

Getting Started on Each Shift

At the beginning of every ED shift:

• Introduce yourself to the attending and senior resident:
  • “Hi, I’m [Name], MS3/MS4 interested in EM-IM. I’d love feedback on my presentations and differentials today.”
• Ask about expectations:
  • How many patients should you pick up at a time?
  • Preferred presentation style and length?
  • Expectations about procedures (IVs, suturing, splinting, ultrasound)?

Clarifying expectations early avoids misalignment and shows maturity.

Picking Up and Owning Patients

To stand out:

• Be proactive but safe:

  • As soon as you’re free, ask: “May I pick up the next patient?”
  • Start with lower-acuity cases; build toward more complex or higher-acuity patients as the team becomes comfortable with you.

• Own the case:
  Ownership doesn’t mean independence—it means responsibility. For each patient:

  • Do a focused but complete history and exam.
  • Check prior records if available.
  • Follow up on every lab and imaging result.
  • Reassess the patient periodically and update the team.

Structured ED Presentations: Concise and Impactful

ED presentations must be tighter than typical medicine ward presentations. Aim for 2–4 minutes. A useful structure:

1. One-liner: Age, key comorbidities, chief complaint, and sick vs. not-sick impression.

   • “Mr. Smith is a 68-year-old man with CAD and COPD presenting with 2 hours of worsening shortness of breath; currently appears mildly dyspneic but hemodynamically stable.”

2. Focused HPI: Onset, timing, severity, associated symptoms, relevant negatives tailored to your differential.

3. Key PMH/medications/allergies relevant to the problem.

4. Focused physical exam: Emphasize abnormal findings first.

5. Initial data: Vital signs, EKG, point-of-care testing, immediate labs/imaging if already done.

6. Differential diagnosis: Prioritized (3–5 items), with justification.

   • “Top considerations are PE, COPD exacerbation, and pneumonia; ACS and CHF are also possibilities.”

7. Plan:

   • Diagnostics: specific labs, imaging, bedside tests.
   • Therapeutics: meds, fluids, non-invasive ventilation, procedures.
   • Disposition: admit vs. discharge, and to what level of care.

Practice saying “My leading diagnosis is X because Y; I’m also considering A and B due to Z.”

Clinical Rotations Tips: Managing Uncertainty and Acuity

Emergency medicine rewards students who can navigate ambiguity.

• Sick vs. Not Sick First
  Before reciting a full H&P, answer: “Is this patient potentially unstable?”

  • Look at: mental status, work of breathing, blood pressure, perfusion, and general appearance.
  • If they look sick, say: “This patient looks unwell; I’d like to present at bedside.”

• Think in Worst-First Differentials
  For every chief complaint, ask:

  • “What are the 2–3 life-threatening causes I must rule out?”
  • “What are the most common benign causes?”
    This habit mirrors how EM-IM physicians think.

• Use Time Wisely

  • Between patient tasks, quickly read up on similar cases using point-of-care resources.
  • Look up one “Pearl” per patient—something you can mention to your attending when discussing the plan.

Procedures and Hands-On Skills

For EM-IM applicants, procedural comfort is a big plus.

• State your interest early:

  • “I’m working on my suturing/IV/ultrasound skills—please let me know if there are opportunities.”

• Common student-accessible ED procedures:

  • Simple laceration repair
  • Splinting
  • Basic ultrasound views (FAST, cardiac, IVC) under supervision
  • IV placement, arterial blood gas, Foley insertion, NG tube

• Learn the indications, contraindications, steps, and complications for any procedure you perform. Be able to explain them.

Disposition and Communication

EM-IM physicians constantly make disposition decisions—admit, observe, or discharge—and communicate with inpatient teams.

• Practice stating your recommended disposition:

  • “Given X and Y, I recommend admission to medicine for further workup and management.”
  • “If imaging is negative and labs reassuring, I think a safe discharge with close follow-up is appropriate.”

• Ask to listen in or help prepare for:

  • Sign-out to the next shift
  • Update calls to inpatient teams
  • Discussions with consultants

Observe how experienced EM physicians frame cases concisely and advocate for appropriate admission level of care—skills vital to EM IM combined training.

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Excelling on Internal Medicine Rotations: Depth, Synthesis, and Continuity

Your internal medicine rotations showcase your ability to manage complex, multi-morbidity patients over time—central to emergency medicine internal medicine careers.

Core Expectations in Internal Medicine

On IM wards or consult services, you’re expected to:

1. Develop thorough history and physical exam skills.
2. Build thoughtful, problem-based assessments and plans.
3. Follow patients longitudinally and notice subtleties over days.
4. Communicate effectively on rounds and in notes.
5. Practice evidence-based medicine and appropriate documentation.

Owning Your Patients on the Wards

To excel:

• Know your patients cold

  • Be the person the team turns to for details: last bowel movement, daily weights, overnight events, test results, family discussions.
  • Before rounds, see each patient, review new data, and update your assessment.

• Pre-round efficiently

  • Prioritize sickest or most complex patients.
  • Have vitals, labs, imaging, and overnight events ready in your notes.
  • Bring a notecard or template with key data for each patient.

Structured IM Presentations: Organized and Analytical

Internal medicine values structure and reasoning in presentations. A standard format:

• Opening summary:

  • “Ms. Jones is a 72-year-old woman with HFpEF and CKD admitted 2 days ago with acute decompensated heart failure, now improving on IV diuretics.”

• Overnight events: New symptoms, rapid responses, vital sign changes, procedure results.

• Subjective: Patient’s current symptoms, changes since yesterday.

• Objective:

  • Vital trends (highlighting notable changes)
  • I/O, weights, key exam findings
  • Pertinent lab and imaging results (triage to what matters)

• Assessment and Plan: Problem-based by system or issue:

  • Numbered list with a brief assessment followed by concrete plan.
  • Example:
    1. Acute decompensated HFpEF, improving
       • Assessment: net –2.5L over 48 hours, improved oxygen requirement, still mild bibasilar crackles.
       • Plan: Continue IV furosemide 40 mg BID, goal net –1L/24h, monitor BMP twice daily, strict I/Os, daily weights, low-sodium diet, cardiology consult for long-term management.

Strive to think one step ahead: anticipate next labs, imaging, or consultant recommendations.

Clinical Rotations Tips for IM: Reading and Reasoning

• Daily micro-learning

  • Pick one major problem per patient and read a high-yield, short resource (UpToDate section, guideline summary).
  • Summarize to your resident:
    • “I read about NSTEMI management overnight—guidelines recommend X; I think for our patient Y would be most appropriate.”

• Link ED and IM perspectives (important for EM-IM):

  • When you admit a patient from the ED, think:
    • “Would I have done anything differently if I had seen this patient first in the ED?”
    • “What ED decisions most affected our inpatient course?”

This bidirectional thinking is exactly what EM-IM training emphasizes.

Interdisciplinary Collaboration

On IM rotations, watch how the team:

• Works with case managers and social work for safe discharges.
• Involves PT/OT and nursing in mobility and care planning.
• Coordinates with outpatient providers and specialists.

Take initiative:

• Ask, “Can I call the primary care provider or family to update them?”
• Offer to draft discharge summaries or patient instructions under supervision.

EM-IM programs appreciate applicants who understand continuity and transitions of care.

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Integrating EM and IM Skills: How to Think Like an EM-IM Physician

To stand out as an EM-IM combined candidate, don’t treat your EM and IM rotations as separate silos. Start building an integrated approach.

Develop Bidirectional Clinical Thinking

For each patient:

• In the ED, ask:

  • “If I were going to follow this patient on the medicine ward for 5 days, what information, tests, and documentation would I want now?”
  • “How can I set up the inpatient team for success?”

• On the wards, ask:

  • “If I saw this patient crashing in the ED, what would my initial stabilization and workup look like?”
  • “Were there early warning signs that could have been addressed earlier?”

Write down examples of patients where earlier ED decisions greatly affected inpatient care, or vice versa. These become powerful stories for your EM-IM personal statement and interviews.

Case Example: Chest Pain Across Settings

• ED perspective:

  • Rule out immediate life threats: STEMI, PE, aortic dissection, tension pneumothorax.
  • Serial ECGs, troponins, risk stratification, quick disposition decision.

• IM perspective:

  • Clarify long-term cardiac risk profile.
  • Optimize secondary prevention, risk factor modification, and follow-up.
  • Coordinate stress testing or cath, medication titration, and education.

As a student interested in EM-IM, you might say on rounds:

• “In the ED we focused on ruling out acute MI and PE. Now that she’s admitted, I think our focus shifts to risk modification and figuring out why she’s having recurrent atypical chest pain despite negative workups.”

That kind of integrated thinking signals genuine interest in combined training.

Communication Across the Transition

Practice and observe:

• ED-to-IM handoffs: How are cases framed? What crucial info helps the ward team?
• IM-to-ED returns: What discharge instructions or follow-up plans might reduce preventable ED bounce-backs?

Ask attendings:

• “From your EM-IM perspective, what do you wish ED/IM teams did differently during transitions?”

Their answers give you insight and language for your future applications.

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Practical Strategies to Maximize Third Year Rotations and EM-IM Applications

Your third year rotations and early fourth year are your best opportunity to build a strong portfolio for EM-IM combined programs.

Prioritizing Rotations and Scheduling

If your school allows scheduling flexibility:

• Aim for strong performance in core IM and EM rotations
  • These are heavily weighted by EM-IM programs.
• Consider an early sub-internship (sub-I) in IM or related field to:
  • Show you can function at near-intern level.
  • Secure a detailed, supportive letter of recommendation.

If your school has a dedicated EM clerkship:

• Try to complete it before you apply for away rotations or EM-IM audition rotations; this improves your readiness.

Building Relationships and Securing Letters

Strong letters from both EM and IM faculty are vital.

• Identify potential letter writers:

  • EM faculty who saw you multiple shifts and can comment on your work ethic, clinical growth, and team skills.
  • IM attendings who supervised you on wards or sub-I and can attest to your reasoning and longitudinal care.

• Ask for “a strong letter of recommendation” explicitly. Provide:

  • Your CV and brief summary of your career goals (including EM-IM interest).
  • A short list of patients or cases where you worked closely with them, to jog their memory.

Documenting and Reflecting on Experiences

Keep a simple log during your clerkships:

• Interesting or complex cases (chief complaint, key decisions).
• Moments where you saw EM and IM interacting well—or poorly.
• Times you made a clear impact on patient care.
• Feedback you received and how you applied it.

This log becomes material for:

• Personal statement content that feels specific and authentic.
• Interview responses to “Tell me about a time…” questions.
• Demonstrating longitudinal growth.

Balancing Clinical Performance and Studying

While clerkship success depends heavily on clinical impressions, standardized exams still matter.

• Use “micro-study” strategies:

  • 10–15 minutes between patients to review relevant topics.
  • Question banks focused on chief complaints you saw that day.

• Try to link daily practice with exam prep:

  • For each patient, ask, “How could this case appear as a test question?”

Time spent on the floor does not replace dedicated study—but it does make that studying more efficient and memorable.

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Frequently Asked Questions (FAQ)

1. Do I need both EM and IM letters to apply to EM-IM combined programs?

Yes. Most EM-IM combined programs expect:

• At least one standardized EM letter (often using the SLOE format if your institution or away rotation provides it).
• One or more strong internal medicine letters from ward or sub-I experiences.

Some programs will also accept or value letters from critical care, cardiology, or other specialties that demonstrate your ability to manage complex patients.

2. How many EM and IM rotations should I do if I’m aiming for EM-IM?

Aim for:

• Core EM rotation at your home institution.
• One EM or EM-IM away rotation, ideally at a program with an EM-IM track or strong combined culture.
• At least one IM sub-internship (general IM, hospitalist service, or ICU) to show readiness for high-level responsibility.

Beyond that, choose electives that reinforce your interests (e.g., ICU, cardiology, ultrasound), but don’t overschedule at the expense of doing well on your core clerkships.

3. What common mistakes hurt students on EM rotations?

Frequent pitfalls include:

• Being too passive—waiting to be told which patient to see.
• Overly long presentations not tailored to the ED environment.
• Failing to follow up on results or re-evaluate patients.
• Spending too much time with one low-acuity patient while missing opportunities to see a variety of cases.
• Appearing disengaged during busy shifts (e.g., phone use, sitting while others are moving).

All of these are correctable with awareness and early feedback.

4. How can I show genuine interest in EM-IM during rotations without sounding rehearsed?

Integrate your interest naturally:

• Ask attendings who practice in both ED and inpatient settings how they approach specific cases differently in each context.
• Share reflections like, “I enjoyed stabilizing this patient in the ED, and I’d also be interested in following their long-term CHF management on the ward or clinic side.”
• When discussing career plans, emphasize the synergy you see between acute care and chronic disease management, not just that you “like variety.”

If your actions—strong performance on both EM and IM rotations, thoughtful questions, and integrated thinking—match your words, your interest will come across as authentic.

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By approaching your third year rotations and clerkship success with intentionality—mastering both swift ED decision-making and nuanced inpatient management—you’ll not only excel in clinical performance but also present as a compelling candidate for emergency medicine internal medicine combined programs.