Excelling in Clinical Rotations: A Guide for Preliminary Medicine Success

Understanding the Role of Clinical Rotations in a Preliminary Medicine Year

A preliminary medicine year (prelim IM) is often the gateway to many specialties—neurology, anesthesiology, radiology, dermatology, PM&R, ophthalmology, and more. Even if you know you aren’t pursuing a categorical internal medicine career, your performance in third year rotations and your prelim year will strongly shape letters of recommendation, your reputation, and your readiness for advanced training.

Excelling during clinical rotations—both as a third-year student and later as a prelim intern—comes down to three pillars:

1. Clinical competence (knowledge, reasoning, and basic skills)
2. Professionalism and work ethic (how you function on a team)
3. Communication (with patients, staff, and supervisors)

This guide will walk through how to stand out on your medicine clerkship, sub-internships, and early internship rotations, with a specific lens on preliminary medicine. You’ll find practical strategies, examples, and clinical rotations tips that directly translate into better evaluations, stronger letters, and more confidence at the bedside.

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Foundations Before You Start: Mindset, Expectations, and Preparation

Shift Your Mindset from “Student” to “Team Member”

Rotations in prelim IM are less about showing you’ve memorized minutiae and more about demonstrating you can help care for actual patients. Aim to transition from:

• “What do I need to know for the test?”
  to
• “How can I make a real difference for this patient and this team today?”

Ask yourself each morning:

“If I were the primary intern on this patient, what would I need to know, plan, and anticipate today?”

This mindset automatically leads to:

• Better presentations (they’re more focused and clinically relevant)
• Stronger assessments (you’re thinking like the intern you’re about to become)
• Greater trust from your team

Know What’s Expected on Medicine Rotations

Expectations vary slightly between schools and programs, but across most sites, evaluators look for:

• Reliability: On time, prepared, follows through on tasks
• Clinical curiosity: Asks good questions, reads about patients’ conditions
• Ownership: Knows “their” patients in detail, anticipates next steps
• Team orientation: Works well with residents, nurses, and other staff
• Professional behavior: Respectful, honest, and receptive to feedback

Ask your senior resident on day 1:

“Could you share what an excellent medical student looks like on this rotation? How can I be most helpful to you and the team?”

This early question signals maturity, self-awareness, and a desire to contribute.

Pre-Rotation Study: High-Yield, Not Exhaustive

Before your internal medicine or prelim rotations start, focus on:

• Common inpatient conditions: CHF exacerbation, COPD exacerbation, pneumonia, DKA/HHS, sepsis, GI bleed, AKI, cirrhosis complications, stroke, NSTEMI, PE/DVT
• Core management frameworks:
  • Chest pain: ACS vs non-cardiac, basic rule-out steps
  • Shortness of breath: CHF vs COPD vs pneumonia vs PE, etc.
  • Altered mental status: AEIOU TIPS, labs and imaging to order
  • Fever and sepsis: Sepsis bundle basics (cultures, fluids, early antibiotics)

Use one solid resource (e.g., Step Up to Medicine, Pocket Medicine, or an institution-specific medicine handbook) rather than skimming many sources. Aim for pattern recognition rather than memorizing guidelines line-by-line.

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Day-to-Day Excellence on the Wards: What High-Performers Actually Do

Pre-Round Like an Intern

Your preparation before attending rounds is the single biggest determinant of how you’re perceived. To pre-round effectively:

1. Arrive early (usually 30–60 minutes before team rounds)
2. Check vitals, I/Os, overnight events, and new labs
3. See each patient in person—even if briefly
4. Update your written or mental checklist:
   • Overnight issues
   • Today’s active problems
   • Pending tests and consults
   • Discharge barriers

Aim to know your 3–5 patients cold. On a good medicine rotation, you should be the person with the most up-to-date, granular knowledge about your assigned patients (e.g., last bowel movement, current diet, who the family spokesperson is, what PT/OT recommended today).

Example: The difference this makes
Average student: “Mr. J is feeling better. His creatinine is down, and he’s tolerating PO.”
Excellent student: “Mr. J reports less shortness of breath, no chest pain, and is ambulating 30–40 feet with PT. His creatinine improved from 1.8 to 1.4 today after holding lisinopril and careful fluid resuscitation. He had one soft bowel movement overnight and is tolerating a cardiac diet.”

One is generic; the other sounds like the intern presenting their own patient.

Master the Art of Clear, Concise Presentations

For clerkship success, you need to present clearly, efficiently, and with a logical assessment and plan. A standard SOAP-like structure works well:

• Subjective: Key overnight events and patient-reported symptoms
• Objective: Focused vitals, I/Os, exam, key labs/imaging
• Assessment: Problem-based, prioritized
• Plan: Specific, actionable next steps

Example of an excellent inpatient medicine presentation snippet:

“Ms. R is a 64-year-old woman on hospital day 3 for community-acquired pneumonia, now clinically improving.

Overnight, no acute events. She reports less pleuritic chest pain and decreased cough; no hemoptysis, no GI symptoms.

Vitals: afebrile, HR 88, BP 128/76, RR 18, on 2L NC with O2 sats 94–95%. On exam, scattered crackles at the right base but improved aeration; no increased work of breathing.

Assessment and Plan:

1. Community-acquired pneumonia, improving

• Day 3 of ceftriaxone/azithromycin; plan 5-day total course
• Wean O2 as tolerated, target >92%
• Encourage IS and ambulation with nursing/PT
• Follow up repeat CBC tomorrow AM

2. Type 2 diabetes, controlled

• Continue basal insulin and sliding scale
• Monitor PO intake; adjust insulin if she remains <50% of meals

3. Disposition:

• Likely discharge in 1–2 days if O2 requirement resolves; needs PCP follow-up and pneumonia vaccine status review.”

Notice: clear prioritization, an explicit plan, and anticipation of discharge needs.

Practical Tips to Improve Presentations Fast

• Practice out loud to yourself before rounds.
• Write down a 1–2 line “headline” summary.
• Ask a resident: “Can you give me feedback on my presentation format today?” and then incorporate it the next day.
• Time yourself; many attendings want 2–4 minutes per patient.

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Clinical Reasoning and Knowledge: Thinking Like a Prelim IM Intern

Build a Problem-Based Assessment

On a prelim medicine year, you’ll largely use problem-based notes and presentations. Get used to structuring your thinking by problems:

1. List active problems in order of acuity.
2. For each, briefly summarize status.
3. Offer a diagnostic and/or therapeutic plan.

Example (structured assessment for a patient with sepsis):

1. Sepsis secondary to pyelonephritis
   • Improved hypotension, lactate trending down from 3.8 to 1.9.
   • Plan: Continue IV ceftriaxone, reassess cultures at 48–72 hours, consider narrowing antibiotics if cultures return; maintain fluids at X mL/hr, monitor UOP, daily CMP, CBC.
2. AKI likely prerenal vs ATN
   • Cr 1.9 from baseline 0.8; urine sodium/potential FeNa pending.
   • Plan: Avoid nephrotoxins, strict I/Os, maintain MAP >65, repeat BMP this PM.
3. Type 2 diabetes
   • Holding metformin; sliding scale insulin. Monitor for hypoglycemia.

This structure shows you’re actively managing problems, not just restating labs.

Talk Through Your Differential Diagnosis

One of the highest-yield ways to impress attendings is by articulating a differential diagnosis with reasoning. You don’t need the “perfect” answer—just a logical, prioritized list and rationale.

Example: Shortness of breath differential

“For her acute shortness of breath, my main considerations are:

• CHF exacerbation, given history of systolic heart failure, weight gain, and crackles
• COPD exacerbation, given chronic COPD and wheezing
• Pneumonia, given low-grade fever and productive cough
• Less likely PE, as she’s hemodynamically stable without pleuritic chest pain or unilateral leg swelling.

I’d like to prioritize getting a CXR, BNP, ABG if concern for CO2 retention, and adjusting her diuretics and inhalers accordingly.”

This shows structure, prioritization, and awareness of “can’t-miss” causes.

Strategic Reading: Use Patients to Drive Your Learning

To make your clinical rotations tips actionable, pair each patient with 1–2 targeted reading topics:

• New DKA patient today → read a 2–3 page summary of DKA diagnosis and management.
• New cirrhosis admission with ascites → review SBP diagnosis and treatment.
• New NSTEMI → read initial management and post-MI secondary prevention.

Keep a short “rotation learning log” with:

• Patient initials
• Diagnosis
• Short bullet summary of what you learned
• One question you still have

This not only cements knowledge but also gives you great talking points during teaching sessions and at the end-of-rotation evaluation.

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Professionalism, Teamwork, and Communication: The “Soft Skills” That Matter Most

Be Dependable and Proactive

On prelim IM rotations, residents and attendings quickly recognize students who:

• Do what they say they will do
• Don’t need to be reminded to follow up on tasks
• Volunteer for small but meaningful jobs

Examples of helpful, high-yield tasks for students:

• Calling the lab about a missing test result
• Drafting a discharge summary or discharge instructions for resident review
• Pre-charting on new admissions
• Following up on imaging results and notifying the team
• Helping to organize family meetings (e.g., ensuring all parties know the time, confirming interpreter availability)

Ask daily:

“What can I take off your plate?” or “Are there one or two tasks I could own today to be more helpful to the team?”

Communicate Well With Nurses and Staff

Your relationships with nurses, case managers, therapists, and unit clerks significantly impact both patient care and how you’re perceived.

Practical strategies:

• Introduce yourself by name and role to the nurse(s) caring for your patients.
• Before proposing a plan, ask nurses: “How has Mr. X been doing? Anything you’re worried about?”
• When issues arise (e.g., a patient refusing labs), circle back with the nurse and problem-solve together.

This demonstrates that you understand medicine is a team sport—and it often leads to nurses advocating for you in feedback channels you may not directly see.

Handling Difficult Conversations and Emotions

In a preliminary medicine year, you’ll see death, severe illness, and family distress. As a student or prelim intern:

• Be present: It’s okay to sit quietly and listen during emotional moments.
• Use simple, empathetic language: “I’m really sorry you’re going through this.”
• Know your limits: Don’t deliver bad news alone; observe attendings and senior residents first.

Debrief with your team or a mentor if a case affects you deeply. Emotional awareness is a sign of professionalism, not weakness.

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Excelling Specifically as a Prelim Medicine Intern

Your preliminary medicine year is unique: you’re functioning as an intern in internal medicine while planning to move into a different advanced specialty. That creates specific opportunities and challenges.

Own Your Patients, Even If It’s “Not Your Final Specialty”

Evaluators quickly detect whether you are mentally “half in” because you’re going into anesthesia, radiology, etc. That can hurt your evaluations and letters.

Instead:

• Treat every patient as if you’ll be their doctor for years.
• Embrace the chance to master foundational skills you’ll use in any specialty: fluid management, antibiotics, perioperative medicine, cardiovascular and pulmonary basics, diabetes management, and cross-cover skills.
• Verbally connect what you’re learning to your future field:

  “I’m going into neurology, so I’m paying special attention to how we manage strokes and encephalopathy on the medicine side.”

This shows integrated thinking, not disengagement.

Develop Intern-Level Efficiency

To thrive in prelim IM:

• Use checklists (paper or digital) for each patient: active problems, meds, pending labs, imaging, consults, follow-up items.
• Batch tasks: write notes, put in orders, and make phone calls in focused blocks rather than constantly switching.
• Learn the EMR shortcuts early; ask a savvy co-intern or resident to walk you through their favorite tools (smartphrases, templates, order sets).

Example daily rhythm for a prelim IM intern:

1. Early pre-rounds on your patients
2. Update your checklist + to-do list for the day
3. Team rounds with focused presentations and updating plans in real time
4. Block time right after rounds to:
   • Put in all orders
   • Call consults
   • Place discharge and follow-up orders for expected discharges
5. Afternoon: follow-up labs/imaging; family calls; update notes; discharge summaries
6. End-of-day: sign-out preparation, anticipate overnight issues and give clear cross-cover plans

Build Relationships for Strong Letters of Recommendation

Even if you’re not applying to categorical IM, your preliminary medicine year is often where you earn crucial letters.

To maximize this:

• Identify 1–2 attendings early in a rotation whom you’d like to get to know.
• Show consistent excellence with them: punctuality, ownership, curiosity.
• A few weeks into the rotation, say:

  “I’ve really appreciated working with you and learning from your approach to X. I’m applying to [specialty], and I was wondering if you’d feel comfortable writing a strong letter of recommendation for me.”

Offer them your CV, personal statement draft, and summary of projects or notable cases you’ve worked on. Strong letters often emphasize:

• How you function as a team member
• Your reliability and professionalism
• Your clinical reasoning and work ethic

All of that is built day-by-day on the wards.

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Staying Well: Avoiding Burnout During Rotations and Your Prelim Year

High-achieving students and interns often sacrifice their well-being to “perform.” That’s neither sustainable nor necessary.

Manage Your Energy, Not Just Your Time

• Sleep: Protect at least one consistent sleep anchor (e.g., midnight–4 AM) even on tough stretches.
• Nutrition: Pack snacks and water; hospital food is notoriously inconsistent.
• Micro-breaks: 3–5 minute walks outside, stretching, or brief breathing exercises between tasks can significantly lower stress.

Set Realistic Learning Goals

Instead of trying to “master internal medicine” during your prelim year, aim for:

• 1–2 key learning points per patient per day, and
• 1 mini-topic to read about in the evening (10–15 minutes max).

You’ll learn far more through this steady, focused approach than by trying to read an entire textbook in a weekend.

Use Support Systems and Mentors

• Connect with co-interns; share strategies and frustrations.
• Seek out a faculty or senior resident mentor—ideally someone who’s gone through a prelim year and understands your advanced specialty path.
• If you feel overwhelmed, burned out, or emotionally numb, talk to someone early—your program leadership, wellness office, or a trusted mentor. Early intervention helps.

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FAQs About Excelling in Clinical Rotations in Preliminary Medicine

1. How can I stand out on my third year medicine rotations if I’m planning a prelim IM year?

Focus on being reliable, prepared, and engaged. Pre-round thoroughly, know your patients’ details, give concise problem-based presentations, and show genuine curiosity. Make it clear that you understand medicine is foundational to any specialty. Ask for feedback early and demonstrate visible improvement—it reassures attendings that you’re coachable and invested.

2. What’s the most important skill to develop during a preliminary medicine year?

The single most important skill is clinical reasoning within a structured, problem-based framework. That means being able to:

• Identify and prioritize a patient’s problems
• Form a reasonable differential
• Propose a diagnostic and therapeutic plan
• Reassess and adjust as new data appear

This skill will serve you regardless of whether you go into neurology, anesthesia, radiology, or another field.

3. How much independent reading should I do during busy rotations?

Aim for 10–30 minutes most days, tethered directly to your patients. Choose 1–2 topics per day based on what you saw: “hyponatremia management,” “acute COPD exacerbation,” “AFib rate vs rhythm control,” etc. Use concise, trusted sources (UpToDate, Pocket Medicine, institution protocols) rather than trying to cover large textbook chapters in one sitting.

4. I’m worried my attendings will think I’m less committed because I’m not going into internal medicine. What can I do?

Be transparent but frame it constructively:

“I’m planning to go into [specialty], but I see this medicine year as my chance to build strong fundamentals in managing acute illness, fluids, and comorbidities. I want to get as much as I can out of this rotation.”

Then back that statement up with behavior: show up early, know your patients well, contribute to the team, and engage in teaching. When faculty see your genuine effort, they usually become strong advocates, regardless of your ultimate specialty.

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By combining strong clinical reasoning, disciplined preparation, excellent communication, and sustainable work habits, you can not only excel in clinical rotations and your preliminary medicine year, but also launch into your advanced specialty with confidence, credibility, and a strong foundation in patient care.