Essential Guide to Medical Shadowing in Preliminary Medicine Year

Understanding Medical Shadowing in Preliminary Medicine

Medical shadowing is one of the most powerful—and often underutilized—tools for strengthening a residency application, especially if you are targeting a preliminary medicine year (prelim IM). For many applicants, prelim IM is a bridge: to neurology, anesthesiology, radiology, dermatology, ophthalmology, PM&R, or even a categorical internal medicine spot later on. But programs still want to know: have you actually seen what inpatient internal medicine looks and feels like?

Well-structured medical shadowing:

• Clarifies whether a prelim IM year fits your goals and personality
• Helps you speak concretely in your personal statement and interviews
• Provides faculty contacts for letters, mentorship, and potential advocacy
• Demonstrates seriousness and professionalism, particularly for non-traditional or international graduates

This guide walks you through how to use shadowing strategically for a preliminary medicine path: what to look for, how to find shadowing, how many shadowing hours are needed, and how to turn observation into real value on your ERAS application.

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Why Shadowing Matters Specifically for a Preliminary Medicine Year

Unlike categorical programs, a preliminary medicine year is one intensive year of mostly internal medicine before you switch into your advanced specialty. That changes how programs evaluate you—and how shadowing can help.

1. Demonstrating Fit for an Intern-Level IM Year

Prelim interns shoulder many of the same responsibilities as categorical IM interns:

• Managing multiple complex patients on inpatient teams
• Taking short calls, cross-cover, night float
• Calling consults, coordinating discharges, fielding pages
• Communicating rapidly with nurses, ancillary staff, and families

Through shadowing on inpatient wards, you’ll see:

• The pace and cognitive load of a busy academic medicine service
• How residents prioritize, sign out, and manage competing demands
• The emotional and ethical challenges of caring for critically ill or complex patients

When interviewers ask, “Why is a prelim IM year right for you?” your shadowing gives you concrete, credible examples:

“During my shadowing on the general medicine service at University Hospital, I observed how the interns had to rapidly reprioritize patient care when a patient decompensated during morning rounds. Seeing how they used checklists, team huddles, and clear communication with nursing staff showed me both the intensity and the structure that keeps teams functioning safely. That experience made me confident I could thrive in a prelim year’s fast-paced environment.”

2. Aligning Shadowing With Your Advanced Specialty

If you’re pairing a preliminary medicine year with an advanced specialty (e.g., neurology, anesthesia), thoughtful shadowing can connect the dots:

• Shadow an internal medicine team + your advanced field
• Understand how strong internal medicine skills support later specialty training
• Learn which prelim programs best complement your long-term goals

Examples:

• A future neurologist shadows both stroke service and general medicine; they see how managing blood pressure, infection, and cardiac issues in the medicine setting directly impacts neurological outcomes.
• An anesthesia-bound applicant shadows in the pre-op clinic, OR, and inpatient medicine service, realizing how critical it is to interpret labs, manage chronic medical conditions, and optimize patients preoperatively.

You can later articulate:

“Through shadowing inpatient medicine alongside shadowing anesthesia, I saw how robust training in internal medicine is essential for safely managing perioperative patients. This reinforced my decision to pursue a preliminary medicine year rather than a transitional year.”

3. Strengthening Applications for Nontraditional & IMG Applicants

Shadowing is especially important if:

• You’re a non-traditional applicant with a gap in clinical activity
• You are an IMG needing recent U.S. clinical exposure
• You’re changing career direction or reapplying

For these groups, documented medical shadowing:

• Shows continuing engagement with patient care
• Gives you updated, U.S.-based clinical references
• Demonstrates understanding of the U.S. inpatient system and norms

You may not get credit as “hands-on U.S. clinical experience,” but sustained, structured shadowing is still valuable—especially if paired with observerships or research.

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What Types of Shadowing Are Most Valuable for Prelim IM

Not all shadowing experiences are equal when your goal is a preliminary medicine year. Programs care more about depth, relevance, and reflection than just raw hours.

1. Inpatient Internal Medicine Shadowing

If you can only choose one type of experience, prioritize inpatient medicine:

Ideal settings:

• General internal medicine wards
• Hospitalist services
• Step-down or intermediate care units
• Night float or short-call observation (if allowed)

Key things to pay attention to:

• How interns manage the workflow of a full patient list
• Use of sign-out tools (e.g., handoff notes, SBAR, I-PASS)
• How pages are triaged during the day and overnight
• The interplay between residents, attendings, nurses, case managers, and consultants

This exposure lets you later discuss—specifically—what you’ve seen:

“During my shadowing on the general medicine service, I observed how the interns structured their day around a rolling to-do list, balancing admissions, cross-coverage, and discharges. Seeing the importance of clear handoffs and early discharge planning shaped how I think about being an effective prelim intern.”

2. Subspecialty Medicine & Advanced Specialty Shadowing

Because prelim IM is often a stepping stone to an advanced field, it’s wise to include:

• Your target advanced specialty (e.g., anesthesiology, neurology, radiation oncology)
• Related medicine subspecialties (e.g., cardiology, nephrology, pulmonary, ICU)

This combination allows you to make connections such as:

• How mastery of internal medicine issues (electrolytes, heart failure, infections) is critical in neurology, anesthesia, radiology, etc.
• Why a rigorous preliminary medicine year will prepare you better than a more generalized transitional program, if applicable.

3. Ambulatory Internal Medicine & Continuity Clinics

Although prelim years skew inpatient-heavy, many include:

• Ambulatory blocks or continuity clinics
• Specialty clinics (e.g., endocrine, HIV, rheumatology clinics)

Shadowing in clinic helps you:

• Understand the importance of outpatient follow-up after hospital discharges
• See how chronic disease management interfaces with inpatient episodes
• Develop talking points about continuity of care and systems-based practice

4. Shadowing With Future Colleagues: Residents vs Attendings

Try to shadow:

• Residents (PGY-1 and PGY-2) to see the day-to-day reality of intern life
• Attendings to see higher-level decision-making and teaching styles

A useful strategy:

• Spend one or two days shadowing an academic hospitalist or ward attending
• Then ask to spend additional time following a resident throughout their full day

This dual view helps you understand what will be expected of you as a prelim intern and how teaching and supervision actually work.

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How to Find Shadowing in Internal Medicine and Prelim Settings

Many applicants struggle most with the logistics: how to find shadowing, secure permission, and make it meaningful. There isn’t one perfect pathway, but there are several reliable strategies.

1. Start With Institutions You Already Have a Link To

Always begin with places where you have a built-in connection:

• Your medical school or alma mater (even if abroad; sometimes they have U.S. partners)
• Hospitals where you’ve done rotations, observerships, or research
• Clinics where you’ve volunteered or worked as a scribe, MA, or research assistant

Approach:

1. Identify an internal medicine physician or hospitalist who knows you.
2. Send a concise, professional email (2–3 paragraphs) including:
   • Who you are and your stage (e.g., “US IMG applying for a preliminary medicine year”)
   • Your specific interest in prelim IM and internal medicine inpatient experience
   • A clear, time-limited request (e.g., “Would it be possible to shadow you for 1–2 weeks on your inpatient service?”)
3. Attach your CV and include dates you’re available.

Many physicians are more receptive when you show:

• Your goals (e.g., “I’m hoping to better understand the day-to-day responsibilities of a preliminary medicine intern.”)
• That you understand institutional requirements (HIPAA training, vaccination documentation, background checks, etc.)

2. Use Formal Shadowing or Observership Programs

Some U.S. hospitals and medical schools have:

• Structured observership programs (especially for IMGs)
• Alumni or feeder-school arrangements
• Volunteer-based clinical observer roles

Search terms that help:

• “[Hospital name] internal medicine observership”
• “[Medical school] clinical observership program”
• “shadowing program for pre-residency applicants”

While these may be labeled “observership” rather than “shadowing,” they often serve a similar function and carry more institutional legitimacy—especially when you want to document experiences and obtain letters.

3. Tapping Into Your Network Strategically

If you lack direct institutional ties, use your extended network:

• Mentors and faculty from research projects
• Previous supervisors (e.g., from scribing, volunteering, or public health jobs)
• Your medical school’s alumni network in internal medicine or your advanced specialty
• Specialty professional organizations (e.g., anesthesiology or neurology societies) that offer clinical exposure programs

Key principle: Make it easy for people to help you. Provide:

• A very clear ask: “shadowing on an internal medicine inpatient team for X weeks”
• Flexibility on dates and locations
• A one-page CV and brief explanation of your long-term goals

4. Cold Outreach: When You Don’t Know Anyone

Cold outreach can work, but needs to be targeted and professional:

1. Identify hospitalists or academic internists in teaching hospitals that sponsor prelim IM programs.
2. Look for physicians involved in education (e.g., associate program directors, core faculty).
3. Send a concise, well-structured email demonstrating you:
   • Understand what a preliminary medicine year involves
   • Have realistic expectations about the shadowing role
   • Are committed and professional

You may not get many replies, but you only need one or two positive responses.

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How Many Shadowing Hours Are Needed—and How to Document Them

A common anxiety point for applicants is “How many shadowing hours are needed?” There is no universal numeric requirement for residency, unlike some pre-med programs, but there are reasonable targets and principles.

1. Hours That Make Sense for Prelim IM Applicants

Think in terms of depth and continuity, not just hours:

• Minimum meaningful exposure:
  • ~40 hours (e.g., 1 full-time week) of inpatient internal medicine
• Stronger, more persuasive exposure:
  • 80–160 hours (2–4 weeks), ideally across one or two services

For IMGs or applicants with long gaps in clinical activity:

• Aim for at least 2–4 weeks of recent, hospital-based internal medicine shadowing or observership within the last 1–2 years.
• If you can layer this with an official observership or externship, even better.

Programs won’t reject you because your shadowing hours are “only” 50 instead of 200; they care whether you:

• Understand the realities of intern year
• Can discuss your experience thoughtfully
• Have recent, credible U.S. clinical exposure (especially for IMGs)

2. Quality Markers Programs Implicitly Look For

When they read your ERAS application and letters, program directors will infer quality from:

• Setting: Inpatient academic internal medicine is highly relevant.
• Supervisor: Hospitalists, academic internists, or subspecialists with teaching roles.
• Duration: More than a couple of isolated days—enough to see a full cycle of admissions, rounds, discharges.
• Recency: Within the last 1–3 years, especially if you’ve had time out of clinical training.

You want your experience to sound like:

• “4-week inpatient internal medicine shadowing on general medicine and cardiology services”
• “2-week hospitalist service shadowing with daily teaching rounds and admissions exposure”

…rather than:

• “A few days shadowing various physicians”

3. How to Record and Report Your Shadowing

Keep a simple log that includes:

• Dates and total hours
• Name and role of supervising physician(s)
• Setting (e.g., general medicine ward, hospitalist service, ICU)
• A brief description of your responsibilities (observation only, conferences attended, etc.)

In your ERAS application, experiences can be described as:

• “Clinical Observer – Internal Medicine”
• “Inpatient Hospitalist Service Shadowing”

Use the description box to highlight:

• Teams you followed (ward team, night float, consult service)
• Specific learning points relevant to a preliminary medicine year
• How the experience shaped your goals and understanding of intern responsibilities

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Making the Most of Your Shadowing: From Passive Observer to Active Learner

Shadowing can be superficial or transformative. The difference lies in how you prepare, behave, and reflect.

1. Before You Start: Set Clear Goals

Clarify what you want from your experience, for example:

• Understand a typical day of a prelim IM intern
• Observe how residents manage time, handoffs, and pages
• See how internal medicine training supports your future specialty
• Explore whether a medicine-heavy prelim year suits your temperament

Share a concise version of these goals with the attending or resident you’re shadowing. This shows maturity and guides what they choose to teach you.

2. On the Wards: Professionalism and Engagement

Key behaviors that leave a strong impression:

• Be early: arrive before rounds, ready to join pre-rounding or team huddles.
• Dress professionally: business attire, white coat if appropriate, ID badge clearly visible.
• Protect confidentiality: never discuss patients outside clinical areas and never handle the EMR unless authorized.
• Ask focused questions at natural breaks:
  • “How do you typically structure your pre-rounding on a full census?”
  • “What aspects of this rotation are most challenging for prelim interns?”
• Offer small, helpful tasks if permitted:
  • Fetching printed lists, helping gather supplies, or organizing non-clinical materials.

Even as an observer, you can be remembered as “the most engaged, thoughtful shadow student I’ve had in a long time.”

3. After Each Day: Reflect and Capture Stories

Spend 10–15 minutes after each shadowing day writing:

• Brief summaries of 1–2 notable patient encounters (de-identified)
• What you learned about intern responsibilities, teamwork, and decision-making
• How the day influenced your view of a preliminary medicine year

These reflections become:

• Stories for your personal statement (“There was a patient I saw during shadowing who…”)
• Talking points in interviews (“When I shadowed on the hospitalist service, I noticed that…”)
• Evidence of growth and insight over time

4. When (and How) to Ask for a Letter

If your shadowing is:

• At least 2–4 weeks long
• With consistent observation by a single attending or small faculty group
• Marked by active engagement and visible professionalism

…you can consider asking for a letter of recommendation (LOR).

Approach near the end of your time:

“I’ve really valued the opportunity to shadow you and learn about inpatient internal medicine. I’m applying for a preliminary medicine year followed by neurology, and I was wondering if you would feel comfortable writing me a strong letter of recommendation based on what you’ve observed of my professionalism, engagement, and understanding of internal medicine.”

If the answer is anything less than fully positive, thank them and do not push. You want letters that are genuinely enthusiastic.

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Integrating Shadowing Into Your Prelim Medicine Application Strategy

To maximize the value of your medical shadowing experience in preliminary medicine, integrate it across your entire application.

1. Personal Statement

Weave in 1–2 concise, specific narratives:

• A challenging case you observed that shaped your respect for internal medicine
• An insight about intern life that made you confident you can thrive in a high-volume prelim year
• How shadowing reinforced your choice of advanced specialty and the need for strong medicine training first

Avoid generic lines like:

“I shadowed many physicians and learned a lot about medicine.”

Instead, be concrete:

“During shadowing on an inpatient general medicine service, I followed a patient with advanced liver disease whose course illustrated how multiple comorbidities interact. Watching the intern balance diagnostic uncertainty, fluid management, and family communication solidified my desire to develop strong internal medicine skills through a rigorous preliminary year.”

2. Interviews

Use shadowing to answer questions like:

• “Why internal medicine for your preliminary year?”
• “How do you know you’re ready for intern-level responsibilities?”
• “What do you understand about the challenges of a prelim IM year?”

You might say:

“In my shadowing on the hospitalist service, I saw firsthand how demanding intern days can be: managing a full list, responding to pages, and supporting medical students while keeping the team on schedule. Importantly, I also saw how checklists, pre-round routines, and team communication make that workload sustainable. Those observations motivated me to seek a prelim IM year in a program that emphasizes structured teaching and support.”

3. Program Selection

Use what you learned in shadowing to choose prelim programs that:

• Match the patient populations and acuity levels you’ve seen and are comfortable with
• Offer exposure to subspecialties that align with your later field (e.g., neurology-heavy rotations, strong ICU training for anesthesia-bound applicants)
• Have an educational culture that fits your learning style (high-volume service vs smaller, more hands-on teaching teams)

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Frequently Asked Questions (FAQ)

1. Is shadowing enough, or do I need hands-on U.S. clinical experience for a preliminary medicine year?

Shadowing alone is rarely as strong as hands-on U.S. clinical experience (e.g., clerkships, sub-internships, supervised observerships with documented responsibilities). However, for some applicants—especially IMGs or those out of training—shadowing may be a necessary starting point.

Aim for:

• Hands-on experience whenever possible (student electives, sub-Is, externships)
• Shadowing and observerships to supplement, especially on internal medicine inpatient services

Programs know that access varies widely; they will look for sustained, recent exposure and thoughtful reflection more than a single label.

2. How many shadowing hours are needed to “look good” for prelim IM?

There is no formal cut-off, but for most applicants:

• 1 week (~40 hours) of inpatient internal medicine is a reasonable minimum
• 2–4 weeks (80–160 hours) makes your experience more robust and credible, especially if you are an IMG or have a clinical gap

Quality matters more than pure hours. A focused 2-week inpatient internal medicine shadowing block with a strong faculty mentor is better than 200 scattered, unfocused hours across many specialties.

3. Can I count shadowing as clinical experience on ERAS?

You should be honest and precise. In ERAS:

• List shadowing/observerships as “Clinical Observer” or similar roles
• Clearly describe your responsibilities as observational, with any allowed limited participation (e.g., attending rounds, conferences, case discussions)

Do not label pure shadowing as “sub-internship” or “externship” unless it truly was. Nonetheless, well-described shadowing on internal medicine services is still respected and can support your prelim IM application.

4. What if I can’t find internal medicine shadowing specifically—will other specialties still help?

Yes, but try to connect the dots. Shadowing in:

• Your advanced specialty (e.g., neurology, anesthesia)
• Closely related fields (e.g., cardiology, ICU, ED)

…can still help you articulate why you want strong internal medicine training first. However, if at all possible, invest effort into at least some direct internal medicine or hospitalist shadowing, as that will most closely resemble your prelim IM year and resonate most with prelim program directors.

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Thoughtfully planned and executed, medical shadowing can transform your preliminary medicine year application from generic to compelling. By focusing on relevant settings, sustained engagement, and clear reflection, you demonstrate not just that you’ve seen internal medicine—but that you understand, respect, and are ready for the intense, foundational year you are about to undertake.