The Ultimate Guide to Medical Shadowing in Emergency Medicine-Internal Medicine

Understanding Medical Shadowing in Emergency Medicine–Internal Medicine

Medical shadowing is one of the most valuable early experiences you can pursue when considering a combined Emergency Medicine–Internal Medicine (EM IM) career. Shadowing helps you confirm your interest in both acute care and longitudinal internal medicine, understand the realities of the workflow, and gather compelling stories and insights that will strengthen your residency application.

For the EM IM combined pathway, shadowing carries an additional layer of importance: you’re exploring not just two specialties, but how they come together. You’ll want experiences that highlight both sides—emergency medicine internal medicine practice in the ED and on the wards—and, ideally, exposure to physicians who are dually trained.

This guide will walk you through:

• What EM IM combined training looks like and how shadowing fits in
• How to find shadowing opportunities (both EM, IM, and combined)
• What to do before, during, and after your shadowing shifts
• How many shadowing hours are needed and how to document them
• How to translate your shadowing into a stronger EM IM application

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EM–IM Combined: Why Shadowing Matters Even More

Emergency Medicine–Internal Medicine residency is a five-year combined training program that prepares physicians to practice in both the emergency department (ED) and internal medicine settings (inpatient and outpatient). Graduates can pursue careers in:

• Academic emergency medicine with inpatient consult roles
• Hospital medicine with ED coverage
• Critical care fellowships
• Administrative leadership roles bridging ED and inpatient care
• Rural or community practice where broad scope is essential

Because the pathway is relatively small and specialized, program directors want evidence that you understand:

1. The acute, high-intensity nature of emergency medicine
2. The diagnostic depth and continuity of internal medicine
3. The interface between the ED and the hospital—where EM IM physicians often thrive

Shadowing experiences are one of the best ways to demonstrate this. Simply stating “I like both EM and IM” is not enough. You’ll need concrete examples that show you’ve seen:

• Rapid triage and resuscitation in the ED
• Medical decision-making for complex inpatients
• Handoffs between ED and inpatient teams
• Systems-based issues like boarding, throughput, and disposition
• How EM IM physicians think across settings and timelines

Example: What “Combined” Insight Looks Like

Imagine you shadow a dual-trained EM IM attending:

• In the ED, you watch them stabilize a patient with septic shock, start antibiotics, and initiate vasopressors.
• On the inpatient service the next day, you see the same physician adjusting the sepsis patient’s management on the floor, dealing with renal function trends, family discussions, and discharge planning.

This continuity gives you a perspective that pure EM or pure IM shadowing might not, and it becomes a powerful story for your personal statement or interviews.

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How to Find Shadowing in EM, IM, and EM–IM Combined

Finding high-quality medical shadowing, especially in a specific niche like emergency medicine internal medicine combined practice, requires persistence and strategy. You’re not just looking for “any” doctor—you’re trying to get as close as possible to dual-trained physicians and settings where their skills are most visible.

Step 1: Start with Your Own Institution

If your medical school or undergraduate institution is affiliated with a teaching hospital, this should be your first stop.

Who to contact:

• EM clerkship director or residency program coordinator
• IM clerkship director or residency program coordinator
• Combined EM IM program director (if your institution has one)
• Office of Student Affairs or Career Advising

Use a concise email that includes:

• Your current training level (premed, M1, M2, etc.)
• Your specific interest in EM IM combined training
• Your request for shadowing, not hands-on patient care
• Your scheduling flexibility and any institutional requirements (HIPAA training, vaccines, etc.)

Sample email subject line:
“Request for EM–IM Shadowing Opportunity (MS2 Interested in Combined Training)”

Even if your institution does not host an EM IM combined residency, many academic centers have at least one or two dually trained faculty members. Ask explicitly:

“Are there any EM–IM combined or dual-trained physicians on faculty who might be open to having a student shadow for a few shifts?”

Step 2: Use Online Program and Faculty Directories

If local options are limited, look outward:

• Review the Society for Academic Emergency Medicine (SAEM) and AAIM directories for combined EM IM programs.
• Visit EM IM program websites; many list faculty with dual training.
• Look for faculty bios mentioning “dual-boarded in Emergency Medicine and Internal Medicine” or “EM–IM graduate.”

Once you identify names, you can:

• Ask your school’s advising office to help you arrange an away shadowing or observership.
• Reach out directly if the institution accepts external shadower requests.

For non-local shadowing, you may need:

• Proof of vaccination and TB testing
• HIPAA or institutional privacy training
• Proof of malpractice coverage (occasionally, for observerships)

Step 3: Leverage Student Organizations and Mentors

Student groups and mentorship programs can be powerful connectors:

• EM interest groups and IM interest groups
• Emergency Medicine Residents’ Association (EMRA) student sections
• American College of Physicians (ACP) student chapters
• Specialty pathway or career advising programs at your school

Ask peers:

• “Has anyone shadowed in emergency medicine internal medicine combined settings?”
• “Does anyone know dual-boarded faculty who teach in both EM and IM?”

Often, another student’s introduction can open doors faster than cold emails.

Step 4: Combine Separate EM and IM Shadowing

Not every location will have EM–IM faculty. When you can’t find dual-trained physicians, aim for strategic breadth:

1. Shadow in the ED: Fast-paced decision-making, stabilization, initial differential diagnosis, triage, and disposition choices.
2. Shadow on IM wards or in clinic: Longitudinal management of chronic illnesses, diagnostic complexity, transitions of care, and multidisciplinary teamwork.

Together, these experiences can still give you a “combined” perspective, especially if you deliberately look for the transition points between settings.

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Preparing for Your EM–IM Shadowing: Logistics and Mindset

Clarify Institutional Requirements Early

Every hospital has its own rules for medical shadowing. Before your first shift, confirm:

• Dress code (typically business casual with closed-toe shoes; white coat if appropriate)
• Identification badge process
• HIPAA or privacy modules to complete
• Restrictions in sensitive areas (e.g., psychiatric ED, trauma bays, isolation rooms)

If you’re preclinical or premed, you will likely have observer-only status—no direct patient contact or documentation. As a clinical medical student, your role may blur with typical clerkship duties, depending on policies.

Set Clear Learning Goals

Go in with specific, written goals that relate to EM IM combined training. For example:

• “Observe how physicians decide when to admit vs. discharge a complex medical patient.”
• “Compare approaches to undifferentiated dyspnea in the ED and on the wards.”
• “Understand how handoffs between ED and internal medicine teams are structured.”

Share one or two of these goals briefly with your supervising physician at the start of the shift. This orients them to what you’re hoping to see.

Bring the Essentials

• Pocket notebook or small notepad
• Pen and a watch with a second hand
• Updated immunization record (if requested)
• List of questions you hope to ask during downtime

Avoid:

• Using your personal phone for note-taking unless explicitly allowed
• Bringing large backpacks or distracting items into patient-care areas

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Making the Most of Your EM–IM Shadowing Shifts

Your goal is to observe clinically, think critically, behave professionally, and walk away with insights you can later apply to your EM IM combined residency application.

In the Emergency Department

In the ED, focus on how emergent presentations intersect with internal medicine-level complexity.

Key questions to guide your observation:

• Triage and acuity:

  • How do clinicians distinguish who needs immediate resuscitation vs. who can safely wait?
  • How are internal medicine comorbidities (e.g., CHF, COPD, cirrhosis) factored into triage?

• Diagnostic strategy:

  • Which tests are ordered immediately vs. deferred?
  • How do physicians make decisions under time pressure and uncertainty?

• Disposition decisions:

  • What prompts admission to internal medicine vs. observation or ED discharge?
  • How are borderline cases handled (e.g., “could go either way” between admit vs. discharge)?

• Interdisciplinary interaction:

  • How do ED providers communicate with hospitalists, ICU teams, and consultants?
  • How do EM IM physicians leverage their knowledge of inpatient care when planning disposition?

Concrete example to watch for:

A patient with chest pain, borderline troponin rise, multiple comorbidities, and limited social support. Observe:

• How the ED team stabilizes, risk-stratifies, and negotiates with inpatient medicine or cardiology.
• What social and systems issues weigh into whether the patient is admitted or discharged with close follow-up.

These kinds of cases are ideal when you later describe what draws you to the interface of emergency medicine internal medicine care.

On Internal Medicine Wards or in Clinic

On IM services, your lens shifts to depth, continuity, and systems-based practice.

Key elements to focus on:

• Diagnostic refinement:

  • How are ED diagnoses confirmed, refuted, or broadened with more data and time?
  • How do teams reframe “chest pain” or “shortness of breath” into specific, nuanced diagnoses?

• Longitudinal care:

  • How are chronic diseases addressed during acute hospitalizations?
  • How are medication reconciliations handled for complex patients?

• Transitions of care:

  • How do IM teams interpret ED documentation?
  • How do they plan for discharge and prevent readmission?

• Systems perspective:

  • How do hospital bed availability, social work resources, and outpatient access shape decisions?
  • What frustrations do IM teams have with ED handoffs and vice versa?

Try to connect each inpatient case back to its likely ED presentation:
“What might this have looked like when they first came to the ED? How would I have managed the first two hours of this patient’s care?”

Professionalism and Etiquette While Shadowing

Shadowing in EM IM environments, especially the ED, demands heightened professionalism:

• Introductions:

  • Introduce yourself to every patient as a student observer (or your appropriate role) and let the supervising physician confirm that your presence is okay.
  • Respect any patient who declines having a learner present, especially for sensitive complaints.

• Confidentiality:

  • Don’t discuss cases in public areas (elevators, cafeteria, publicly accessible spaces).
  • Keep written notes de-identified (no names, dates of birth, or room numbers).

• Boundaries:

  • Do not perform any procedures or exams unless explicitly allowed and supervised, and only if your role and institutional rules support it.
  • Do not speak independently to patients about diagnoses, prognoses, or management plans.

• Engagement:

  • Ask questions during natural pauses—not during codes, resuscitations, or high-conflict encounters.
  • Aim for questions that show you’re thinking at the EM IM interface: “How did their history of cirrhosis change your decision to admit vs. discharge?”

Reflecting During and After Shifts

Immediately after each shadowing session, take 10–15 minutes to jot down:

• 2–3 memorable patient encounters (de-identified)
• 1–2 things that surprised you about EM IM practice
• An example where ED and IM priorities seemed to conflict—and how it was handled
• Any moment that reinforced or challenged your desire to pursue a combined pathway

These reflections will later become the raw material for:

• Personal statement paragraphs
• ERAS experiences descriptions
• Interview answers (e.g., “Tell me about a clinical experience that solidified your interest in EM–IM combined training.”)

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Shadowing Hours, Documentation, and Using Your Experience for EM–IM Applications

Shadowing Hours Needed: How Much Is Enough?

There is no fixed national standard for “shadowing hours needed” for EM IM combined programs, but you can think in ranges and balance:

• For premeds:
  • 40–80 hours of shadowing across specialties is common, with at least 20–40 hours in EM and/or IM if you’re already leaning in that direction.
• For medical students:
  • Formal clerkships will provide far more than basic shadowing hours. What matters more is intentional exposure to both ED and IM settings, plus any electives or sub-internships that demonstrate focused interest.

Specific to EM IM combined interest, you should aim for:

• Exposure to both EM and IM environments (even if not labeled as “shadowing”)
• At least some time (even a few shifts) directly observing dual-trained faculty if possible

Programs won’t usually ask for exact hour counts, but they will notice if your application clearly demonstrates:

• Substantial EM exposure but no internal medicine experiences (or vice versa)
• Or, ideally, meaningful engagement in both arenas

How to Log and Document Your Shadowing

Maintain a simple log with:

• Date and location
• Physician’s name and specialty (e.g., “Dr. X, EM–IM dual boarded”)
• Approximate hours per session
• One brief learning point or reflection per shift

This log:

• Helps you reconstruct accurate dates and descriptions for ERAS
• Provides concrete details for personal statements and interviews
• Serves as a memory aid if you request a letter of recommendation later

For ERAS, you won’t list “shadowing hours” as a separate category, but you can include:

• “Clinical Shadowing in Emergency Medicine and Internal Medicine” as an Experiences entry (particularly if you’re preclinical or non-US grad).
• Key EM IM shadowing within the narratives of your Most Meaningful Experiences or in your personal statement.

Turning Shadowing into Application Strengths

Use your EM–IM shadowing experiences to:

1. Articulate your motivation

   • Describe a specific patient encounter that highlighted the need for physicians skilled in both acute stabilization and longitudinal management.
   • Explain how you saw EM IM combined physicians bridge gaps between ED and inpatient care.

2. Demonstrate understanding of the combined pathway

   • Reference observed challenges at the ED–inpatient interface: boarding, communication, conflicting priorities.
   • Explain how dual training uniquely positions physicians to address these issues.

3. Shape your career vision

   • Based on what you observed, outline how you might use EM IM training in the future (e.g., academic combined practice, hospital leadership, critical care, rural breadth practice).

4. Inform letters of recommendation

   • If you spent substantial, repeated time shadowing (especially as a medical student), a supervising EM IM or EM/IM attending may be able to comment on your insight, professionalism, and commitment—even from an observer role.

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Frequently Asked Questions (FAQ)

1. Do I need to shadow a dual-trained EM–IM physician specifically to match into an EM IM combined program?

It’s not strictly required, and many applicants match without direct shadowing of EM IM physicians. However:

• You should have meaningful exposure to both EM and IM settings.
• Ideally, you will have at least one mentor or contact who can discuss the realities of EM IM combined training, even if not dual-trained themselves.

If dual-trained physicians are available, shadowing them is a major plus because:

• It gives you deeper, more accurate insight into the combined pathway.
• It often leads to stronger, more specific application narratives.

2. How can I find shadowing if my school doesn’t have an EM–IM combined program?

You can still build an EM IM-relevant portfolio by:

• Shadowing or rotating in a busy ED with strong internal medicine interfaces (e.g., ED observation units, ED-run admitting teams).
• Spending time on internal medicine wards and in continuity clinics.
• Asking EM and IM faculty whether they know any dual-boarded colleagues regionally and whether observerships are possible.
• Attending EM and IM interest group events where visiting faculty might share their EM IM combined experience.

The key is to be intentional: seek opportunities that clarify how acute and longitudinal care intersect.

3. Is there a minimum number of shadowing hours needed specifically for EM–IM combined applications?

Programs do not typically state a hard minimum. Instead, they look for:

• Clear exposure and commitment to both EM and IM.
• Thoughtful reflection that shows you understand the combined nature of training.

As a rough guideline:

• Premeds should aim for a balanced EM/IM exposure within their overall shadowing.
• Medical students rely more on clerkships and electives; formal “shadowing hours” become less important than the quality and focus of your clinical experiences and how you describe them.

4. How should I discuss my EM–IM shadowing in my personal statement or interviews?

Be concrete and specific:

• Describe 1–2 encounters that reveal the interface between emergency and internal medicine (e.g., a complicated admission decision, management of multi-morbid patients, or a case highlighting continuity from ED to inpatient).
• Highlight what you learned about systems issues (boarding, communication gaps, resource constraints) and how EM IM physicians are uniquely positioned to improve them.
• Connect the experience to your future goals, such as leading quality improvement across ED and hospital medicine, practicing in resource-limited settings, or pursuing critical care as an EM IM graduate.

Focus less on “I loved the adrenaline” and more on “I saw how dual training allowed physicians to care for complex patients across settings and timelines—and I want to develop that same breadth and flexibility.”

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By approaching medical shadowing with intention—seeking experiences that illuminate both emergency medicine and internal medicine, and especially where they meet—you’ll gain far more than hours on a log. You’ll develop the insight, stories, and professional identity that distinguish a strong applicant to EM IM combined programs and guide your future career at the intersection of acute and longitudinal care.