Bronxcare Internal Medicine
Internal medicine at BronxCare is a 12-week rotation that is primarily inpatient at the main hospital on Grand Concourse. You can expect an email from the site explaining when and where to arrive for your first day on the Friday before you start your rotation. For us, we were told to meet at 10am in the IM conference room on the 10th floor of the Milstein building behind the main hospital. The 10th floor of this building is also where you can find the administrative offices for the IM department, as well as many attending’s offices.
My rotation was during the COVID-19 pandemic, and scrubs were worn on every rotation in and out of the hospital. If you’re reading this post-COVID, they may have switched back to business casual. I went back and forth between wearing a white coat and wearing a pullover, they didn’t mind, but again in the future they may require a white coat.
The orientation itself is very rushed, lasting 30 minutes tops. If this is your first rotation at BronxCare, you will fill out a lot of demographic and employee health services (EHS) forms. A lot of students felt like the orientation didn’t provide much in the way of important information that we as students would actually need, such as how to log into the computers and EMR, how to write notes in the EMR, look up lab values, or how to review imaging studies. It instead focused on how to use a fire extinguisher and other general safety protocols that, while important, you’ve probably been exposed to before. BronxCare uses AllScripts for their EMR. It may take a couple of weeks to actually get your AllScripts access, which can be frustrating as you are unable to look up patient information and write notes until then.
After orientation we were sent to EHS for health clearance. The office is across from the main hospital on the other side of Grand Concourse. This process was pretty chaotic, as the small clinic was inundated with multiple students across all rotations, in addition to an influx of actual employees needing various things. We were told that there was no way they would be able to get to us that day, and to come back tomorrow.
On arrival the next morning, the clinic was again packed, and it ended up taking several hours to navigate through the EHS process. Worth noting is that BronxCare DOES NOT access Complio, and may or may not accept your own personal immunization records. Bring physical copies of your immunization and vaccination records to the EHS clinic, but don’t be surprised if they repeat all of your blood work, drug screening, TB skin test, etc. While I was up-to-date anyway, this was a nice (and free!) way to have everything completely up-to-date again to use for future rotations, so I look at it as a positive.
As far as ID badges and hospital access, we were not sent for ID badges until late in our second week. You must take the shuttle bus to the Fulton location for this. Double check the spelling of your name before you leave, as many students had their names misspelled and only realized it after the fact. Your ID badge will not provide access to the hospital and will not work on any of the door scanners (such as supply rooms). Security guards will badge you through when you arrive at the hospital in the morning, and you will have to ask staff for access to the supply rooms as needed. You can take the elevator to any floor of the hospital without badge access, but the elevators are notoriously slow. If you end up taking the stairs, you will not be able to access the 5th and 6th floors, as the stairwell is locked to those floors (even though anyone can take the elevator there).
The IM rotation is broken up into three 4-week blocks, where you will change floors, supervising residents, and attendings on the first day of each month. You will be assigned to one of the IM floors in the hospital:
7th: Progressive care unit (PCU) (i.e., pulmonary/critical care step down)
9th: Cardiac telemetry
10th: Hematology/oncology and renal
15th: Progressive care unit (PCU) (i.e., pulmonary/critical care step down)
17th: General medical/surgical
During orientation on the first day, you will be allowed to sign up for which of the floors you wan to rotate through, and during which month. There are limits as to how many students are on each particular floor, as some are busier than others, so the program directors leave it to the students to divide the floors and months up between themselves. They gave us about 10 minutes to sort it out amongst ourselves and submit a schedule. My schedule was September (7th floor), October (9th floor), and November (17th floor).
The hours are pretty laid back, and in general you are expected to be there between 7am - 3pm Monday through Friday. There are no requirements for nights, call, or weekends. You will be assigned to follow a PGY-1 resident, and they will be the ones filling out your evaluation each month. You will be assigned a different resident when you change floors at the end of the month, although a few students ended up with the same resident, as the residents also rotate floors on a monthly basis. Your resident will have a half-day of outpatient primary care clinic each week that you are expected to attend with them. If you have morning clinic, you and your resident will take an Uber to the clinic after rounds and return in the early afternoon. If your resident has afternoon clinic, you can attend clinic with them or go to morning clinic with a different resident. The downside of attending afternoon clinic is that you likely won’t finish with clinic and arrive back at the hospital until 5-6pm.
Each day from 1-2pm there is a medical student lecture. For the first 6-weeks, PGY-3 residents would present various topics to us. During the second half of the rotation, we as students would present a full patient case to an attending and the group. A single student would present each day. Thursday’s are a little different, and consisted of rheumatology case presentations that pairs of students would present to Dr. Franchin, who is both the head of the rheumatology department and the medical student clerkship director. He will send an email out at the beginning of the rotation with various rheumatology cases and questions, and a schedule of which students will present on which days. You and your partner will prepare and lead a discussion on your assigned rheumatology case. Grand rounds are on Thursday mornings from 8:30am - 9:30am.
7th floor is a pulmonary/critical care step down floor, also known as the progressive care unit (PCU). This was my first (and favorite) rotation in IM, as I’m interested in critical care and this rotation allowed a great deal of exposure to complex and critically ill patients on ventilators, hemodynamic pressor support, and complex antibiotic therapies. In addition, there are many procedures that happen on this floor at the bedside, including ultrasound guided paracentesis, intubations, nasogastric tube placement, blood draws, and ABG’s. Depending on your level of comfort and previous experience, the residents will allow you to perform blood draws and ABG’s independently once you have demonstrated competency, and will allow you to assist them in other procedures.
For the 7th floor I would arrive at 6:30am in order to read up on the new patients and prepare my patient(s) for presentation to the attending around 8am. I would also pre-round on these patients, sometimes with my resident and sometimes alone. Attending rounds can vary, with some preferring to physically round and see each patient as a large group, and others preferring to do rounds sitting at the computers and then independently seeing the patients themselves later. I was generally expected to present at least 1 patient to the attending each morning, but I would follow all of the patients that my resident was following and would help out with any procedures on the floor or interesting cases as they arose.
9th floor is a cardiac telemetry floor. Expect to see patients with heart failure, chest pain, and other cardiac related complaints. However, this is also a catch-all floor for any patient in the hospital that may require telemetry (e.g., we had a burn patient that was being followed by plastic surgery on this floor because of recent syncope necessitating continuous telemetry). This is a BUSY floor, with a lot of patients and a lot of turnover. The attending that we had on this floor preferred walking rounds, and the number of patients, and in particular new patients admitted overnight, meant that rounds would often last over 2 hours. The remainder of the day consisted of students writing notes and verifying things such as pharmacy information, with the residents preparing discharge summaries. There are hardly any procedures on this floor, although if you are following a patient who is going for a cardiac catheterization (or another procedure that you are interested in watching) the residents are fine with you going to the procedure as long as the team performing it is okay with you being there (I never had any issues).
17th floor is mostly for surgery patients, but it also serves as a general medical/surgical unit with medicine patients. This floor is less busy and allowed ample time to study right before the medicine shelf exam. The patients on this floor are relatively low acuity, so you probably won’t see much in the way of complex pathology, and there are basically no procedures.
Some general information about BronxCare that applies to all of the medicine floors is that many of the patients who present to BronxCare are lower income and often have many complex social issues. The social workers are constantly going back and forth with the medical team in order to arrange temporary housing/shelter placement, transportation, etc. for patients. It wasn’t uncommon for patients to remain admitted to the hospital because social work had not cleared them for discharge, even though medically they had been cleared. Likewise, there is a large percentage of homeless patients who actually refuse to leave the food and shelter of the hospital. Another frequent issue is patients who present to the hospital for acute exacerbation of chronic medical conditions as a result of being unable to afford their medications. While you may not ultimately practice in an area with these issues, I found it to be a very interesting perspective, and an educational opportunity, to learn how to manage the medicine side of things with the social issues that arise.
Also, if you find yourself with some time to spare before starting clinicals, I would highly recommend picking up a book on medical Spanish. I don’t have an actual number to cite, but in my experience it was more common for a patient to speak Spanish as opposed to English. This added another layer of complexity to the rotation. Simple questions that may take only seconds to ask could often become complex and lengthy by the time you went through the translator phone. Longer tasks such as admitting a new patient and performing a full H&P could easily eat up a large chunk of time due to the back-and-forth with the translator and things being repeated due to poor audio quality on the phone.
Overall I feel like I learned a lot during this rotation, and the hours weren’t terrible at all, allowing a lot of time to study for the medicine shelf exam. The residents and attending were all very relaxed and were eager to teach if you had a question. They seemed to genuinely care about the students and our experience being there. The biggest negative I would say was having to constantly go through a translator phone, which I felt took away from being able to have a more conversational approach with patients and could make developing a good rapport tricky. If you are offered IM at BronxCare though, I would still recommend it.
Trey Kennedy, MS3