Sub-internship Success: A How-to Guide

by Callie Thompson, MD and Jane Zhao, MD

For those who are not familiar: A sub-internship is a rotation that a medical student does, in their fourth (and last) year, in which they are expected to function as an intern. We lovingly refer to such a person as a sub-I, sub-intern, or acting intern. Usually, at least one of these rotations is done at an outside institution. And typically, this is considered a month long job interview.

What follows are our tips/suggestions for a successful rotation.

Keep in mind that these are general guidelines, and that each medical school will have slightly different expectations of their surgical sub-interns.

Away rotations: Only do a sub-internship at a place that you might want to train at for residency if you are ready to work, work, work. This is your chance to knock the socks off the people you are working with. You need to show them how good you are and they need to come away from it thinking "we want her/him in our program." Because of these odds, many attendings and residents will tell you that the underwhelming returns of matching at a program where you have completed an away rotation are not worth the amount of money and effort you pitch in.

On the other hand, do an away rotation if you want to take advantage of the opportunity to gain some perspective on how residency programs may differ and which characteristics of a program you absolutely need and which you may be willing to sacrifice when push comes to shove, e.g. location, demographics, prestige. Furthermore, obtaining a letter of recommendation from an away rotation is a great way to gain invitations to programs that typically only interview regional applicants. This holds especially true for those who stayed in one location from undergraduate and medical school and have a desire to move elsewhere for residency.

Another word on away rotations: Do not ever turn down an away rotation you applied for at a hospital where you would like to interview for residency. Turning down the opportunity to visit a program for a month after you have taken the time to apply for it and after the program has taken the time to approve you is the single quickest way to blacklist yourself from the program when interview season rolls around.

Scheduling and letters of recommendation: Generally speaking, the earlier you schedule your sub-internship the better because most students take advantage of this time to also ask for letters of recommendation from faculty members they work with. Make sure the faculty member knows you, make sure they are going to say something good about you, and give them enough notice so that they aren’t rushing to meet a 48 hour deadline. Thus, July, August, and September are prime months. Keep in mind that if you schedule your rotation in the midst of interview season, you may have to request numerous absences, which will detract from your experience and even possibly reflect negatively on you. Scheduling a sub-internship earlier in the school year also provides faculty who have worked with you a greater level of comfort to advocate strongly for you if programs use a democratic process to create their rank list. This comes in handy if you absolutely need to match to a particular program or city.

Choosing the site of your rotation: Numerous programs request a letter from either your medical school’s chair of surgery or program director. If you haven’t had the chance to meet with either of them during other occasions, you may want to figure out which service they belong to, and try to rotate through there.

Given that a good surgeon should also have a firm understanding of medicine, a strong letter from a respected attending from a different department such as internal medicine can also go a long way in making your application shine, so if you have enough time, it certainly would behoove you to attempt a sub-internship in medicine.

A sub-internship is also a great chance to try out a particular surgical subspecialty you might be interested in pursuing further down the road, e.g. colorectal, trauma and critical care, or pediatrics. If you end up falling in love with it, you now have a stronger incentive to match to certain programs, or if you end up hating it with a passion, you have saved yourself from years of potential misery.

Set yourself up well: This starts by developing a full understanding of the dynamics of the system setup and the people on the service you will work with. Will you be working on a high-volume service with fast turnover? Will you be working on one where the norm is one to two elective cases every other day? Are the attendings known for their Socratic style of teaching? Do the residents go out of their way to include students in the work up of patients? Play to your strengths, particularly if you are trying to obtain a letter. Some sub-interns’ strengths come out in chaotic situations, when their reliability and collected composure are a sweet breath of relief to ragged residents working in a hectic environment. Some sub-interns love being pimped and shine best when being grilled with question after question while their classmates stare gape-mouthed and hopeless. Do you rock at presenting and working up patients? Are you better with procedures? Figure out how your strengths will complement the needs of the service you are joining, and make sure you choose and prepare accordingly. For better or worse, your performance will be evaluated subjectively, and it doesn’t take much for a poor impression to be wrongly formed of a usually wonderful sub-intern or a positive one of an otherwise average sub-intern.

Eliminate distractions: This is your opportunity to take on the responsibilities of an intern. Help manage the list. Know every patient. Unlike your third year clerkship, you do not have assignments or a shelf exam to worry about during your acting internship (disclaimer: this is not true at every medical school). Plan out your year to avoid having to work on your personal statement, ERAS application, away rotations, scheduling interviews, or study for the USMLE Step 2 during this time. You can take full advantage of the freed up time to play an active role on the team and gain more hands on patient care experience.

Presentation: If you are expected to give a presentation (many rotations require them), get started on it early, and identify both a resident and a faculty member to advise you. Be sure that you already have an idea in mind before you speak to them and get your presentation done early enough that they can help you make improvements if need be.

Prioritizing: A real intern probably spends more time on the wards than in the operating rooms, while a third year medical student gets the best possible snapshot of what it’s like to be a surgeon by being in the operating room whenever possible. What’s a sub-intern to do? As a fourth year medical student, you are somehow expected to find the happy medium between both.

Some pearls:

You need to be able to function like an intern which means you need to have a good idea of how to manage your time and balance multiple patients at a time. You aren't a third year student anymore, so you need to carry more than two to three patients at a time. Ideally, you should know the entire service, just like the intern does. Even if there is a third year medical student on your service, you should know everything about their patients too without stepping on their toes.

In the mornings, do your best to help the third year medical students and interns collect vitals and pre-round on patients. Chat with the nurses and ancillary staff for events that occurred overnight.

For rounds, you will most likely follow steps for success that won’t have deviated much from your third year clerkship: Carry marking pens, suture removal kits, gauze, tape, and consent forms in your pockets. Split up patients with the other medical students on your team, and take down dressings on all patients who are postop day two. Have a penlight at the ready to shine on the incision for your resident to have better visualization. Propose alternative treatments for patients who appear to quickly be running out of conventional options. And so on.

Go into the patient’s room with the senior resident or fellow, and gain a sense of what the plan for that day will be. You have no idea how helpful you can end up being when you run the list with the other junior residents later or when you spare the time to follow up on labs and imaging while the rest of the team is occupied handling tasks that only they can do with the MD or DO behind their name.

The intern may not be able to make time to be in the operating room, but you do. Since you are a sub-intern and not an actual intern, your priority is to get the most of your undergraduate medical education. However, you should be demonstrating your ability to be an intern in less than a year so don’t ignore the floor work. Also, not helping the intern and going to the OR the entire time will be noticed and not in a positive way since that isn’t really the function of a sub-I.

When you do go to the operating rooms, first (as always) you must know the patient you are operating on. Help roll the patients into and out of the rooms. Retract. Answer questions about anatomy, pathophysiology, ethics, or whatever else the attending or resident wants you to answer. Drive the camera. Again, this part won’t be much different from when you were a third year medical student. Let third year medical students have opportunities to scrub into cases you have seen before. If you desperately want to be involved in a case, and there are two students, ask the attending if both of you can scrub. Teach the third year medical student basic skills, and share opportunities to do procedures in the operating rooms and by the bedside with them. You had great residents and sub-interns when you rotated through that made surgery rock your world. Now it’s your turn to pay the favor forward.

If the team is short-staffed, your priority is to take care of the floor patients or clinic patients depending on where your are assigned. If you are done with your tasks on the floor, then make your way to clinic (even if you weren’t assigned), and see patients and present to the attendings. Come up with plans for the patients. Look out for your third year medical students and have them present to you before they present to the resident/attending, and help them polish their presentation.

Be proactive rather than reactive, and let your residents know what you are up to, especially once you have completed a task. If you ask if you can do anything to help, they will invariably reply, “No thanks. You really don’t have to. Seriously.” So if you see that they have a million and one tasks to complete, take the initiative to tackle a task within your ability that doesn’t put patients at risk, and provide your upper level with the completed result. That is the difference between a stellar, unforgettable sub-intern and one who is great.

Ask for help when you are unsure, and take advantage of this time to ask questions that may seem silly or dumb. Now is the time. While it sometimes may not seem to be the case, you shouldn’t be expected to know everything about surgery. Residency is after all a training process. It’s better to clarify what you don’t know now, rather than wait later when you have actual responsibility over patients.

Remember, not always knowing the answer is forgivable. What’s important is being reliable and teachable. Surgery is one of the most exhausting specialties out there, and not everyone has the physical or emotional fortitude to pursue the field. This has led to a phenomenon where even 80 hours per week are sometimes perceived as not enough. Thus, we don’t think we’re remiss in stating that a honest hard worker of above average intelligence is often preferred over a genius who can’t be relied on, a statement true for most walks of life but one that sub-interns should particularly take to heart.

Read: Just because you don’t have a shelf exam to prepare for anymore doesn’t mean you should stop studying. Read up on your patients. Find relevant articles. Create treatment algorithms and cheat sheets.

There are some folks who function well on three hours of sleep. If you are not that type of individual, give yourself permission to crash when you return home in the evening. Instead, set aside time early in the morning to jot down notes about the patients who will be operated on for the day. Be smart about it. If there are too many cases for you to scrub into, and you’re pressed for time, then concentrate on those whom you know for sure you will be operating on. For those patients, know the following:

o pertinent details from patient’s history, labs, and imaging

o indications for the operation

o crucial anatomy and steps of the operation

o possible short-term and long-term complications

o important details of perioperative management

Hopefully, if you have read up about each patient prior to their operation, then as the rotation goes on, you will be able to anticipate the general management and time course of all the patients on the service during their post-operative stay in the hospital.

Share what you have learned with the other medical students on your service. It helps guide their studying and cements the knowledge further in your mind. Remember the big picture. By helping others, you indirectly improve the care of those patients who will be one day be treated by other members of your team.

Pay it forward. Take the third year medical students under your wing. Teach them how to tie surgical knots. Share with them stories of your own frustrations and triumphs from your time as a third year. Remind them to eat. Buy them coffee, or share a granola bar. Help them with their presentations. Let them know when it is okay to text the upper level and ask, “is there anything else I can do to help?” which we all know is universal student code speak for “may I please leave?”

Lastly, if you really want to stand out, give the sub-intern and third year medical students who will trade you out for the next month a heads up about what to expect once they come onto service. This will make not only their lives easier but also relieve a weight off the shoulders of your upper levels. Your patients may even benefit from safer care.

You will impress everyone if you show them how helpful and kind you are to others, even when it doesn't directly benefit you.

In conclusion: what does it take to succeed as a sub-intern? If you can in anyway make the service run as smoothly as possible and life better for the residents then you can be rest assured that you’ve done a good job.

Did we miss anything? Let us know your own suggestions for sub-internship success in the comments below.

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Medical students, click here for more information on how to succeed on your third year medical student surgical clerkship.

Surgical interns, click here for advice on how to build the foundation for future success by starting off intern year the right way.

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Callie Thompson is a chief resident in general surgery at the University of Washington. Callie aspires to be a burn and trauma surgeon and a translational scientist. Her research interests include genetic variations and their associations with the development and outcomes of disease and illness. Callie is married to an internist and has three children ages 1, 3, and 7.

 







Jane Zhao is a general surgery resident at the University at Buffalo, State University of New York. She obtained her medical degree with a scholarly concentration in Clinical Quality, Safety, and Evidence-based Medicine from the University of Texas Medical School at Houston and completed her undergraduate studies in Medicine, Health, & Society at Vanderbilt University. She was the 2012 recipient of the Shohrae Hajibashi Memorial Leadership Award and chaired the AWS Blog Subcommittee from 2013 to 2014. Her interests include healthcare social media, quality improvement, and public health. She can be followed on Twitter.

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