Sub-internships (Sub-Is) are clinical rotations that fourth year medical students pursue at hospitals affiliated with their home medical school or at hospitals affiliated with other medical schools (i.e., away rotations). The fourth year is expected to effectively function as an intern under the supervision of senior house staff and attending physicians during the sub-I. Many medical students apply for sub-Is at hospitals where they wish to apply for residency. Sub-Is are essentially auditions for residency programs and are thus important for obtaining a coveted spot in top programs. In this post, I provide helpful tips for acing your sub-I.
1 | The Difficulty with Sub-Internships
There is often a significant amount of hesitation surrounding sub-I selection during medical school. The reasons for this are multifactorial: negative recommendations from advisors dissuading students, horror stories from colleagues, self-doubt, and a general fear of the unknown are among the most common ones I have encountered.
Part of the problem lies in the non-standardized nature of Sub-I’s. While most schools expect students to do a Sub-I during fourth year, recommendations regarding away rotations vary. For my specialty, Neurosurgery, it is generally expected that applicants complete 2-4 rotations at other programs, using this time to gain experience, earn letters of recommendation, and to try and earn an interview spot at a program. Other specialties vary in their recommendations and requirements. In addition, restrictions are commonly placed by the schools themselves. Medical students are often limited by both timing (i.e., when they can leave to go do Sub-I’s) and amount (i.e., how many Sub-I’s they are allowed to do). For people who are focused on doing a rotation to earn a letter, this is often limited to the early summer to late fall of the fourth year. For those of you who have not gone through this process yet, you can imagine the difficulty in obtaining a spot at some of the more competitive programs during such a limited time frame.
Nevertheless, these rotations give students the unique challenge of experiencing a period of training at another training program. I did four Sub-I’s when I was a fourth-year medical student – mostly due to the unwritten requirements of applying to my specialty – and the academic and clinical growth I gained during those Sub-I’s was unparalleled. This was in part due to the elevated expectations of representing my home program, as I took pride in not embarrassing the people who had trained me by showing up unprepared. Throughout my time as a rotating student and during my later experience supervising Sub-I’s as a resident, I have recognized several traits and behaviors that really help students stand out.
2 | Professionalism
First and foremost, professionalism. You are not only representing yourself when you go on away rotations, you are representing your school and your mentors. This concept goes back to the basics. Our patients (which will be your patients in the blink of an eye if you are a nervous med student reading this) expect a certain degree of polish from medical providers. They are often presenting in a time of need or severe distress, and they rely on us heavily to assuage their fears. Therefore, it is important that you show them your best face. This goes for every member of the team, including the Sub-I’s. The people evaluating you will notice your patient interactions and treating your patients poorly will reflect poorly on you.
However, professionalism is a relatively nebulous concept. For starters, maintaining cleanliness is crucial. While I myself was the kind of student who studied in the comfort of sweatpants from my home throughout my pre-clinical years, showing up unkempt to a Sub-I – or any job interview for that matter – will be quickly recognized. This is particularly difficult because you’ll often be working long hours, in a city potentially far from home, and staying at an accommodation that is less than comfortable (trust me, I remember my poor med student days well). I remember spending a month-long rotation sleeping on a blow-up mattress on the floor of a MD-PhD student’s apartment. He was kind enough to offer me a room because I had been too busy with other rotations to find a place to live in my next Sub-I. That being said, I did what I could to make sure I arrived showered and fresh every day, somewhere between 3 and 4 AM, so I could preround. A critical step in ensuring this happens is to pack appropriately for Sub-I’s. Take only the essentials, and for the love of Cushing don’t pack the morning before you leave like I often did.
The next step of professionalism is to arrive prepared. I do not just mean with your stethoscope in hand and your white coat pressed, I mean prepared to do the task for which you will be assigned. If you’re doing a Sub-I in medicine and you have a patient with an obscure complication of Polycythemia Vera, read about it! That way on rounds when the attending looks at you, you have more to offer about the pathology than “I think it’s a bloodborne disorder.” Similarly, for my budding surgical colleagues, if I ask you to tie a suture, do not hesitate. It tells me you have not practiced or you are afraid of failing. Trust me, we have all been in your shoes and we expect you to still fail at your stage. What we are really testing you on is if you prepared, and with that is the implication that you recognize the time that we – as an institution and department – are taking in your education is valuable. While this may seem like something most people should have picked up on during their clinical MS3 year, it is much harder to implement with the constraints of the long hours required during a Sub-I, especially as fatigue sets in. Forming a routine of preparing every night after your shift, no matter how tired you are, is paramount to success during your time on the wards.
3 | Other tools for success
Another key to success is camaraderie. As residents, you will quickly realize that your department and clinical service are able to treat the endless onslaught of disease on a daily basis by working as a team. Most students are pretty good about being team players during third year and keep an eye out for each other. However, many student’s competitive natures come out when they start their Sub-I’s. Though you may not think it, you are under scrutiny by people who are continuously searching for red flags in your behavior. The thing that disappoints me most about candidates rotating with us is finding out from someone (nurses who overheard, office staff, other residents) that the Sub-I’s are not working as a team. What you do not want is to be the student who is the cause of that rift. On the other hand, demonstrating strong collaborative behavior with other students as well as the residents and attendings will vastly improve how you are viewed by that program.
The Sub-I’s are also a great time to start forming habits you want to have when you are a resident. I think these rotations are an excellent time to start learning how to teach. I would try to impart what little knowledge I had at that point to the third years who were also on rotation with me. Bear in mind that I do not mean for you to pimp the other students, but rather to impart little bits of knowledge they may not have yet. You were just a third year yourself, so you are in the perfect place to remember what gaps in knowledge you yourself had just a few short months ago.
Next, stay on top of paperwork. There is often a lot of red tape to get through to rotate at another institution. Make sure you do this quickly; waiting until the last minute can paint a very bad impression. This also goes for notes. If your tasks include writing notes and helping on rounds, make sure you do so in a timely fashion. These things come with practice, so make sure you spend the first few days really learning the electronic medical record and charting system whenever you start a rotation.
Finally, remember what your role should be. You are a sub-I, and you will do better (and enjoy it more) if you really embrace your role as a member of the team. As a third year on rotation, most people follow the herd while hoping to learn bits and pieces from watching. However, Sub-I’s are given a chance to learn more quickly from first-hand experience the way residents are by taking more direct ownership of patients. Make sure to check with your supervising residents often, but take these opportunities to practice being an intern. Your team will be happy for the helping hand and will hopefully be eager to train you. Thus, staying enthusiastic and integrated with the service will really help you shine.
Sub-I’s are a strange period during med school. You are expected to grow up quickly during these rotations. Take these opportunities seriously, prepare thoroughly, and use them as a jump-start to residency. Instead of focusing on impressing everyone, shift your efforts to becoming the best team-member you can be. The residents and attendings supervising you will take notice of your labors.
As always, Med School Insider’s advising services are a great way to ask us for more directed advice.