MD & DO How are SUBI's different from 3rd year clerkships?

[deleted1129181]

In terms of day-to-day activities, how are SUBI's different from clerkships?

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[mrbreakfast]

Highly variable between institutions, but generally speaking you can think of it as a clerkship on steroids. Carry more patients, have actually decent presentations, help out with some floorwork for your patients. In some places, you can place orders on your patients as well (which the resident has to sign for them to actually have effect). You might also be expected to teach the clerkship students a little if the resident is busy.

The ideal sub-I at my institution would be able to fully present 3-5 patients, including answering specific questions about them from the attending, place routine orders (to be cosigned) and send pages/talk to other teams on behalf of the team for those patients, handle discussions with nursing/bedside discussions (with the resident present, of course), write detailed notes/keep the hospital courses updated each day, and be able to give signout on their patients to the night team. They'd also be able to take H&Ps on new patients themselves without too much assistance.

This is the ideal, but really I've only ever seen one person be able to do all of this perfectly. Sub-Is are to learn, after all. You can think of it as a way to "ease into" being an intern, without all the pressure and emergencies, etc.

 

[diesel2202]

Highly variable between institutions, but generally speaking you can think of it as a clerkship on steroids. Carry more patients, have actually decent presentations, help out with some floorwork for your patients. In some places, you can place orders on your patients as well (which the resident has to sign for them to actually have effect). You might also be expected to teach the clerkship students a little if the resident is busy.

The ideal sub-I at my institution would be able to fully present 3-5 patients, including answering specific questions about them from the attending, place routine orders (to be cosigned) and send pages/talk to other teams on behalf of the team for those patients, handle discussions with nursing/bedside discussions (with the resident present, of course), write detailed notes/keep the hospital courses updated each day, and be able to give signout on their patients to the night team. They'd also be able to take H&Ps on new patients themselves without too much assistance.

This is the ideal, but really I've only ever seen one person be able to do all of this perfectly. Sub-Is are to learn, after all. You can think of it as a way to "ease into" being an intern, without all the pressure and emergencies, etc.

That's how our sub-I experience is structured at my instutition as well. And students definitely fall within a spectrum as far as how well they perform. I've had some who function at the level of an intern and others who can't handle as much responsibility.

 

[deleted1129181]

That's how our sub-I experience is structured at my instutition as well. And students definitely fall within a spectrum as far as how well they perform. I've had some who function at the level of an intern and others who can't handle as much responsibility.

What are some common reasons they can't handle as much responsibility? Is it simply a matter of how long it takes a student to complete a task? Is it a communication issue about how they interact with nurses and how they do consults? Or is it more of a lack of knowledge and ability to do an H&P well?

 

[mrbreakfast]

What are some common reasons they can't handle as much responsibility? Is it simply a matter of how long it takes a student to complete a task? Is it a communication issue about how they interact with nurses and how they do consults? Or is it more of a lack of knowledge and ability to do an H&P well?

It's all of these, and more. Medicine is challenging because students have to transition from being excellent students in preclinicals (something at which they are very experienced) to doing a "job" as a clerkship student, which involves organization, task triaging, making decisions and defending them in real-time, working as a team, and "customer service" in a way - things many med students, who have never held an actual job, have never really done. Even the students with incredible book-smarts can panic with the simple assignment of "hey, let's go see what's going on with this new patient. I'll let you do the talking."

There are lots of things which come with experience, but in general I would stay students often struggle with coming up with simultaneously concise yet organized and informed presentations, being efficient with tasks, and talking to patients like they aren't other medical students. As a sub-I, I already expect you to have at least some skill in all of those.

Another issue is reporting vs. interpreting information. Med students are very good at reading the notes the overnight resident wrote. But what do you think? As a sub-I, you will already have a year of experience in clinicals. You've presented hundreds of times. If you don't know how to improve, watch the residents and try to emulate them. But you can always get better.

It also is a stepwise process. If you do a good job giving a stable updates, I'll let you tell the next patient he had a small stroke and explain it to him. If you do a good job with that, maybe you can tell the next patient's family that grandpa isn't ever going to wake up. If you didn't do a good job with the small stroke patient, we'll try again with the next one. No one ever starts out perfect. But the good sub-Is learn and adapt from their misses and hits. It doesn't matter where you start out, it matters where you end up.

The same applies to intern year as well, by the way. All fresh interns suck. We don't expect you to be perfect, we expect you to get better.

 

[deleted1129181]

It's all of these, and more. Medicine is challenging because students have to transition from being excellent students in preclinicals (something at which they are very experienced) to doing a "job" as a clerkship student, which involves organization, task triaging, making decisions and defending them in real-time, working as a team, and "customer service" in a way - things many med students, who have never held an actual job, have never really done. Even the students with incredible book-smarts can panic with the simple assignment of "hey, let's go see what's going on with this new patient. I'll let you do the talking."

There are lots of things which come with experience, but in general I would stay students often struggle with coming up with simultaneously concise yet organized and informed presentations, being efficient with tasks, and talking to patients like they aren't other medical students. As a sub-I, I already expect you to have at least some skill in all of those.

Another issue is reporting vs. interpreting information. Med students are very good at reading the notes the overnight resident wrote. But what do you think? As a sub-I, you will already have a year of experience in clinicals. You've presented hundreds of times. If you don't know how to improve, watch the residents and try to emulate them. But you can always get better.

It also is a stepwise process. If you do a good job giving a stable updates, I'll let you tell the next patient he had a small stroke and explain it to him. If you do a good job with that, maybe you can tell the next patient's family that grandpa isn't ever going to wake up. If you didn't do a good job with the small stroke patient, we'll try again with the next one. No one ever starts out perfect. But the good sub-Is learn and adapt from their misses and hits. It doesn't matter where you start out, it matters where you end up.

The same applies to intern year as well, by the way. All fresh interns suck. We don't expect you to be perfect, we expect you to get better.

Thank you so much! This was a wonderful, insightful post!

 

[aldol16]

Depends on your specific sub-I but generally can split into medicine and surgery type sub-I's.

For medicine, as a sub-I you're expected to carry your own patients (often with only the senior resident as your supervisor, meaning you function like an intern). Since you can't place orders, you end up pending your orders and the senior reviews and signs them. This is what it's like at a place where med students get access to the EMR and can pend stuff. For places where that's not possible, I can't comment on sub-I's at those places. As a third year, you're not really faulted for not knowing things. You're there to learn. As a sub-I, you need to know the basics and start to get at more advanced knowledge like the intricacies of management - and to apply these in your plan.

For surgery, as a sub-I you're expected to be able to anticipate things and help the team out. The critical part is you being a team player. People won't tell you what to do anymore - you're expected to anticipate jobs/tasks that need doing and to volunteer to do those. In the OR, same things apply as third year - help out where you can, anticipate things, help set up, roll the patient in/out, etc. For surgical specialties, it's less about what you know and how many patients you are personally responsible for (you're likely not going to be personally responsible for any), and more about whether you're a team player and if the residents would like to have you on the team.