Advice on Starting IM Sub-I After Long Hiatus

[hiiiiiiiiiii]

Hey Guys! So I'm starting my IM Sub-I in two weeks and am a little bit nervous. I consider myself to be an excellent student (lots of honors, high steps , yada-yada-yada) but have been out of the hospital on out-patient electives and a "research elective" since June. To say, the lifestyle has been Kushy compared to M3 is an understatement. I did well on my IM core rotation last March but feel like I may have forgotten loads of information and have fallen back into my more natural laid back mentality, which I have to crank up in to succeed in the hospital. Further, my transcript will be submitted to ERAS (applying neurology) prior to the grade being released, which I think might cause me to let my guard down even more; however, I still want to make good impressions on the attendings and residents, as I respect our IM dept a lot for the tough cases they deal with and am considering doing my prelim with our home program. I also sort of want to treat it as a 4 week simulation of intern year for practice.

Any advice on how to get back into the swing of things? I'm more of a reader than video watcher and abhor anki, so any tradition reads with high yield overviews would be great (not trying to read Harrison's though lol). Also, any advice for mentally preparing myself for the long and taxing days? Last year I went straight from OB to IM so mental preparation was not needed hahaha

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[AzBasRad]

You will most likely be fine without any prep given you strong prior clinical performance. Things will start coming back once you get back to the floors. For context, I am in TY now, and started residency with IM rotation > 1 year after my Sub-I and no meaningful clinical electives in between ( I am going into rads). Obviously, I was rusty in the beginning but things started coming back after a few days.

But if you must review stuff, Amboss has On-Call Survival Guide in its knowledgebank covering the most common ailments (chest pain, SOB, sepsis etc) for inpatient rotations, which I found extremely helpful.

 

[deleted1100659]

Hey Guys! So I'm starting my IM Sub-I in two weeks and am a little bit nervous. I consider myself to be an excellent student (lots of honors, high steps , yada-yada-yada) but have been out of the hospital on out-patient electives and a "research elective" since June. To say, the lifestyle has been Kushy compared to M3 is an understatement. I did well on my IM core rotation last March but feel like I may have forgotten loads of information and have fallen back into my more natural laid back mentality, which I have to crank up in to succeed in the hospital. Further, my transcript will be submitted to ERAS (applying neurology) prior to the grade being released, which I think might cause me to let my guard down even more; however, I still want to make good impressions on the attendings and residents, as I respect our IM dept a lot for the tough cases they deal with and am considering doing my prelim with our home program. I also sort of want to treat it as a 4 week simulation of intern year for practice.

Any advice on how to get back into the swing of things? I'm more of a reader than video watcher and abhor anki, so any tradition reads with high yield overviews would be great (not trying to read Harrison's though lol). Also, any advice for mentally preparing myself for the long and taxing days? Last year I went straight from OB to IM so mental preparation was not needed hahaha

when I was a med student, onlinemeded videos really helped me excel in clinicals

 

[hiiiiiiiiiii]

Thank you two for the posts! @DrAmazingishere I was thinking OME but I had trouble paying attention to any of videos other than the peds section during M3. My ADHD kicked in for the other vids ahhh
@AzBasRad That is reassuring! I think I still have my Amboss account so I'm going to give that a try. I found their other articles really helpful for Step2

 

[Styrene]

Hey Guys! So I'm starting my IM Sub-I in two weeks and am a little bit nervous. I consider myself to be an excellent student (lots of honors, high steps , yada-yada-yada) but have been out of the hospital on out-patient electives and a "research elective" since June. To say, the lifestyle has been Kushy compared to M3 is an understatement. I did well on my IM core rotation last March but feel like I may have forgotten loads of information and have fallen back into my more natural laid back mentality, which I have to crank up in to succeed in the hospital. Further, my transcript will be submitted to ERAS (applying neurology) prior to the grade being released, which I think might cause me to let my guard down even more; however, I still want to make good impressions on the attendings and residents, as I respect our IM dept a lot for the tough cases they deal with and am considering doing my prelim with our home program. I also sort of want to treat it as a 4 week simulation of intern year for practice.

Any advice on how to get back into the swing of things? I'm more of a reader than video watcher and abhor anki, so any tradition reads with high yield overviews would be great (not trying to read Harrison's though lol). Also, any advice for mentally preparing myself for the long and taxing days? Last year I went straight from OB to IM so mental preparation was not needed hahaha

You made it this far and did very well. Just be yourself, and you will again do well.

 

[mrbreakfast]

My general recommendations for neuro sub-Is (which probably applies to IM sub-Is as well):

1) Pick up every new admission (within reason) until you're following 5-6 patients. Getting up to this speed may take you a week or more, that's fine. Getting used to the volume is important for neurology as well, as at busy programs you may end up covering way more patients than a medicine team does.
2) Get a good presentation plan together and follow it. Sounds obvious, but a lot of medical students struggle with coming up with organized, concise presentations. As a medicine intern I typically (mentally) organized things by both problem-based and organ system-based methods to make sure I didn't miss anything. Some attendings will expect a plan for every abnormality/problem the patient has even if the presentation takes 20 minutes.
3) Find ways to help the residents without asking "how can I help?" Examples include med reconciliation on patients, calling families with updates, calling PCPs, whatever. One of the best med students I ever had wasn't the best in terms of book-smarts but whenever we said "ok, I'm going to go talk to the family at bedside to get more info" or whatever, they'd reply "oh, I already did that while you were busy with X, here's what I got."
4) Dependent on your program/EMR, but ask if you can put in orders to be co-signed, and write good notes that can be copied by residents. They'll love you for this.
5) Read about your patients' problems every night, and be ready to give a brief talk about what you learned. For example, during my medicine sub-I I was asked to give brief talks about multiple sclerosis subtypes and disease-modifying agents and on vasculitis syndromes. I don't ask students to do this, but some attendings love doing it.
6) Also program dependent, but for neuro sub-Is at least I expect them to provide some teaching and organization of the clinical students. You don't have to be an expert on anything, but for example I would expect a neuro M4 to be able to teach the clinical rotators about the basics of stroke syndromes (e.g. ACA/MCA/PCA) and how to work up strokes, or help teach the neuro exam. This might be tougher on medicine, but you can teach as you yourself learn.

Hopefully at least a little of that is helpful. The main point is that effort and interest are obvious to everyone. Work hard now, you'll have plenty of time to relax before residency.

 

[Redpancreas]

Thoughtful post but I wouldn't worry about any prior knowledge as you have gone through medical school and have the essentials. There's no great primer other than just diving in. OME is kind of more tuned for the boards (i.e. a Step 2 CK board resource masquerading as a clinical resource). Honestly, the most efficient thing to do would be to peek at the H&Ps and progress notes and get a glimpse of the phenotypes of the patients admitted and the basic work-ups. Some places admit a lot of Sickle Cell/Pancreatitis especially in underserved areas, other's don't. Everyone admits Heart Failure, Cellulitis, AKI, GI Bleed though so know those. Instead of focusing on knowledge bits, focus on good technique.

1) When it comes to management, keep it simple and be decisive. IM can get very academic, very fast and I recommend you let your categorical colleagues focus on that but especially as a prelim intern, you should focus on the high impact basic things. If the patient is coming for a GIB are they actively bleeding from the upper tract...do they have 2 LBIV, PPI, GI consulted, and if so is there good reason you haven't called the ICU? Same with an AKI. The management is to rule out new oliguria or severe electrolyte issues if present (if so call nephrology) but otherwise if volume down historically or on exam, you can't go wrong with fluids, a microscopic UA, and a one time post-void bladder scan. If volume up, just get a history and diurese (higher dose for higher creatinine because that's how lasix works). Don't get into the rabbit holes of whether to check FeNa or start NS vs. LR.

2) Kind of a semi-contradiction to point #1, but when writing H&Ps or taking histories try to dive a bit deeper. The H&Ps depending on your training program sometimes can anchor on what's on the History Tab and you should always do your due diligence to question each relevant diagnosis and verify things yourself (imaging reads, etc.). The same thing goes for patient histories. A good example is when the patient comes in for GIB, the ED asks them the standard ABC questions of GIB. Who knows what the ED team talked the patient into having (melena, etc.). By the time you talk to them they've rehearsed their story a few times, if you just ask them if they have had black stools, they may just say yes because someone else told them they did. Don't be afraid to prod deeper and ask questions from different angles and if something doesn't make sense (they're coming in with reported severe GIB but they haven't had a witnessed episode and they've been sitting in the ED all day), Don't feel shy about asking the patient if things dont make sense or pulling out your phone, googling melena, and asking them if they had that. You'll catch errors that way, some more relevant than others.

3) One good resource to have handy is Pocket Medicine by Sabatine. I believe the latest edition is blue. Prior to working up anything, give that book a reference. Also, UptoDate is pretty on point.

 

[hiiiiiiiiiii]

Thank you all for such wonderful and thoughtful responses!! You all gave me the perfect combination of reassurance and practical advice. Wish me luck

 

[Elite Medical Prep]

You will be surprised how quickly you will get back into the swing of things. And at least you have been continuing with clinical activity in one form or another. For students taking a gap year for non-clinical reasons, I have heard many recommend starting with non-SubI electives to get back in the groove but it doesn't sound like you'll have much of an issue. Have faith in yourself!

 

[hiiiiiiiiiii]

You will be surprised how quickly you will get back into the swing of things. And at least you have been continuing with clinical activity in one form or another. For students taking a gap year for non-clinical reasons, I have heard many recommend starting with non-SubI electives to get back in the groove but it doesn't sound like you'll have much of an issue. Have faith in yourself!

Thank you, my friend! I am starting on the 27th and am actually really looking forward to it now. Everyone has been so encouraging and helpful on the thread and I really appreciate it!