How to succeed on a Sub-I/Acting Internship

[drpectin]

So I am returning from 2 years of full-time research and beginning my fourth-year of medical school Bonanza. I have chosen General Surgery as the field I will be applying into. I would like to pose this question:

How does one best succeed in a Acting Internship?

I know that this truly is institution dependent and what I'm getting at is that beyond having an understanding of Surgical/medical fundamentals what medical student/AI characteristics are necessary to exceed expectations?

Some pearls that I've discovered:

1. Do not be a burden to your resident/interns - this seems like an obvious but in reality is a fine line and probably depends on how you fit in with people. Most residents I spoke with said that I should always be on top of whatever my responsibilties are, like checking labs, vitals, post-op checks, evening rounds... Did I miss anything?

2. Know your reponsibilities - A no brainer but really important. You should really ask point blank your attending what he expects. Are you supposed to me like a real intern and helping manage the floor issues or are you going to be in the OR with your attending and focusing on him and his patients.
Please correct me or add anything you might think is important.

3. Fitting in - Being familiar with the computer system, Head OR nurse/clerk, chiefs, interns etc... will help you be more effective.

4. I'm looking for more specifics - All I have are these general ideas, Please help.

5. Anticipating and Being proactive not reactive - just thought that one up.

6. And of course Surgical Recall's Ultimate intern "HAMMERHEAD".

I've got 3 SubI rotations lined up 1 home, 2 away. I think that this would be a boon for all MSIV's. Any help/advice would be appreaciated. Like how important is getting to know the away inst.'s PD? Very or not much?

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[Plastikos]

I think by far the most important thing is to be pleasant to all you interact with, and have an easygoing personality (ie, does not get rattled). IMHO, if you can just "be cool" and have the staff/residents actually like you for a person the battle is mostly won. After this, every task you do or do not do is interpreted in light of these rosy glasses. You will get praise for the most mundane things and if theres something you didnt know or do right, they get all excited to show you how it works/their first time learning.

At least thats how it was for me on my sub-Is, and basically all of med school.

 

[Blade28]

Good advice, both of you.

 

[DNASplicer]

I am also a few weeks away from a trauma surg subI and looking to shine. Any advice is appreciated!

My first rotation was psych and my senior resident gave me sage advice that I follow for all rotations (when the energy is there). Know the layout of the floors (bathroom is essential), designation of beds, introduce yourself to the ancillary staff, eat when you can, sleep when you can, smile, find out the hours of the dinning hall, etc.

I have closely watched other subIs that seemed to get praise. Here's what I've seen: 1- when on call and the night is not a terror they collect vitals on progress notes for patients they are cross-covering (they are instantly loved). 2- they ask the JMS's questions... which I HATED. I will choose to TEACH them. Have a topic or two ready to teach. 3- act cool and like you know what's going on.

I also think it's good to know where the ER is and how it's run. I would also find Radiology and case the joint.

Any other advice?

 

[LovelyRita]

From the Clinical Rotations forum

 

[Winged Scapula]

All good advice, especially the part about being easy to get along with and knowing your way around. I can tell the difference between the 3rd years and the 4th year students by how comfortable they are and their willingness to do things/check up on stuff without being asked (ie, the 3rd year will hang around in the OR, watching me or the nursing staff put the Foley in, put the SCDs on, etc. The 4th year will start to do these things on their own, or at least ask if we want it done before doing so). Hesitancy is not a valued manner in surgery!

 

[Pilot Doc]

No arguments with any of the good advice above. I would distill it into
1) being pleasant and easy to get along with - bears repeating
2) Helping carry the clinical workload of the service. If you can simply smooth the mundane aspects of they job they'll love you. Make sure that vitasl, lab results, gauze, scisssors are all immediately at hand. Make sure no time is spent waiting for someone to do somethign that could have been done earlier or more efficiently.

 

[Dimoak]

I'd just like to underscore the keeping your cool bit. I'm always a really mind-mannered and easygoing person. Rarely do I ever lose my cool, but when I started working at a hospital, I've found that I really came close on a small number occassions. Sometimes, in just about any discipline, it can get really hectic with all sorts of people talking to you or demanding something of you at once (some of which may not even seem reasonable to you). I'm really glad I've thankfully always been able to keep my cool all these times, even when I felt like the other person was truly the one in the wrong. It's really easy to get in alot of trouble from one slip up, and you'd likely endup with alot of explaining and apologizing to do. Also, you may endup souring relations with another person simply because of a dumb mistake. I've come close to losing my cool and just snapping a few times, but I'm so thankful that I just kept in my frustration or anger until it could mellow out and I'd realize that it was really no big deal, but in the emotion of the moment, you may say something you'll regret later. Just be sure to keep your cool as best as you can! Best of luck to you!

 

[mysophobe]

Very good advice. Everyone will remember you for the one time you lost it.

 

[Swimdoc]

The above is all awesome adivise.

My biggest advise is to put in as much or more time in the hospital than the interns do. Don't expect to go to an AI and get let out early cuz there's nothing going on at 3pm. The residents want someone who will be dependable and hardworking next year, and this would not help that reputation.

(I went to a fun city for my AI and tried getting out a couple hrs early a couple times -- they didn't say anything, but in retrospect, I don't think they liked that)

Also, be very knowledgeable about your patients and ready to give a quick summary at any time. I didn't know one patient very well (cuz I wasn't following her) and the PD asked me about her... it wasn't my most eloquent moment.

 

[Dr. V]

Personally I am not a big fan of away rotations because I feel that unless you don't look good on paper all you can really do is harm your chances. If you are a little shaky on paper and need to improve your stock that's one thing, but otherwise it can be a no win situation. The better you look on paper the more dangerous it is.

That said, one of the best ways to endear yourself to the residents is to volunteer to take admissions. Jump on them like there is nothing in life you love more and you just can't wait till the next one. The interns will love you and will give you pearls to help you look better to the upper levels and attendings. If you do this every intern will be vocal about wanting to be on call with you because you actually HELP them and you will have done well for yourself.

 

[jayman]

Be nice. Be attentive. Be helpful. Read about the things you got wrong or didn't know. Try and give your third years a helping hand - they will REALLY appreciate it.

Don't be a jackass, no matter how frustrated you may feel or how tired you may be. Don't ask to leave. Don't show up another member of your team. When you're post-call, don't forget to get coffee for your post-call interns/residents the next morning before rounds...don't ask to do it, just do it the first time you've pulled an overnight shift...your team will REALLY appreciate it.

 

[Winged Scapula]

Just be sure to keep your cool as best as you can! Best of luck to you!

Good advice. In a few instances I've had to soothe things over when an AI went a bit ballistic because somethings weren't being carried out by the nursing staff. I appreciate the concern that my orders are done, but pissing off ICU staff doesn't help me (or you, or the patient) much. 😉

 

[DNASplicer]

All very helpful advice. I appreciate it and your time!

Good luck to all!

 

[MediCane2006]

Have fun and let people know that you are having fun...not in an obnoxious way, but try not to take things too seriously, and try to be a fun person to work with. This may include helping the intern with scut, giving the second year a sympathetic ear to vent complaints, etc.

Also, this may seem obvious but carry yourself like an important member of the team. This means you don't leave till ALL the work is done, you take responsibility for being on top of treatment plans, lab results, etc. and you go from being a reporter of data to being a physician - i.e., interpreting lab results, thinking about antibiotic choices, you get the idea. Then compare your ideas to the treatment plan that the resident and attending implement, and when appropriate, ask the resident about how his/her plan differed from yours. Even if you're way off base, this shows the resident that you're trying to learn the thought process.

Hope this helps!

 

[Winged Scapula]

The AIs I was most impressed with also checked in on patients during the day. Between OR cases, before evening rounds, before clinic, etc. They thought about these patients and doing well on the rotation before they thought about going and getting lunch or hanging out in the call room on a slow day. They spent time with the patients and got to know them, better than the rest of the team and their knowledge was helpful in managing the patient.

The students I was less impressed with were those who would not show up for the OR because they had class in 45 mins and then I would find them in the cafe drinking coffee. At least have the decency to come to the OR to watch, put in the Foley, etc. until classtime or hide out in a less than public place.

 

[Dr. V]

The AIs I was most impressed with also checked in on patients during the day. Between OR cases, before evening rounds, before clinic, etc. They thought about these patients and doing well on the rotation before they thought about going and getting lunch or hanging out in the call room on a slow day. They spent time with the patients and got to know them, better than the rest of the team and their knowledge was helpful in managing the patient.

The students I was less impressed with were those who would not show up for the OR because they had class in 45 mins and then I would find them in the cafe drinking coffee. At least have the decency to come to the OR to watch, put in the Foley, etc. until classtime or hide out in a less than public place.

Kimberli, are your Sub I's different than ours? When I did my Sub I there was only myself, the chief, and the attending seeing my patients. Interns never had to bother with anything on them, they were my responsibility from the time they hit the door till they were discharged including H&P and Discharge Summaries and their dictations.

That's what made it so popular to be on call with me, if they had 6 admissions and I took 3 then the intern only had 3. In a situation such as this I would think you would have to check on your patients before you leave, check on them during the day etc.

Is it different or did those that never checked just not care about their patients and expect the Chief to do everything?

 

[Winged Scapula]

Kimberli, are your Sub I's different than ours? When I did my Sub I there was only myself, the chief, and the attending seeing my patients. Interns never had to bother with anything on them, they were my responsibility from the time they hit the door till they were discharged including H&P and Discharge Summaries and their dictations.

That's what made it so popular to be on call with me, if they had 6 admissions and I took 3 then the intern only had 3. In a situation such as this I would think you would have to check on your patients before you leave, check on them during the day etc.

Is it different or did those that never checked just not care about their patients and expect the Chief to do everything?

Perhaps they are. We require all patients seen by medical students to also be seen and examination verified by one of the residents, and the note co-signed. So there is a little less work for the intern as the H&P and daily notes are written by the AI, but they still have to see the patient (although I suspect on many occassions they did not).

While the H&P is useful, we consider doing discharge summaries and dictations as a matter of course (ie, more than 1 or 2) scut work. These are the responsibility of the PAs or the interns, not the medical students. Besides, they (the AIs) may do a poor job of these which displeases the attendings.

Doing half of the admissions might be considered excessive in my book. I would rather the AI focus on a few patients in detail rather than know several minimally. Then again, with the exception of trauma (which has few AIs here), we would rarely get the 6 or so admissions a night you seem to get. But I do expect the AIs to take more call than the others and do more work, including admissions.

As the Chief I round in the am and the pm with the team, and depending on the attending with them as well (some were more independent and would round on their own and call me with concerns, changes, etc.). The AIs I was less impressed with seemed to spend more of their time in the OR with the attendings, especially the program director - which is fine - but they didn't utilize the time between cases, clinic, etc. to check and see how their patients were doing. A lot can happen between am and pm rounds and the best AIs knew this and pre-rounded before pm rounds to make sure I was aware of any change in clinical status, new labs back, culture results, consult results, etc. Not every AI seemed to realize how important this was and how much I felt it showed real interest rather than just sucking up to me or the PD (on that last note - I also check with the PAs and the interns on how they feel the Med Students are doing. I have had occassion to find the student be overwhelmingly nice and helpful to me, while treating the PAs and interns poorly. I despise that attitude.)

So, yes it appears that expectations here are different (in the old days Penn State used to let the medical students take "call" until 10 pm and then go home. It tends not to foster the surgical mentality here.).

 

[Dr. V]

Yep, it's definately different then. Here the 4th years don't have any class to attend and if that rotation is a Sub I then you basically are an intern that needs their orders cosigned and answer to the Chief and Attending. They still don't want you carrying as many patients as the interns have to, usually around 2-4 is all, but it is your responsibility to write and do everything on those patients. Our daily notes didn't have to be cosigned, only our orders. The interns on whatever service really, really liked it because even if you only took 3 patients that was three less for them to have to keep up with on their already hectic schedule.

The first thing I learned was how easy it was to forget to write for routine labs and having to turn around and go back to the hospital after hours or getting there early enough the next day to get the info before morning rounds LOL. For some reason I never had a problem with bigger things but the more common ones like a CBC etc I would forget at first. It was an eye opener that's for sure and it was easy to see even only having a small number of patients that an interns work is never done.

You don't HAVE to do the Sub I route here, and it is very attending dependant (as I am sure it is everywhere). Many of my classmates complained they didn't have as much autonomy as some of their friends at other med schools so I just assumed that other schools Sub I's were at least the way mine was (knowing that mine was one of the better ones because of the luck of the draw on my attending).