I'm doing my Sub-I and I don't know what to do!

[GonnaBeAnMD]

I'm doing my Sub-I rotation right now and I'm responsible to look over 5 third years... my attending says to just watch over them so I do just that. I read their notes, answer any questions they have until rounds - and then just shadow the group during rounds without asking many questions. I try to answer any questions the attending has that the 3rd years can't answer. Sometimes I won't know the answer to something like "what antibiotic is the patient on?" and feel like an idiot but the doc doesn't ask me - he asks the 3rd year that is following that patient. I just feel like I'm screwing up my chance to match at that hospital - but at the same time don't want to come off as a gunner. Anybody know what to do with this situation? Thanks in advance 😎

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[PeepshowJohnny]

So, it sounds like you're functioning more like the medical school equivalent of a senior resident with the medical students as your interns.

If that's so, you need to train your med students to be better students by doing the things a senior resident does to make his interns look good. Have them keep a current med list for all their patients written down and available, run through their presentation on rounds in the morning with you to make sure they don't say something wrong, forget anything, leave it out.

 

[pincheeric]

There is no better time to be a gunner than now. You are auditioning for this hospital, you need to shine. I agree with the above about making sure your 3rd years are on the ball. I assume you have your patient list, so before rounds each morning have them all give you each patient's vitals and other info so you can record it on your list. Have them photocopy their current med list and lab sheets if they keep them. If they don't make them do it. Do your best to make them look good, but you should cover yourself too. Each morning check the patients' labs yourself and lay a hand on each one. Your job should be to fill in any gaps the 3rd years leave, just like your intern should know anything you don't know. Other than that, you could ask more questions on rounds or volunteer to put together a presentation on an interesting pathology you've encountered.

 

[MSKalltheway]

I agree with the above poster in that it is within your right to gun this time around. To be honest, the 3rd years on your team should take a back seat to you anyway. For instance, I know that any sub-I that I had so far has first priority to scrub in on cases, take whatever admissions they want, or anything else that can make them look good. Since you have added responsibility, then you are obligated to step your game up, especially if its in the field you want to go into.

Btw, does anyone else think that a 4th year having 5 3rd years to 'look after' is a bit unfair? I understand the senior to intern comparison, but I dont think sub-I's should need to be doing that for clerks. I still think the residents should be doing all that if there are no interns present. Advice? Sure. Help? That would be nice. But we are all still just students...or maybe I just have the wrong idea...

 

[PeepshowJohnny]

I was going to say it seems quite odd, as a Sub I at my programs is pretty much "You're an intern who carries fewer patients" to transition you into being an Intern next year. However, I think I've heard other people on here mentioning having to be the boss of the third years during fourth year rotations so maybe it's not that unusual.

 

[bjackrian]

For my sub-I, at least for now, the MS3's and I have different patients, but I am expected to give at least one didactic talk per week on a general peds topic for them. Kind of a nice combination, if you ask me. There are no interns at the hospital where I'm sub-I-ing (only PL-2's), and apparently in the past some sub-I's have wound up supervising M3's after the attendings realized that they knew what they were doing.

 

[SLUser11]

I agree with the above poster in that it is within your right to gun this time around. To be honest, the 3rd years on your team should take a back seat to you anyway. For instance, I know that any sub-I that I had so far has first priority to scrub in on cases, take whatever admissions they want, or anything else that can make them look good.

I disagree with this. When I was a sub-I on surgery, I received some excellent advice from the attending regarding scrubbing surgeries:

"You have the next 5 years to learn how to operate. Let them scrub, and instead focus on your patient care."

As a fourth year, you have seen most of the basic surgeries, while for most of the third years, this will be their only exposure to these things. I think it's unfair for the sub-I to get the pick of all the surgeries, etc. And it's definitely not OK to make them take "the backseat." Your supervisors are not just watching to see if you can be a bad@ss gunner, they're also watching to see if you can be a team player. Of course, this doesn't apply only to surgical rotations.


Honestly, the Sub-Intern shouldn't worry about competing for patients or procedures. They should focus on the innumerable responsibilities that an intern has besides writing a progress note in the chart.

Learning how to:
-write orders
-solve problems
-get patients from point A to point B (and then to the door)
-Interacting with ancillary services
-etc, etc.

I respect the sub-I with 5 patients that he knows everything about and does everything for more than the sub-I with 10 patients that has marginal knowledge and basically just writes notes on them in the morning.

 

[andrewwilliam]

I know that any sub-I that I had so far has first priority to scrub in on cases, take whatever admissions they want, or anything else that can make them look good. Since you have added responsibility, then you are obligated to step your game up, especially if its in the field you want to go into.
=======================================================

Andrew William
http://www.alcoholaddiction.org/montana

 

[Anka]

I disagree with this. When I was a sub-I on surgery, I received some excellent advice from the attending regarding scrubbing surgeries:

"You have the next 5 years to learn how to operate. Let them scrub, and instead focus on your patient care."

As a fourth year, you have seen most of the basic surgeries, while for most of the third years, this will be their only exposure to these things. I think it's unfair for the sub-I to get the pick of all the surgeries, etc. And it's definitely not OK to make them take "the backseat." Your supervisors are not just watching to see if you can be a bad@ss gunner, they're also watching to see if you can be a team player. Of course, this doesn't apply only to surgical rotations.


Honestly, the Sub-Intern shouldn't worry about competing for patients or procedures. They should focus on the innumerable responsibilities that an intern has besides writing a progress note in the chart.

Learning how to:
-write orders
-solve problems
-get patients from point A to point B (and then to the door)
-Interacting with ancillary services
-etc, etc.

QUOTE]


This sort of thing is probably very program dependent. At my program (and med school before it was my program), the rule is that SubI's scrub on their choice of cases, are expected to be in the OR any time a case is going. If the sub I defers to the junior medical students on big cases, he is interpreted as not being agressive/interested enough. Because it is the expectation, no one really sees it as gunning, although the junior students definitly try to be on a rotation when there isn't a sub I if they want to have their pick of cases. As far as patient care, the sub I is expected to preround or at least get vitals on the entire service each morning, while the junior students might preround on one or two patients (and often just show up for rounds). We were expected to get the experience of interacting with consults, running the floor on the weekends when there aren't any cases going, on our medicine subinternships, or during SICU months.

Best,
Anka

 

[SLUser11]

This sort of thing is probably very program dependent. At my program (and med school before it was my program), the rule is that SubI's scrub on their choice of cases, are expected to be in the OR any time a case is going....As far as patient care, the sub I is expected to preround or at least get vitals on the entire service each morning, while the junior students might preround on one or two patients (and often just show up for rounds). We were expected to get the experience of interacting with consults, running the floor on the weekends when there aren't any cases going, on our medicine subinternships, or during SICU months.

Best,
Anka

Well, I have no doubt that the Sub-I role is program dependent, but what do you think about the role you just described? Now that you're a fourth year, your level of responsibility has been upgraded to vitals monkey for the entire team instead of 1-2 patients. Also, if you want to learn how to function as an intern, on your sub-internship no less, you will have to do it on some other rotation, or when there's some down time. Your main priority, if you want to get into surgery next year, is to be in the OR cutting suture.

In the meantime, the third year has been reduced to an extremely trivial role, having little or no responsibility, and doing little to no prerounding. Also, they are getting bumped off all the cases by the Sub-Is, so they're not getting a good operative experience either. That's an excellent way to keep a student from being motivated about surgery, and end up resenting the rotation. Those that like surgery will just go on to do the same thing as a fourth year and help the cycle continue.


Are you in New York? Just curious........

 

[SLUser11]

I just searched your posts and found this one:

Don't get me wrong, I could get med students to help me out, but I'm not allowed to ask them to do "scut". And scut is anything the student in question interprets as scut..........But it takes more time to let the student see the consult, have the student present to me, go see the consult myself, discuss the patient again with the student so we can go over any differences in our exam, etc. than it does to just bang it out myself.

I remember being a student... it was only a few months ago. One of the things I loved about my surgery clerkship was that I was definately part of the team -- getting numbers, checking labs, prerounding, taking out staples, whatever. I learned by doing that stuff, too. My most miserable experiences were the ones in which I was marginalized as a member of the team. I feel bad that I can't pass on to students what I liked so much... but I can't. If a student decides I've "scutted them out", I'll get in trouble for it.

Anka

Wherever you are at, and I bet it's somewhere prestigious....possibly in the Northeast but I can't be sure.......the system is broken.

I know that you are frustrated and scared of getting in trouble, but you need to be an agent for change. Otherwise, things will never get better.


Break the cycle. Take the extra time to involve students. The reason they feel like getting vitals is scut is because it's the only activity the residents ask of them. If they were super-involved in all aspects of care, they might not feel that way.

Also, I will quote another attending from school, this one was a neurologist:

"It's not scut until it's old hat."

If you've never started an IV, placed a foley, helped move a patient, gone to radiology for imaging, etc, then you are not above it. It is important to remind students of that.

 

[Anka]

You nailed it. Somewhere prestigious in the northeast (but not New York by any means). But to be fair I got to do a lot more in the OR than cut suture and retract as an M4 (heck, I did more than that as an M2). The reward for prerounding on the entire service was getting to do a lot in the OR, and there was always that trade off. It never felt like abuse, it felt like you took care of the team and the team took care of you. And I really did learn plenty about taking care of patients on the floor and in the unit. I felt well prepared when I started internship.

As far as the system being broken, the system I was raised in exists less and less. If a student put in the sort of work I put in, I'd be willing to reward it the way I was rewarded as a student. But I'm also happy to play by the newer set of rules where the student isn't expected to do anything for the team, but I also don't really have to risk anything by letting the student do something. Generally, I can tell which way the student prefers things to be and go along with it -- no skin off my nose either way. If a student wants to see consults, they do that and I'm happy to take the time to teach them in that context. If the student wants to "go read", more power to them.

As far as the subIs bumping M3s off cases, in general there were never days where the M3s didn't scrub in most of the day every day they weren't required to be in clinic or such -- it's a high volume program. However, the M4s would scrub a whipple and the M3 would scrub the distal pancreatectomy.

Anka

 

[SLUser11]

You nailed it. Somewhere prestigious in the northeast (but not New York by any means). But to be fair I got to do a lot more in the OR than cut suture and retract as an M4 (heck, I did more than that as an M2). The reward for prerounding on the entire service was getting to do a lot in the OR, and there was always that trade off. It never felt like abuse, it felt like you took care of the team and the team took care of you. And I really did learn plenty about taking care of patients on the floor and in the unit. I felt well prepared when I started internship.

As far as the system being broken, the system I was raised in exists less and less. If a student put in the sort of work I put in, I'd be willing to reward it the way I was rewarded as a student. But I'm also happy to play by the newer set of rules where the student isn't expected to do anything for the team, but I also don't really have to risk anything by letting the student do something. Generally, I can tell which way the student prefers things to be and go along with it -- no skin off my nose either way. If a student wants to see consults, they do that and I'm happy to take the time to teach them in that context. If the student wants to "go read", more power to them.

As far as the subIs bumping M3s off cases, in general there were never days where the M3s didn't scrub in most of the day every day they weren't required to be in clinic or such -- it's a high volume program. However, the M4s would scrub a whipple and the M3 would scrub the distal pancreatectomy.

Anka

Your post supports my theory that the more prestigious the med school, the more worthless and entitled the med student is.

j/k.

I guess it's easier to let the med student dictate their own course, but I would encourage you to force them to get involved, even if they resent you for it. You will find out the farther along you get that it's less important to be their buddy, and more important to provide a surgical education.


Something to think about.......

 

[Anka]

I guess it's easier to let the med student dictate their own course, but I would encourage you to force them to get involved, even if they resent you for it. You will find out the farther along you get that it's less important to be their buddy, and more important to provide a surgical education.

I don't care about being their friend, but the administration has made it clear that the students are to be treated with kit gloves.

Anka