Improving sub-Is in pediatrics?

[oldbearprofessor]

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I'm curious for the residents, esp. the interns to describe whether their sub-I made any difference in the adjustment to internship. After all, I assume the reason they have become common (and required in many schools) is to help transition med students into interns. Yet, it doesn't seem to me that it has made any real difference.

I suspect the reason has as much to do with volume of patients than acuity. That is, a sub-I is seeing only a couple patients usually and the intern is admitting a handful or two in a night. Also, there is no one co-signing.

Still, the question remains "Is the mandatory or expected sub-I useful in transitioning to internship?"

I'm interested in the answers. If I wait and ask in 6 months, the transition will have seemed so easy.....😉

Edit: moved to new thread

I'd love to hear ideas about what makes for good and bad sub-Is and how they can be improved. Remember that some things can't change - orders will always need to be co-signed for example. But other things can and maybe should. Or maybe sub-Is just aren't that important?

 

[CrazyPeds527]

So I think the answer to the question is yes and no.

Yes it helped, but only because my own sub-I was set up the following way:

I was on call my first night; i took call with one intern, but alternated taking admits. So, when she took 4 hits, i took 4 hits as well. I was q4 for the month. I wrote my own orders (cosigned by senior resident, not busier intern), called my own consults, discharged my patients, dictated their summaries (co-signed by attendings) and worked my general butt off. It was hard, and it was worth it. I thought i would be well prepared...

However, i didn't know how hard it would be to: take 40-50 pages a night, cover 10-30 patients regardless of rounding on them that morning; take admit after admit no matter how ridiculous (when i was a sub-i, i got relatively shielded from the "no-educational value patient", now, i just have to admit them and work them up).

And it's only july.

Still, looking back to last july right now, i can only think of how utterly terrified i would be if i did NOT do a sub-i, and was relatively clueless as to how challenging it is to take call and survive as an intern. Now, i am only semi-clueless as to how hard this year is going to be.

So in the end, i think it is really valuable to do a subI, but in no way prepared me for the insanity of residency. 🙂

 

[165808]

I honestly have to go with "not that much" as my answer 🙁

As a sub-I, I admitted patients and followed them, but didn't cross-cover any other patients. I feel that's a HUGE part of internship, learning to manage patients overnight that you know very little about and be able to prioritize their care and make decisions. So coming into my first call, I had no clue what to do with my crosscover patients.

As far as patients I personally admitted, I still didn't make many decisions or really have much independance. I did as far as calling consults and entering orders, but they weren't MY orders. They were always basically told to me by either the senior or attending. Even when I asked if I could try to do it myself, everyone was too tired to sit and babysit me writing orders, so the answer was generally "not tonight, maybe next time we'll do that."

Every order I wrote, even to heplock a stupid IV, had to be co-signed. Which I totally understand!! But at 4am when I want to write a simple order, I had to page my senior and have her cosign. Sometimes she just plain wouldn't return my pages because she wanted to sleep. It was really frustrating. I've never felt more like an annoyance in my life!!

I think my situation probably isn't the norm, however. Unless you're thrown in there as a sub-I and learn to crosscover and write your own orders, I think it's pretty useless. For those of you who think it really helped, I'm jealous!! I feel so very stupid right now, and I haven't even started my first ward rotation 🙁

 

[TexasRose]

This might deserve its own thread but I'm curious for the residents, esp. the interns to describe whether their sub-I made any difference in the adjustment to internship. After all, I assume the reason they have become common (and required in many schools) is to help transition med students into interns. Yet, it doesn't seem to me that it has made any real difference.

I suspect the reason has as much to do with volume of patients than acuity. That is, a sub-I is seeing only a couple patients usually and the intern is admitting a handful or two in a night. Also, there is no one co-signing.

Still, the question remains "Is the mandatory or expected sub-I useful in transitioning to internship?"

I'm interested in the answers. If I wait and ask in 6 months, the transition will have seemed so easy.....😉

I have to say that I don't think the Sub-I was really that much help. I only carried 3-4 patients at a time. All my notes were co-signed. It was often easier for the upper level to just do things (write for tpn, etc) instead of asking me to do it and then checking and signing it all. Also, call at my institution for a sub-I basically meant admitting one patient before midnight. (again, the upper level had to come behind me and see the patient, etc, so he didn't want me to accept patients after midnight.)

I think I got more of an intern experience as a Sub-I in the NICU where the patient load was lighter and it was easier to take the time to let me do as much as I could on my own.

Neither of those experiences prepared me much for having 8 sick heme/onc patients my first week of internship. It's a steep learning curve, but a week+ into it I'm already much better at it than an entire month as a med student could have made me.

 

[TexasRose]

Oh, and ditto on the cross-cover thing. Sub-I's don't even begin to prepare you for making a decision on a patient you've never laid eyes on before the "relapsed ALL on chemo now has fever of 103" call. (run of the mill today, but scary as heck last week!)

 

[elr1983]

As a newly minted 4th year medical student, I was just wondering if any of the current interns had any advice on how to make the sub-i experience more helpful for intern year, as it seems the consensus is that it wasn't great prep. I'm actually doing my sub-i a few months down the road, after doing NICU, ID, and cardiology. In hindsight, would you guys have asked if you can help with some of the crosscover issues? (I can imagine this would be somewhat challenging, as you'd have to be pretty much attached to the on call intern.) Try to carry more patients? Any advice would be much appreciated. Thanks!!!

 

[165808]

As a newly minted 4th year medical student, I was just wondering if any of the current interns had any advice on how to make the sub-i experience more helpful for intern year, as it seems the consensus is that it wasn't great prep. I'm actually doing my sub-i a few months down the road, after doing NICU, ID, and cardiology. In hindsight, would you guys have asked if you can help with some of the crosscover issues? (I can imagine this would be somewhat challenging, as you'd have to be pretty much attached to the on call intern.) Try to carry more patients? Any advice would be much appreciated. Thanks!!!

The only real advice I have as far as that....just try to be involved in entering as many orders as you can. Come up with a plan in your head, propose that plan, then let your senior tell you why or why not that should be done. At least, that's what I would have found helpful. Just always have a plan in your head that you can check against what is actually done for your patient.

As far as cross-covering....I think most sub-Is aren't allowed to do that because it's not very helpful to anyone. Yes, you'd have to be attached to your senior all night, because you can't order anything without them. It also may be more overwhelming than you can handle realistically. Just try to be attentive to what the interns do and why they do it....if you can 😕

 

[CrazyPeds527]

A) How to make your Sub-I worthwhile:
Jendizzle gave great advice: be involved! Don't sleep 5 hours just because you can; do an extra admit, carry 4 patients instead of 2 (if you can), stress that you would like to come up with your plan and write your orders. Ask questions of your residents. The cross-cover thing just isn't that helpful until you are the one making the decisions and im not really sure how to remedy that as a med student.

B) How to improve a Sub-I on a larger scale?
Hmmm...this is much more challenging. Many of the issues complicating sub-is are logistical: i.e it's july in pediatrics, not december. The patient load is just not as high when everyone is doing their sub-i before interview season. Last week, our team of 4 interns and 2 sub-is had 15 patients to divide among us; 2 weeks ago it was 38 patients. So part of it is also hit and miss; you catch a slow month, you feel screwed. But if you are taking your sub-i in january, when the team is slammed, even if you are taking 4-6 patients, the interns and seniors may just end up doing a lot for you, because it is easier/faster and they are struggling to finish their work and make work hours as it is.

The cross-cover issues i'm not really sure how to solve; except maybe one night on the month, have the sub-i hold the pager, with the intern staying awake expecting to get paged with every question the sub-i has. this way, the subi can at least begin to make their own decisions (with oversight) and appreciate what cross cover truly means. But this has serious logistical problems, and means having an intern willing to do this, which brings me to my last point:

Everyone's favorite phrase when describing any med school rotation is "team-dependent", but it is very true. If you have a senior resident who is too busy to teach, and simply does everything him/herself, then you aren't going to learn anything when you aren't thinking for yourself. Same goes for the intern who doesn't let the sub-i actually do anything on call, and takes all of the admits because it's "faster." That may be true, however, it doesnt change the fact that you are there to learn. But bringing this up to your senior resident or attending sets you up for a possible "bad evaluation", which is intrinsic to the entire process of evaluations being flawed and has been touched on ad naseum in the other forums, so i won't rehash that arguement here.

I guess the only tangible thing i can think of is having the sub-i take admits alternating with the intern, so at least they carry the same load as the team. The cross cover thing i dont think can be solved at the med student level, unless someone has seen it work well somewhere.

 

[TexasRose]

I was just thinking...

I suppose one could ask at this point, why do we need to make the Sub-I more like real internship? Every program is slightly different in the way they operate. Shoot, at my program every floor is slightly different! Being on the neuro floor would not have prepared me for most of the cross-cover issues on the heme/onc floor. You learn by doing and ultimately the only way to do that is to be the intern on call. I think the job of the med student is to learn about the physiology and the medicine, not the logistics of being an intern.

 

[m1234d]

yeah, I would agree with TR here. I mean, I didn't really act any different on my subI than I did on any other elective. I really had more of a "subI" when I was the only med student on the GI service and there were no residents (and where I came from, we didn't have fellows). The only good thing about my subI was that it was July, so I got to watch the new interns go through the craziness of the first week, and I knew what to expect a little. And the intern experience at my home school is dramatically different from my experiences at my new program-- I covered more kids my first night than there are general peds beds at my med school program.

p.s. TR Tuesday we are on call together!

 

[ms. a]

I haven't found that my time as a sub-I was really at all helpful as an intern now. I also don't feel behind everyone else due to the fact that my sub-I was in surgery, not peds (long story). I probably got more out of my Pedi GI elective, where I was the only student, working directly with fellows and attendings. And I probably got the most out of my SICU rotation. I worked more on both of those than on my sub-I.

On a more exciting note, I'm psyched that I'm home from call an hour early today, and actually got to spend 4 hours straight in the call room last night on heme-onc call, with my pager silent for more than 3 hours. Awesome! It's all because TR is taking such good care of her patients, so they're not bothering me. 😉

 

[elr1983]

Thanks for the great responses, everyone! 🙂

In response to the question of whether or not it's important to make 4th year sub-i's more like intern year, I totally see your point that maybe it's not that important. I guess I'm just nervous about intern year and want to be as prepared as possible. Also, one of my attendings mentioned that since the 80 hour work was put into effect, he believes that pediatricians are coming out of training with less experience than they have had in the past. As such, he encourages all 4th year students interested in peds to spend as much time in peds electives/sub-i's as possible 4th year because you're missing some hours in residency. Whether or not I believe that to be true, I'm not so sure....

 

[oldbearprofessor]

Also, one of my attendings mentioned that since the 80 hour work was put into effect, he believes that pediatricians are coming out of training with less experience than they have had in the past. As such, he encourages all 4th year students interested in peds to spend as much time in peds electives/sub-i's as possible 4th year because you're missing some hours in residency. Whether or not I believe that to be true, I'm not so sure....

I don't buy the premise (that the 80 hr work week makes for substantially less experienced attendings) or the conclusion (do more med student pedi electives).

 

[DarthNeurology]

I'm curious for the residents, esp. the interns to describe whether their sub-I made any difference in the adjustment to internship. After all, I assume the reason they have become common (and required in many schools) is to help transition med students into interns. Yet, it doesn't seem to me that it has made any real difference.

I suspect the reason has as much to do with volume of patients than acuity. That is, a sub-I is seeing only a couple patients usually and the intern is admitting a handful or two in a night. Also, there is no one co-signing.

Still, the question remains "Is the mandatory or expected sub-I useful in transitioning to internship?"

I'm interested in the answers. If I wait and ask in 6 months, the transition will have seemed so easy.....😉

Edit: moved to new thread

I'd love to hear ideas about what makes for good and bad sub-Is and how they can be improved. Remember that some things can't change - orders will always need to be co-signed for example. But other things can and maybe should. Or maybe sub-Is just aren't that important?

I have done two sub-internships and found them to be little different from electives in fourth year and third year rotations. During my core rotations I would take on a lot of patients and go to do quite a bit, i.e. write progress notes and basically try to manage the patients with the interns/residents. On sub-I's you learn to write orders more directly, but this isn't such a big deal we've all being reading admit/daily orders daily during third year.

On my sub-I's the residents just happened to be less willing to relinquish control/responsibility so I would write admit orders, they would change them, I would offer a plan, they would wait to see what the attending did. I learned the most on a clerkship with an awful resident (who later was fired!) whom I had to double-check their work and remind them not to do this or that before talking to attending.

I learned most on elective rotations such as cardiology or nephrology where in reality the residents didn't have a big leg up compared to students as we were learning finer points from the attending.

Sub-Is can be a cattle call where basically you learn some clerical skills and a little bit of management skills, . . .but if your team isn't good or your residents don't teach or worse, you don't teach yourself, then you won't learn. I learned *much* on medicine/peds clerkships by seeing huge numbers of patients.


Sub-I's have been around since world war II, when they were invented via the necessity of having more interns in the hospitals. I believe that Sub-Is have this grandiose image that you will become an intern during fourth year, in today's litigation infested environment I would wager that even today's interns and some junior residents don't have as much responsibility as sub-I's during world war II. Back then you could basically "decide" you wanted to practice surgery based on your own experience and just go do it. Not today.

I feel strongly that a Sub-I is nothing more than a slightly more involved, and I mean only a miniscule more involved, extra month of pediatrics. Most third years are running up the learning curve as fast as they can, and this will continue in internship. A one month rotation is just one step on the mountain to being an compassionate and competent physician.

If I had an extra month of pediatrics inpatient ward added on to the standard 6 week rotation would this give me a leg up in internship? I would have maybe 40% more experience, and maybe would be 2-4 weeks out of the gate earlier than other peds residents without a sub-I, . . . which I would wager I would largely have lost this advantage in one year's time as other factors come into play such as dedication in residency and keeping up with reading. Considering that internship is a whole year (and feels more intensive than any subI) it is ludicrous to believe that a one month rotation, i.e. medicine or pediatrics sub-I would be integral to medical education.

But you know what, there is something that you can do in fourth year I believe more focused and higher yield than a sub-I, this is an elective in a pediatric subspecialty such as infectious disease or cardiology or nephrology. This is where you learn something more applicable to internship than an Sub-I IMHO. I am forever indebted to my cardiology attendings as after four weeks I am able to read EKGs and have an approach similar to what a cardiologist would have to patients. I think it helps to focus on something for a month's time as you can them remember back to that month on the ID service and how you would approach patients with cellulitis.

I think in utility the best fourth year electives are starting with the most helpful:

1. Cardiology
2. Infectious Disease
3. Neurology
4. Nephrology
5. Emergency Medicine
6. Hem/Onc

Also have heard that Pulmonology, Critical Care, Dermatology, and Radiology are also very useful.

A sub-internship should be reclassified as just a fourth year medicine wards rotation as they are much watered down since the second world war. However, some hospitals let Sub-I do a lot, somewhere between a month of internship and a month of general wards in terms of responsibility and going up the learning curve. So, in the end a miniscule effect on what type of M.D. is produced before residency.

However, residency directors I believe love to see a Sub-I in peds or medicine, as it shows enthuasiasm for said field.

I think my outpatient clinic experience helped the most so far in my clinic months, which i gained almost entirely via electives. I will write more when I hit the floors. Updating/improving clinical education could/should be approached by looking at the whole curriculum, i.e. better lectures, little more emphasis on teaching on the wards, a more defined medical student role longitudinally defined across disciplines, and perhaps even changes in the length of certain clerkships to a more graded experience, i.e. those interested in pediatrics could opt to do their "sub-I" after the pediatrics clerkship, i.e. 6 weeks plus 4 weeks of being more involved on teams already known to the student. A lot of time orienting students is lost when going between hospitals and learning new working environments, I spent the first week of my subI just figuring out how the hospital was laid out.

If students could have a seamless transition from clerkship to Sub-I then you would get more learning from the experience. This might even out how patients are distributed so there would be more exposure. I.e. after either surgery, medicine, or pediatrics clerkship the student must do a month sub-I . . . this would stager students throughout the year . . .

In the end I think sub-Is should be renamed just a general medicine or general pediatrics wards clerkship, a lot of hype that doesn't live up to its billing.

 

[DarthNeurology]

I was just thinking...

I suppose one could ask at this point, why do we need to make the Sub-I more like real internship? Every program is slightly different in the way they operate. Shoot, at my program every floor is slightly different! Being on the neuro floor would not have prepared me for most of the cross-cover issues on the heme/onc floor. You learn by doing and ultimately the only way to do that is to be the intern on call. I think the job of the med student is to learn about the physiology and the medicine, not the logistics of being an intern.

I would totally agree. I would wager that most interns after this PGY-1 year would have figured out the logistics of their particular hospital, and how to organize patients via note cards or whatever. I would doubt that any program director would complain about a resident/intern not having the logistics down.

Obviously I tried as a medical student to do excellent work for the team in terms of seeing patients in clinic, being a clerk on the floor, . . . but ultimately when it comes down to it I think it is more important as a future doctor to know why a patient was admitted and the medicine and physiology behind the process, and what is the current treatment and how it is modified for any given patient.

I have seen medicine residents who are great at writing admit orders quickly, following labs, etc . . but when rounding with the attending it is apparent they have no clue about the medicine behind the attendings decisions or even that they care . . . there is too much emphasis on the non-management issues such as getting blood ordered, watching hemoglboin values change by meaningless amounts, doing procedures that some residents have no clue what the heme onc attending will say regarding their patient or what the next step in management is . . . I saw a senior medicine resident who had no idea what an important concept was concerning her patient or why the patient needed to go to the ICU although she was "on top" of all the little details like arranging the transfer etc . . .

Obviously, third year and fourth year medical students are in "clerkships" were one learns to be a clerk, i.e. follow orders, learn how to transfer patients, etc . . . but I think a lot of residents haven't learning the critical medicine skills of tailoring treatment to a specific patient or even learning the nuisances of physical diagnosis or management or basic physiologic principles.

This is why there is a big difference between a hospital with a reputation like Harvard where all the attendings and residents are very academic, i.e. "thinking" physicians who pickup the rare diseases and manage patients very well. Whereas, some community hospitals are run by attendings who are good, but are followed by residents who act more like nurses who just follow orders basically and wait to see what cardiology or some other service says about a patient.

 

[CrazyPeds527]

The age old debate of a community hospital versus academic hospitals, the "harvard" versus wherever is a completely moot point if you haven't seen every hospital in the country, which lets face it, none of us have. It makes people look foolish to make sweeping generalizations about a group of hospitals like that. I have seen residents at places LIKE harvard who couldn't manage themselves out of a paper bag; just because you go to a big name program, doesn't mean you are a powerful academic physician.

"I would doubt that any program director would complain about a resident/intern not having the logistics down. " --> if you have ever worked with a teammate who doesn't know how to do the simplest things, you would know how draining this is. I am not saying that I know how to do everything at my new hospital; i don't. But if it is the end of your intern year, and you cant do simple things like put in orders, it makes life more difficult for the entire team, and that IS something your residency director will be hearing about.

Agreed about knowing the physiology and medicine being more important, but guess what; if you can't function in the hospital you work in, your life is miserable...if you are at a resident's level that can't function by doing the little things, your life (and your co-resident's) is miserable x 50. Being a great doctor/resident in the 21st century means being able to do BOTH - knowing the medicine, AND knowing how to work the system; it gives your patient the biggest advantage in terms of not being stuck in the hospital an extra day, say because you couldn't get the forms filled out in time for stuff to be approved that day.

"...I would wager that even today's interns and some junior residents don't have as much responsibility as sub-I's during world war II. Back then you could basically "decide" you wanted to practice surgery based on your own experience and just go do it" ---> Last time i checked, sub-Is, interns or anyone at that skill level doing things like surgery, or even procedures like LPs without supervision is really not such a great idea. There is a reason for graduated responsibility, and that is patient safety.

That's all

 

[DarthNeurology]

It makes people look foolish to make sweeping generalizations about a group of hospitals like that.


Agreed about knowing the physiology and medicine being more important, but guess what; if you can't function in the hospital you work in, your life is miserable...

Being a great doctor/resident in the 21st century means being able to do BOTH - knowing the medicine, AND knowing how to work the system; it gives your patient the biggest advantage in terms of not being stuck in the hospital an extra day, say because you couldn't get the forms filled out in time for stuff to be approved that day.

"...I would wager that even today's interns and some junior residents don't have as much responsibility as sub-I's during world war II. Back then you could basically "decide" you wanted to practice surgery based on your own experience and just go do it" ---> Last time i checked, sub-Is, interns or anyone at that skill level doing things like surgery, or even procedures like LPs without supervision is really not such a great idea. There is a reason for graduated responsibility, and that is patient safety.

That's all

I wasn't making a generalization as I said "some" community hospitals, and even some lower tier university hospitals run programs, based on my experience before medical school in a very large number of hospitals I have experience with.

I think if you go to what you call a "Big Name" institution you will learn to think through clinical scenarios more rigorously. From my experience at all different levels of hospitals all I can say is that I have seen a big difference in how residents are taught which affects how they perform and approach patients.

Let me elaborate on my comment about doubting that a PD would complain about having the logitistics down. I mean that it would be very rare in my experience to have a PGY-2 who say didn't know where the lab was or didn't know how to juggle the normal number of patients. I have seen lazy residents who left early and didn't do the required work or plain didn't give it their heart. I have not seen a resident who had a good heart but didn't know where the lab was.

Therefore, I think most problem residents who slow down the team have work ethic issues or motivation issues, not that there is a lack of knowledge about how the hospital works.

After my medicine rotation I knew exactly how my service worked, i.e. the forms for almost anything, and if I didn't know I knew who to ask to get it. I knew where the lab was, which radiologist to talk to, etc . . . My point is that these skills are something that everybody picks up and residents learn from necessity fairly quickly, and therefore don't give a medical student a huge advantage heading into residency.

We all have seen residents learning the ropes, but once you have done half a dozen discharge summaries you know how to do them. See one, do one, teach one. These logistical skills are square one, and most medical students are good at anyway upon entering residency, I think it is just the shear volume of patients that is the issue, but again residents learn pretty quickly how to juggle a dozen patients.

Again, I have seen residents with bad attitude, but not genuinely clueless residents, . . .

I have not seen a resident who couldn't "function in a hospital". Learning how to take care of patients takes time, and learning to do it efficiently takes time, but this can all be accomplished in internship. If you had a real-life example of a resident who couldn't function and what they did that would be great. But it could be possible you have rotated at far worse hospitals that I have ever set foot in.

I am not advocating letting interns or resident work with less supervision. Duh, ah, double duh. My point was that in the past Sub-Is did a whole lot more, and that the Sub-Internship as a step in graded responsibility is a miniscule step at that and the workload/education is a shadow of its former intensity in the 1940's.

In terms of being a "great doctor", I think every single doctors these days tries to rush patients out of the hospital, and 95% of physicians can work the system like a pro. Big deal.

I think being an excellent physician should be more narrowly defined in terms of having
1. Excellent clinical knowledge of the best treatment for patients,
2. Not patronizing patients,
3. Taking time to explain treatments and diseases to patients and to listen to patients, and knowing how to have difficult conversations with patients.
4. Tailoring treatment for specific patients, and
5. Being a great team player.
6. Being a great educator of students and residents if in that position.

I think many doctors and residents don't do many of the things above, but prop themselves up by thinking that at least they get their patients out fast and are an excellent doctor in this day and age. Please, this is the easiest thing to do, but not always the right thing to do.

 

[johnnywalker]

every single doctor does not try to rush patients out of the hospital. what a silly thing to write...

and can i get a reference for your WWII knowledge?

 

[oldbearprofessor]

For those attempting to follow this discussion, "Harvard" is a medical school, not a hospital. Pediatrics at "Harvard" occurs in multiple hospitals and across two programs of which I am aware.

Meanwhile, if you want to debate whether community hospitals give better care or teach pedi residents better, feel free to create a thread to do that and please return this thread to talk of sub-Is.

 

[DarthNeurology]

every single doctor does not try to rush patients out of the hospital. what a silly thing to write...

and can i get a reference for your WWII knowledge?

I think more precisely commented upon I should have said that every doctor today is under financial/institutional pressures to discharge patients earlier than in times past, I'm not the first one to make this comment, . . . not that silly as it is reflection of current pressures.

At many hospitals that are people working for utilization review who hound attendings about getting so and so out of the hospital. This maybe warranted in many cases as being in the hospital supposedly increases risk of infections. . . Haven't you had any contact with UR people Johnny?

History of SubIs is well known common general knowledge. Go googilize it yourself with the Googilizer.

 

[oldbearprofessor]

http://www.med-ed-online.org/res00084.htm

 

[TexasRose]

please return this thread to talk of sub-Is.

http://www.med-ed-online.org/res00084.htm

Interesting article. I think they would have been better served by surveying interns who had been on service for a few weeks rather than 4th year med students. Med students don't really know how well-prepared they are until that first call night, IMO. 😉

As for the higher level communication issue (counseling families, giving bad news, etc), that comes with experience. My program gave a few lectures on the topic here and there, but nothing teaches like being in the room when news is delivered.

 

[HappyToBeHere]

I've read through some of the posts, and it seems like a lot of the people thought a sub i didn't help. I have spoken to some people from my school that did it, however, and most seem to think it was worthwhile. Although admittedly it is not as hard as intern year, they felt more prepared than they thought they otherwise would have. I also don't know how sub i's work at other places, but at my school we replace one of the interns, so you really are expected to carry an intern's load in terms of patients. There are senior residents that cover the floors during the night (so you won't get calls about those patients), but you are the only admitting resident at the hospital while you are on call. (And yes, getting stuff signed off on is apparently a huge pain.)

 

[TexasRose]

I've read through some of the posts, and it seems like a lot of the people thought a sub i didn't help. I have spoken to some people from my school that did it, however, and most seem to think it was worthwhile. Although admittedly it is not as hard as intern year, they felt more prepared than they thought they otherwise would have. I also don't know how sub i's work at other places, but at my school we replace one of the interns, so you really are expected to carry an intern's load in terms of patients. There are senior residents that cover the floors during the night (so you won't get calls about those patients), but you are the only admitting resident at the hospital while you are on call. (And yes, getting stuff signed off on is apparently a huge pain.)

That's an interesting way to do it. Our sub-I's are always an extra member of the team. (Nice for the residents who then get to carry a slightly lighter load.) I guess it really depends a great deal on how the sub-I is structured and then on how good the upper level resident and attendings are at teaching/guiding the sub-I to function like a resident.

I maintain though, that the bigger issue as an intern is cross covering 20-30 other patients that you barely know in the middle of the night.

 

[johnnywalker]

yeah, i have had contact with those people 2. i just think you should write what you mean. you have a history of making up truths as you go along (i remember your whole extracirricular arguments from months back) so to ask you to back up your references isn't unreasonable, dorkth neuro

 

[DarthNeurology]

yeah, i have had contact with those people 2. i just think you should write what you mean. you have a history of making up truths as you go along (i remember your whole extracirricular arguments from months back) so to ask you to back up your references isn't unreasonable, dorkth neuro

Ah, I think with my EC arguments I was arguing my point of view, and I believe that ECs have a place everywhere from medical school education to residency applications process.

Maybe you didn't understand that I was talking about the intangible benefits of extracurriculars, like having something to talk about during interviews, to gaining confidence and insight into different aspects of the medical profession. Such intangible benefits are a hard concept to grasp for some . . .

Regardless, I believed what I was advocating and wasn't "making someting up".

Why are you named Johnny Walker? Is that your fav whiskey?

 

[oldbearprofessor]

I've asked that we stick to the topic of improving sub-Is on this thread. I'd appreciate it if old or other disputes and insults go elsewhere. I don't want to have to close the thread because improving sub-Is is an important topic.

so, keep on topic and avoid violating the TOS that you agreed to when you joined SDN please.

 

[riverie]

I think there's something to be said about the mental/emotional preparation a sub-internship provides, even if it for practical reasons cannot replicate the exact working conditions of an intern. I was terrified of my first call night as a sub-i (mostly, in hindsight, for rather irrational reasons, but still causing significant apprehension.) After my first call, when I got to know what was involved in admitting more than the one patient we would as core students, I calmed down significantly, probably because my fear of the unknown was diminished. Also mostly shielded from core students is the juggling of various consult services and having to chase them and the admitting service down on a daily basis. Also, not having an intern who follows your patients with you forces you to think for yourself and make your own plan. My upper levels were great about making me think through the plan first by myself, then providing feedback and suggestions of their own. The one on one time with the upper level during call nights was also great for getting focused, exclusive teaching and I'm grateful to them for taking time out of their sleeping to help me out. By the end of the month, I felt more independent and more able to hold my own on the floor. So, while I still have to master the tasks of cross-coverage and admitting more than 4-5 patients a night, I feel that I'm at least closer to becoming a functioning intern than I would if I hadn't done a sub-i.