Tips for Being An Efficient Sub-I

[seanth]

The transition from M3 to Sub-I as an M4 seems like a decent bit of a jump since you have a lot more responsibility. I was wondering if anyone has advice/books that make for a smooth transition and efficient/diligent patient care.

Thanks!

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[McGillGrad]

1. Realize that the differential and PLAN are your most important duties.

2. Know everything about your patients, which means reading all of their notes and doing a FULL history and physical, even if it has already been done.

3. You have to know the bread & butter cases and their presentations cold before you start. You've already had a full IM rotation, so there is no excuse for blanking on ACS, chest infection or CVA protocols.

4. Just read through Step up to Medicine or do a bunch of Pretest medicine questions. better yet, do the MKSAP questions. They are quick and bread and butter.

 

[cpants]

Anticipation. At this point you should have a pretty idea of what's going on and what the next step will be for your patients. So on rounds, have the CT slip already filled out in your pocket. If you can't read ID's consult in the chart, call the team yourself and find out what the recs are. When you are checking labs, fill out the order sheets for repletements so your intern just has to sign it. Follow up scans as soon as they are available. In your pocket, always carry all current labs/vitals for every patient on service, plus order sheets. Anticipate what the team/patients need, and make it happen.

 

[OveractiveBrain]

Attendings evaluate students based on the RIME spectrum (Reporter, Interpretor, Manager, Educator).

The expectation of the medical student in third year is to be a reporter teetering on interpreter. Saying a patient has edema, dyspnea, and an elevated creatinine is a reporter. Recognizing this as a syndrome for heart failure is an interpreter. Knowing what to do about it (AND WHY) makes you a manager.

As a Sub-I, you should be expected to do everything from the above posters. But realize you are not being evaluated on how well you know your patients. You are being evaluated on your ability to actually make decisions. As mentioned, having a good plan is absolutely crucial. Even if you are wrong, having a plan and a reason for the plan makes you look like some one who is able to make decisions.

Working closely with your resident will ensure that your mistakes are cleaned up before presenting to the attendings. Pay attention to prerounds or resident rounds, and use the resident (or even the interns) as a crutch to solidify your plans and reasoning.

Finally, there are the duh thing:
1. Show up on time
2. Do whatever works needs to be done, even if not asked to
3. Always ask for what else you can do
4. Plan on being there longer than the residents, so when they release you its an "ah thank you" moment, not a "finally, im outta here" moment
5. Be a team player
6. Don't be a jerk, steal patients, steal procedures, or do anything that harms any other team member's experience

 

[McGillGrad]

Attendings evaluate students based on the RIME spectrum (Reporter, Interpretor, Manager, Educator).

The expectation of the medical student in third year is to be a reporter teetering on interpreter. Saying a patient has edema, dyspnea, and an elevated creatinine is a reporter. Recognizing this as a syndrome for heart failure is an interpreter. Knowing what to do about it (AND WHY) makes you a manager.

As a Sub-I, you should be expected to do everything from the above posters. But realize you are not being evaluated on how well you know your patients. You are being evaluated on your ability to actually make decisions. As mentioned, having a good plan is absolutely crucial. Even if you are wrong, having a plan and a reason for the plan makes you look like some one who is able to make decisions.

Working closely with your resident will ensure that your mistakes are cleaned up before presenting to the attendings. Pay attention to prerounds or resident rounds, and use the resident (or even the interns) as a crutch to solidify your plans and reasoning.

Finally, there are the duh thing:
1. Show up on time
2. Do whatever works needs to be done, even if not asked to
3. Always ask for what else you can do
4. Plan on being there longer than the residents, so when they release you its an "ah thank you" moment, not a "finally, im outta here" moment
5. Be a team player
6. Don't be a jerk, steal patients, steal procedures, or do anything that harms any other team member's experience

 

[Thorzuul]

5. Be a team player

I can't stress this enough. Too often from the Sub-I/AI's I've worked with is that there's some level of performance anxiety in the weaker M4's. They have a fear of failing, so they go out of their way to avoid patients. I remember having it too, but I realized quickly that it was better to take a patient than to keep on avoiding it.

Case in point: At my program (Peds), the Sub-I/AI was on call overnight, and the two interns were not (its night float for interns). Two admissions overnight, done both by the Sub-I/AI and a transfer from CT surgery (a baby that was stable, but needed to complete a course of antibiotics, coordinate central line placement, and ultimately transfer to a rehab facility). One intern has two patients going home, so he picks up one of the admits. The second intern has 3 patients already, none going anywhere. The Sub-I/AI discharged all of her patients the previous day, so she takes one of the admits. So who should take the CT surgery transfer?

Intern A: 4 patients total, with one new admit
Intern B: 3 patients total
Sub-I/AI: One patient, new admit (who was admitted by the Sub-I/AI)

Let me sweeten the pot. The Sub-I/AI SAW and examined the CT transfer baby with an attending the previous evening, and got a complete sign-out on the patient from the attending (they went over everything). Who would it make sense to have round on the patient in the AM?

Guess what... the Sub-I/AI decides to ask intern A to take the patient (she knows that Intern B would point out the logical choice of who would take the patient). Seriously.

The best 4th year med students tend to take any opportunity to take the patient, especially in that situation with the patient load. Most residents will protect the Sub-I/AI anyways, if they have too many, the resident will step in and redistribute (or the interns will take any new admissions). If the M4 is wrong on rounds, so what, nobody is going to fail you on the spot (unless of course it really affected patient care). Its the effort in learning, its not about whether you are always right or you know how to handle every patient situation. Even showing the thought process to the residents and attendings goes a long way in showing one's clinical abilities.

That same Sub-I/AI in the above story? She also had a tendency to not complete all of the discharge work for the patient, didn't tell anyone, and the interns would get paged to finalize much of it. Learn from her mistakes, know your patients, do everything an intern would do. Ask for help, but try to do it on your own. Residents usually are your best friend, most will help with the difficult assessment and plans. Give it a shot, but don't be afraid to ask the residents first before you argue a big decision in front of the attending.

 

[jbar]

1: Write down everything you have to do, with little check boxes. It seems stupid but that lab value to check or the IV you need to pull will seem like something you won't forget when they tell you at 10am. But when it's 2am and you can't think straight it's much better not to have to remember.

2: Always see the patient. At the beginning of my medicine sub-I I would get paged about a patient with something like chest pain. I would think "oh, I should call the resident right away so there isn't a delay." And she'd say "what does the patient look like?"

So go see the patient. If it's about crazy vital signs re-check them yourself. I can't tell you how many times I was called about a fever of 101 and it was fine when I checked it. Or that the patient was hypertensive but they had used the small BP cuff. Also you can get the work up started even if you can't put in orders. (That 60 year old guy who gets chest pain in the middle of the night will pretty much always get an ECG, ask the nurse to get it started while you call the resident. Patient's with fevers tend to get blood cultures, so gather the bottles etc.)

3:When cross covering other people's patients really ask what to do if there are anticipated problems. So when they say "oh, this guys sats have been dipping" ask what they want you to do about it if it happens again. Ask if people who sound old and sick have DNRs. Ask if patients in restraints have the restraint orders current.

4: If you do overnight call (which may be going away), bring a spare set of scrubs, clean socks and underwear, and a toothbrush and toothpaste. Even if you've only gotten an hour of sleep if you have a clean mouth and clean clothes you feel much better. Also maybe a sweatshirt and sleeping bag (our call rooms were super cold, and hospital blankets suck)

5: Be nice to the nurses, they can make or break you. Even when you are getting paged about nothing at 2am. And explain to them what you are doing when you ask them to do something. I found they were much happier drawing blood for me or doing an ECG if I told them that while they were doing that I was going to put in orders and call the resident (so they didn't think I was giving them work and was just going to go back to bed.)

5: Echoing what others have said about knowing your patients, you should have a piece of paper for each patient with every days lab values on it. When you have a sick kidney patient people will be like "oh, what was their creatinine 4 days ago"

6: Start your notes early. Nothing sucks like trying to write notes at 4am.