What's your sub-I like?

[ucla2usc]

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For whatever reason, I'm developing some pre-intern anxiety...i.e. I wonder if I am prepared.

So just out of curiousity...what's your school's sub-i like. How many sub-i's did you do?

At my school, our "sub-i" consists of admitting patients, writing h&p, orders, soap notes, following studies, etc.... what it does NOT include is getting paged for your patients' issues...so you often hear second hand from the resident the acute issues in your patient and what they had already done about it. We also need to get our orders cosigned, so residents often would rather just write the stuff themselves to save the grief waiting for you and your orders to sign. We carry about 4 patients each. Is this typical or are other sub-I's acting more like the intern: writing orders un-cosigned and getting paged directly by nursing? I think this is a huge distinction, but who knows?

 

[new_avatar]

For whatever reason, I'm developing some pre-intern anxiety...i.e. I wonder if I am prepared.

So just out of curiousity...what's your school's sub-i like. How many sub-i's did you do?

At my school, our "sub-i" consists of admitting patients, writing h&p, orders, soap notes, following studies, etc.... what it does NOT include is getting paged for your patients' issues...so you often hear second hand from the resident the acute issues in your patient and what they had already done about it. We also need to get our orders cosigned, so residents often would rather just write the stuff themselves to save the grief waiting for you and your orders to sign. We carry about 4 patients each. Is this typical or are other sub-I's acting more like the intern: writing orders un-cosigned and getting paged directly by nursing? I think this is a huge distinction, but who knows?

That sounds about right. I never got paged except once. I wrote progress notes on 3-4 patients, prerounded briefly before rounds. Because of nightfloat I presented patients I never admitted which consisted of me reading the H&P aloud to the team. One of my fellow med students tried writing orders without cosignatures but this was clamped down on by nursing. It is illegal in my state. And nursing would never page the med student because she can't write any orders, which is what nursing wants, someone who can "fix" things.

I followed up on studies too, talked to same family members, wrote consult requests and called consultants on occasion. But since this was after my MSPE I wasn't in super gunner mode. One night on long call (weekend) there were so many admissions (15 or 16 in one night) I just ran around with the admitting resident, she would ask questions, and I would write the H&P as the patient answered.

We have to do 1 sub I and it can be in medicine, family medicine, or peds.

 

[inositide]

that is probably very similar to most people's experiences. some MS4's write orders because it is allowed in their respective states.

my school encouraged nurses to page the sub-i's.

I once got paged late at night by the nursing staff. I said that I was at home and night float should be called. the nurse apologized profusely. best nurse I ever met.

 

[Tinsley]

I was (un)lucky enough to do mine at the VA. I could "write" orders for patients which had to be cosigned on the computer by the resident. This at least adds some thinking and real life practice to the matter. I also was paged for my patients pain issues late at night. How lucky did I feel.

I worked at another private hospital around here when I was a 3rd year and I used to write orders that were supposed to be cosigned by the resident. The nurses would follow my orders however before any such signature. I'm sure it will take a very bad event for that practice to stop there.

Regardless these were both very good rotations for me, helping to build confidence for that first day of internship.

 

[doc-synergy]

got to be paged and call consults on the 2 sub-i's i did. this develops good inten skills - requires practice of quickley summarizing a patient, and knowing what the consult will ask. one was a sub-specialty consult sub-i so i got to page interns with our recommendations. i would recommend asking about specific responsibilities before setting up visiting sub-i's so you can make the most of your experience.

 

[angel80]

My sub-I was practically like an intership, except that I carried less patients (we would admit 2 patients every long call and 1 every short call-instead of 5 and 2), and would cap at 5 patients (instead of 10 like the interns). Also, we couldn't sign our own orders, so I would either put them in the computer and have my senior co-sign, or my senior allowed me to call in verbal orders and give her name and pager number. Our names were put in as first call on the chart, so the nurses and consultants would page us if they needed anything. We would have to sign out our patients to the on-call sub-I at the end of the day (no night float), and the sub-I on call would have to cross-cover about 10-15 patients. Because of that, you got paged repeatedly throughout the night on both your patients, and the other sub-I's patients. Not only did we have to see our patients everyday and right orders, but we had to do a lot of calling/paging the consultants to discuss the plan on the patient. If the patient needed tests done quickly, we would call radiology/lab to try and expedite the process. We had to contact Social Work for the discharge plannning. We were also in charge of dictating all of our patient's discharge summaries after they went home. Overall, it was a very busy month, but I think it gave me a good taste about what internship would be like.

 

[souljah1]

My Sub-I responsibilities were exactly the same as an interns. Took call basically Q4 and was responsible for admitting patients from 8am to 3am on our call day. Our team capped at 10, and there were two interns and myself. Whoever had the fewest patients went first in the admitting cycle. So, depending on how many patients I had, I would admit between 3 and 4 patients every call. I wrote admit orders that had to be cosigned by my R2. My pager number was on the admit order sheet and up on the board, so all nurses and any consults ordered would contact me first. It was awesome, and so much better than third year. During third year, I admitted and followed patients and wrote notes on them - but I felt like it was all just for kicks because there was always an intern co-following the patient with me. For my sub-I, it was truly just me prerounding, getting paged, etc. I'd check in with my R2 during work rounds to make sure that I was thinking correctly. Sub-I's were always kept up to date on their patients - so on days off and on post-call evenings we'd get a call on our cell phone updating us on consults that came in, whether or not someone was discharged, etc. I never felt like I was showing up to help take care of patients whose conditions had changed without me being made aware of it first. It got me really excited for internship, residency, and beyond.

 

[DaBigDawg]

School requires medicine and sugery sub-Is and inpatient and outpatient sub-Is. Consult months do not count as Sub-Is.

on medicine: Admit up to 5 patients on a Q4 call cycles. Cross cover your own patients and the other 3 sub Is patients (4 gen med teams). Total cap of 12 but I only got there once.

put in all your own orders but they have to be cosigned. nurses page you about all patient issues.

 

[greets fr. nyc]

haha~ thank goodness no more co-signs~!
that was the BANE of my existence.... the patient needs some benadryl?... gotta find a resident. the patient needs some tylenol... hafta find the resident... need to put in the admit orders at 2am... ok, where's a resident? ready to d/c home, need to d/c hep-lock... let's page my resident!


the details of our sub-i over here combines some of all the elements noted by OP's:
1) q4 overnight, covered all 4 teams with my co-sub-I overnight. sometimes we'd split the list, sometimes someone would hold the pager while the other admitted.
2) admit from 8am-2am next day
3) admit cap at 3
4) total cap of patients at 12
5) pick up bedholds from night before, q4 (usually 1 extra pt)
6) average census: 5-7 pts.
7) wrote all orders / daily labs / admits / SOAPs / d/c notes / Briggs forms / prescriptions.. and then had to get the resident's stamp & signature.
8) no days off.
(this last point was very painful, but overall, the sub-I was an amazing experience 2/2 the residents i worked under and the attendings as well. couldn't have asked for better mentors.)

 

[mellow yellow]

My SubI at my home institution sucked a$$. My resident was a brand new R2 and he was so stessed with his responsibility that he wouldn't let the intern or myself do a damn thing. So basically I just shadowed my patients like a third year med student would. Actually, I had a hell of a lot more responsibility as a third year than i did as a fourth year which was pathetic.

So I ended up doing a cardiology SubI at UCSF which was an excellent experience. Nearly identical to Souljah's experience. Admitting cycle was q4 and we would take up to 8 new patients per call. There was just one other intern so we would alternate new admissions. I basically pre-rounded myself, my name/pager was attached to the chart, and I got the first call from the nurses. I wrote all of the H/Ps, orders, progress notes (all of these were cosigned), and signed out my patients to the residents on-call. We were also the first service in the hospital to go completely electronic (I think) so everything was computerized except for orders which were written. The experience was absolutely phenomenal. The residents were fantastic. Nothing but great things to say about UCSF. It's definitely the best program in California, maybe in the US?? I also did a GI rotation at UCLA which was great. I saw the consults all by myself, wrote up the consult, and presented to the GI fellow who would then dictate my consult word for word.. Both experiences were great and allowed me to get a sense of what being an intern is truly like.

 

[ucla2usc]

i think my consult months were similiar to the above...see consult, w/u pt, present directly to attending or fellows, page team directly w/ recs.

I have never had the liberty of getting paged for my patients issues, guess I missed out. Sounds like the majority of your sub-i's have been a bit more intense than mine! My work load has always been somewhat light (4 patients). In fact, I usually admit my two patients on call nights (q3) and sleep home, since there's no point to being there if they aren't paging me. It's an open icu though, so right now 3 of my 4 patients are in the unit so that's made for a great learning experience. If the resident would only let me manage them...then i might really learn something.

Oh well...i'm sure things will even out in the end. From what I've heard, med students from my school tend to be pretty decent on the wards wherever they go, so i'm not too worried. All of our non-sub I's have been pretty much the same as my "sub-I" anyhow.

9 days to match!

 

[inositide]

for those of you who haven't had what you feel is a rigorous sub-i, you should not worry at all.

As an intern the learning curve is rapid. You will get up to speed really fast.

One thing everyone is good at by the end of 3rd year is switching gears as needed. Every couple of months you are on a different rotation as a third year, yet it takes only a few days to adapt to the new situation.

As an intern everyone will adapt quickly as needed.

Most people will be leaving their home institution for residency. Almost every hospital is different in some way in terms of preferred practices, procedures, protocols, logistics, etc. Everyone will catch on fast. It happens every year.

 

[AwesomeO-DO]

is it common to do an IM Sub-I at the beginning of the 4th year? I"m moving to another city where I hope to do all of my 4th year rotations, and then get a residency there, and I am trying to figure out when to do sub-I's and rotations within the areas I want to interview. the Sub-I's I plan on doing are in Peds and IM. Peds I would like to do in Nov or Dec because I'd be well accustomed to the area by then and more comfortable with the institution. I will plan a month of anesthesiology in there, maybe Oct.

 

[chicamedica]

I'm doing my sub-i right now, and yeah i'm pretty much supposed to be doing everything an intern would do, but I get a lot of supervision (maybe cause i'm slow, maybe cause my resident is so cool, maybe both). I do write orders, but they do have to be cosigned, although the nurses will sometimes implement them without the cosignature 😱 hopefully that's not illegal here. I do get paged re: my patients, but luckily it hasn't been that often for whatever reason. The other intern on my team seems to get paged a lot more. Could be because the resident checks after me more and ties up some of my loose ends. Team caps at 12 patients, I have officially capped today at 6 patients. Tomorrow's gonna be rough (today already was!).

As for cross-covering, if there were other sub-i's around i'd prob be cross covering their patients, but i am the ONLY sub-i at the hospital this month (and this is a major academic hospital). . . it's been cool, I'm glad i did it this late--i get all the attention, and the staff isn't annoyed at 10 sub-i's bugging them for this and that. On overnight call, though, i split the cross-covering with the other intern, so he carries the sign-out pager half the night, and i carry it the other half.

Dont know if this is exactly how intern year is gonna be, but I will feel a bit more prepared than i am now!

 

[PhillyGuy]

We have the option of doing either a medicine externship or a sub-I. For the externship, you are basicially an addition to the existing team, so you would split the patients with your co-intern. But for sub-I, you replace the intern on your team. You are on the team with one other intern (normally 2), a senior resident and an attending. You pretty much do everything that an intern would do (admission notes, daily progress notes, dc notes, consults, x-cover, family meetings, etc), but you are capped at 5 new admits when on call (vs 6 for intern). We can put orders in the computer, but they have to be verified by the senior resident.