How to Master Your Sub-Internships

Millennial In Medicine: Brian F. 4th Yr Medical Student 

So you’ve taken your board exams, updated your CV with all your research, volunteer hours, and extracurricular activities, and narrowed down your selection to one, maybe two, specialties that you want to pursue. Now what? 

Step 1: Lock down Sub-Is.

 Pending what your medical school allows, you may have anywhere from 2-5 rotations you are allowed to complete in one field during your fourth year of school. You need to do your research on programs. As a DO going into a competitive field like Orthopedic Surgery, I had to sit down and figure out which programs I had the best chance of matching at. I am a firm believer that you have the best chance of matching at a program that you rotate at.  So choose wisely and start early. I started contacting programs as early as September of my third year. Some program coordinators laughed at me since it was so early, but I established a connection early on and followed up regularly until they are starting to schedule students. The last thing you want is for spots to fill up because you waited too long. Now, let’s get down to it:

1. Has this program taken a DO before? Ask. Many haven’t. And many won’t even look at your application if it says you are from an osteopathic school. Hopefully this will change with the merger of the AOA and ACGME, but it probably won’t change overnight. Use caution.
2. Is this program part of a University? If so, they probably will weigh your research a little heavier than others. If this is not one of your strong points of your application, you may want to avoid these programs. And if you don’t like doing research, University programs are known to require more research than ACGME requires from residents throughout their residency.
3. What quality of fellowships do the residents at the program match into? While all this may be a “future you” problem, it is something that you need to think about when selecting a program. Which program is going to set you best up for success?
4. In terms of geographic location, pick an area that you will be happy to live for the next couple of years. And if you have no previous ties to that location, contact the program and explain why you want to go there. My girlfriend has spent her entire life and education in Florida. When she was applying to programs in the Northeast, her application got overlooked at a program until she called and explained that I was looking at programs in the area and we wanted to match close together. She got an interview on the spot. Be vocal.
5. And finally, get all your required forms in on time. Stay organized and return emails ASAP. The last thing you want is to make a bad name for yourself if the student coordinator has to chase you down for something, or worse, cancels your rotation altogether.

Step 2: Crush Sub-Is

You are about to head into what could be the most important months of your life. Pending what specialty you are doing your sub-internships in, your method of preparation may vary, but the overall the formula for success is the same:

1. It goes without saying, but be on time, always (aka slightly early). Be on time for rounds in the morning. Be on time for your cases in the OR. Be on time for resident education. Be on time for lunch. Nothing takes priority over these few months in your life. BE ON TIME.
2. Constantly be reading and learning. If you are going into Internal Medicine, odds are your medical school education laid down a good foundation for the information you need to know on your Sub-Is, however, my medical school barely brushed the surface of orthopedic surgery so my learning curve was pretty steep. You won’t be able to learn everything overnight, but residencies can tell who is putting in the extra effort at home and who is just trying to slide by. Ask what resources the residents used when they were in your position. They usually are more than happy to give advice. You should be reading every single night for the first couple months.
3. Prepare for cases. In any surgical specialty, you should know what cases are scheduled for the next day the night before and what surgeon will be performing the case. Make sure you know the approach the surgeon uses, the steps for how the procedure is done, and every piece of anatomy you will see during the case. Know the dissection planes, the danger zones, and the specific anatomy you want to avoid cutting into. Majority of the questions I was asked during cases were identifying structures the surgeon or resident pointed to or why they were doing a certain step.
4. Do enough, but not too much. And anticipate! Not every surgeon does the same surgery the same way. If you have multiple of the same cases with the same surgeon, pay attention to his or her particular steps. The second time around, anticipate what is coming next and do what you can to make the surgeon’s life easier. But read the room, know the surgeon, and find the balance between standing there doing nothing, and trying to grab tools and do things you are not supposed to. It’s a very fine line.
5. Learn from your mistakes. You will get questions wrong. Guaranteed. Residents and attendings will ask you questions until you get one wrong, but this should be the only time you get that specific question wrong. This is how you build more knowledge through your rotations. They can only ask so many questions on specific topics. So when you are in the same type of case with different surgeons and different residents, do not get the same question wrong twice. And on that note, if you don’t know an answer, don’t just guess and pretend like you know it. Either say, “I’m sorry I don’t know the answer, but I can look it up after the case and let you know.” Or “I’m sorry I don’t know the answer, but if I had to make an educated guess…”
6. Make a good impression with the staff outside of the residency. You want nurses, surgical techs, student coordinators to have good things to say about you. Some programs will ask their opinion of the students. Do what you can to make their lives easier. Write your name on the surgical board when you go into cases. Help set up the room, get the gloves and gowns. Make your parents happy and say please and thank you.
7. Ask for feedback. Not every day or even every week, but once you have established yourself, I would say usually end of week 2/beginning of week 3, ask a resident for some constructive criticism on what you can do better with your remaining time at the program. Or if they have any positive feedback that you should continue to do. You can use this information to finish this rotation strong and start your next rotation with an even better mentality.
8. DO NOT TOUCH THE MAYO STAND. Surgical techs will kill you.

Step 3: The Do NOTs of Sub-Is

1. Do NOT be annoying. One of the residents at my first Sub-I told all the students on the first day that this is the most important rule. I know this seems like a simple thing to most people, but I cannot emphasize this enough. The last thing a busy resident wants is some fourth year medical student who won’t stop talking while he or she is trying to get work done. Ask questions when appropriate. It is ok to walk from patient to patient during rounds in silence while the residents get their thoughts together. A good rule-of-thumb is: in the beginning of each rotation, speak when spoken to. At least until you figure out the personalities of the residents and physicians.
2. Do NOT get too comfortable. Many sub-internships are 4 weeks and when you are with the residents every day for that long, it is easy to feel comfortable around them and say things you shouldn’t say or do things you shouldn’t do. Remember, at the end of the day, they are residents, you are a student. They are not your friends. Know the line between appropriate and inappropriate. I’ve seen it first-hand, students shooting themselves in the foot and ruining their entire rotation after one comment in their last week at the program.
3. Do NOT try to outshine the other students. You will get a chance to show what you know. You don’t need to be the first one to speak, raise their hand, answer questions, every time. It’s ok to let other students get questions right. It’s ok to let others scrub in on the big case. You will have your moments. With that said, don’t be silent. Don’t pass up a chance to answer a question if no one else knows the answer and volunteer if certain tasks need to be done. You should befriend the other students. I made some great friends along the journey and you never know who is going to match at the same program you do.
4. Do NOT “show up” a resident. If a resident gets asked a question from an attendings and he or she doesn’t know the answer, but you do, proceed with caution. I would have to say it’s more of a bad look to make a resident look bad than it would make yourself look good in front of the physician. And please do not ask questions that you already know the answer to. Residents can see right through this.

Step 4: Interview and Follow Up

Hopefully at the conclusion of your sub-internships, you made a lasting impression, displayed your knowledge, weren’t annoying, and got some positive feedback. Your goal, at the very minimum, is to get an interview from every program you rotated at. Your interview is your time to solidify everything the program learned about you during your month there. Or if you didn’t rotate there, this is your time to make your first and lasting impression. Be professional, have your basic interview question answers prepared, brush up on that particular specialty information in case they ask you a few knowledge-based questions, have a question or two to ask the people who are interviewing you, and go with the flow. A lot of interviews are very conversational. If you crushed your Sub-Is, the interviews are the easy part. I think it is a nice gesture to send hand-written “thank you” cards to each attending physician that interviewed me at each program. Figure out your rank list, submit, and then it’s the waiting game. It is one nerve wrecking experience, but you WILL get through it! Best of luck to you all.