A day in the life of a medicine sub-intern

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Structure of an internal medicine team: An attending is the supervising physician who oversees all of the patients and assumes ultimate responsibility. A resident is a PGY2 or 3 directly in charge of the day-to-day logistics and management of the team. Interns are PGY1s who split up the patient list, and do the orders, most of the patient work, etc. Sub-interns are 4th year medical students who function as interns but with a lighter patient load. 3rd year medical students will follow interesting patients of their assigned intern. Depending on the team size, there may be two 3rd year medical students, each following an intern.

It’s been a few weeks since I finished my first medicine sub-internship, and now I’ve had some time to reflect on it. I remember feeling anxious in the days leading up to the rotation, because I was so rusty on my medicine. I had just finished a year of research in the lab, and the only clinical rotations I had done in over a year were in dermatology. DKA and hypertension seemed like daunting disease entities, and I had lost my familiarity for normal lab values. Even trying to prepare for the rotation seemed like an impossible task, because I didn’t even know where to start.

My first day was overwhelming. My resident assigned me two patients with relatively few co-morbidities, in the hopes that I wouldn’t get too bogged down with complications. What should have been two straight-forward patient cases, took me hours to manage. Those hours were spent mainly trying to navigate the EMR (electronic medical record), writing my progress notes, and answering pages. It’s a shame that most of our time is spent on documentation rather than seeing patients, but that can be the reality of hospital medicine.

I quickly picked up my pace a week into the rotation. And all of the medicine I “forgot” third year came flooding back whenever I scanned UpToDate. Although I couldn’t list off SIRS criteria or the CHADSVASC score off the top of my head, I knew what they were, and where I could find the algorithm. I ultimately think that we remember a lot more than we think, and knowing when or where to look for things we don’t remember or understand is what’s most important.

Compared to third year, I felt much more comfortable being in the hospital. Mainly because I knew what exactly my role was. When I was a third year, I was always wondering what I should be doing, if I was in the way, what the expectations were, etc. As a sub-intern, the goals are clear: you are there to take care of your patients. That obviously increases the amount of responsibility you have, but that also means the expectations are clear. Just finish your work.

Sub-intern schedule

7am: Morning sign-out. This is when we get overnight updates on our patients from the night intern and pick up any new overnight admissions. After we get our updates, the night team officially signs-off on the patients and can either go home or stay to present new patients to the day attending (depending on the program).

7:45-8:30am: Resident rounds. By then, we should have checked in on our patients and looked up their labs for the day. We’ll present the patients on our list briefly or in a more formal SOAP (subjective findings, objective findings, assessment & plan) format, depending on resident style. Anything particularly concerning should be brought up and addressed. Some residents do “walking rounds,” where each patient on the list is physically seen by the entire team, but time is often a limiting factor.

8:30-11am: Attending rounds. After we’ve finished running the list with our resident, we meet with our attending to go over the patient plans for the day. We’ll first present the new admissions in a complete HPI (history of present illness) format, and then discuss the old patients. This is also a time for teaching and presentations. As students, we are encouraged to bring in articles and discuss teaching points relevant to our patients.

11am-12pm: Free time. This is when we put in the lab orders, medication orders, and consults for our patients. Consults should be placed early in the morning, so they have time to see the patients in the afternoon. No one likes getting a 3pm consult when the day is almost over. As sub-interns, all of our orders have to be pre-approved by an intern or resident. This can be frustrating since we have to constantly ask others to get our orders approved.

12-1pm: Noon conference. Many hospitals provide free lunch during didactics. This is essentially a mandatory lunch break with teaching.

1pm-5pm: Free time. We try to finish up whatever tasks are left on our to-do list: pages to return, notes to be completed, patient discharge summaries to finish, consults to follow-up on, new medications and labs to be ordered, etc. As a sub-intern, I try to write thorough notes to help me think through disease processes and differential diagnoses.

5pm: Patient sign-out. Time to hand-off patients to the on-call team. Because the night intern has to take care of the entire patient list, we try to keep our sign-out short and brief, so as not to overwhelm the night team. It’s in good form to try to hand-off stable patients who require as little to do as possible.

(8pm): On-call sign-out: If we’re on-call, we will stay later to pick up new patient admissions up until 6pm. If patients arrive after 6pm, then the night team will pick up the admission. At 8pm, we’ll sign-off all of our patients to the night team.

 

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