Expectations

General Philosophy: Strive to function like an intern on the team.
The sub-Internship is more than just a required rotation or a refresher on the wards. Residency program directors across the country expect the sub-Internship to be the definitive testing ground to make sure you are ready for internship. As such, it is critical that you seize this opportunity to function just like the other interns on your team – forming your own independent assessments, developing your own plans, and taking full ownership of the care of your patients (with help from the literature and your team, as needed).

At this point in your education, you should be proficient in performing H&P’s and coming up with an initial differential diagnosis and assessment. Now it’s time to develop your problem solving abilities, improve your efficiency, hone your presentations, and gain comfort designing your own treatment plans. We want to give you as much autonomy as possible.

Course Logistics
You will be assigned to a ward team typically with one resident and two to three interns. For the general medicine teams, admissions are distributed across an Early Call day, a Mid Call day, and a Late Call day, followed by a day of no admissions. The subspecialty teams admit every day.

As a Sub-I, you report directly to the resident, not the interns and you should follow patients directly with her or him. Your attending should co-sign your H&P’s in order to give you feedback, but your resident should co-sign all progress notes and orders.  When your resident is off, your attending is your supervising physician, although your resident may additionally assign an intern to assist you with oversight, co-signature of orders, and documentation.

Workload and Clinical Expectations.
–  You will be on the same call schedule and have the same number of days off as the interns.
–  You should attempt to admit a patient on every admission day just like the interns, aiming to carry a patient max of 4-5 at a time.
–  You should put your own orders in whenever possible.
–  You should sign-out your own patients to the cross-cover resident every day and receive sign-out back every morning at 7am.
–  You will gain further experience with sign-out and cross-cover working three nights with the night team (more below).

Write-Ups and Charting
–  Every patient you admit needs an H&P and daily progress note.
–  Unlike as a third year, H&P’s should be on the chart the day of the admission
–  H&P’s should be co-signed by the attending.
–  Progress notes should be on the chart everyday (ideally by noon).
–  Progress notes should be co-signed by your resident.
–  Copying and pasting portions of other providers’ notes constitutes fraud and is not permitted.

Sub-I Conferences
–  Attendance is required at weekly Sub-I Conferences located at the VA, typically on Thursdays at 2:00 unless otherwise notified.
–  Sub-I Conferences will include preparation for cross-cover and night shift coverage with a focus on plan development. Two conferences will involve practicing real-time respiratory and pulmonary scenarios in the VA’s Simulation Center.
–  Attendance is expected at all other conferences that include interns unless patient care requires your presence.

* Morning Report is at 8am every morning except for Thursday.
* Noon Conference is at 12pm every day except for Thursday.
* Grand Rounds is 11am on Thursday.

“Night Shift” Cross-Cover
Each of you will select three of your “Mid-call” days over the course of the rotation where you will stay until 11:00 and assist with cross-cover.  Doing the cross-cover on your Mid-call day will ensure that you are not doing it at the same time as another Sub-I.  Students on Cardiology and Heme-Onc will do cross-cover on their own unique clinical location, and therefore may select any three nights during the rotation.  This is a requirement of the rotation.  Notify Dr. Hood at Laurence.hood@va.gov to let him know which nights you will cover.

Days Off

This is a mandatory rotation and your presence has an impact on your patients and your team. Just like the interns, you will receive one day off per week, on average.  If an emergency occurs such that you need to be absent more than this, you must obtain prior approval from Dr. Hood.  Failure to do so could result in an unsatisfactory or incomplete grade.   You must also notify your resident and attending.  Please avoid scheduling interviews during your Sub-Internship.  Your team and your patients depend on your participation.  Additional days off will not be granted for interviews.

– Just like the interns, you will receive one day off per week, on average.
– You may pool your days off together if you need to take a weekend off.
– The last day of the rotation is the final Saturday, which most students typically take as their final day off.
– Holidays are not extra days off during the Sub-Internship, although they may be taken as your day off for the week.
– If the first Monday of the rotation is a federal holiday, the rotation and orientation will begin on Tuesday.
– Per Dr. Duff, interviews should not be scheduled during any mandatory rotation. Additional days off will not be granted for interviews.
– See Policies and Procedures for more information about planned and unplanned absences.

Patient Logs
You must continue to maintain patient logs as a requirement for College of Medicine graduation requirement, even during the Sub-Internship. Failure to demonstrate a reasonable effort to maintain logs (defined as less than 10 presentations logged or logging all entries the last week of the clerkship) may result in a lowered Professionalism competency score or an “Incomplete” grade.