Sub-Internship

All fourth year medical students are required to do a sub-internship. The idea of this month-long, in-hospital rotation is to practice acting like an intern (the special medical-world name for a first-year resident physician). The sub-I, with overnight call every fourth night, is usually the most intense rotation in the fourth year, which otherwise features residency interviews and elective rotations. It can be pressure-packed, because students often are relying on the experience to yield at least one letter of recommendation for residency applications, and it can even be an audition for a residency spot in that program. At my medical school, we can choose to do this month either in internal medicine (taking care of adults) or pediatrics. Most of my classmates choose medicine, because they will primarily take care of grown-ups in their residencies and later practices.

I originally scheduled two sub-Is for this year, one in medicine and one in pediatrics, thinking that this would be the best preparation for a family med residency where I will care for people of all ages. The medical school dean, when I sat down with her last year to 1. go over my proposed fourth year schedule and 2. tell her that I was pregnant, replied that the idea of two sub-Is was insane, especially with a new baby. She told me to pick the one that would be most enjoyable for me, and so I picked pediatrics. I knew from my third-year rotations that the approach and the hours in peds would be much more family-friendly, and that there was a good chance I would enjoy my colleagues a bit more as well.

So, that is what I have been doing this month, with three weeks down and one more week to go. The every fourth night call schedule looks something like this:

Day 1: on call. Arrive by 7 AM. "Pre-round" on the patients that I am taking care of, which means check in with nurses and the overnight resident to see if there were any issues or changes since I left the day before, call up new lab values, vital signs, and medication records on the computer, stop in to see and examine the patient, and combine all of that into a daily progress note in the electronic medical record. I try to finish this by 8:00 so I have a half hour to head to the lactation room and pump milk for Brynna. At 8:30, the whole pediatrics team assembles for rounds. For the last three weeks, that team has consisted of the consultant (attending physician), senior (3rd-year) resident, four interns, and four medical students (three 3rd years and me). Sometimes we also have a pharmacist. In peds, we do family-centered rounds, which means that we talk about the patients in their rooms, in front of them and their families. We spend anywhere from 2 to 3 hours seeing all of the patients on our service, which is usually about 10 to 15 kids. In each room, the intern or student who knows the patient best presents the overnight information and the plan for the patient today, and then we take questions from the family. After rounds, we head back to the work room to make all the changes that we've just talked about, using the electronic ordering system to adjust medication doses, order lab tests or xrays, and place requests for specialist teams like neurology or cardiology to stop by and see the patient. I try to pump again before lunch. Lunch on pediatrics is great, there is really good food and usually an interesting teaching conference. After lunch, the new patients for the day start showing up. I alternate admissions with the intern who is on the same schedule I am—each arriving patient needs to have a complete history and physical, and then we need to come up with a plan for treating them and put it in to action. We are supervised by the senior resident, who answers our questions, teaches, and generally makes sure that we don't mess up! On a busy day, that takes all afternoon. If there is downtime, I try to study for my upcoming board exam. I pump in the middle of the afternoon, too. Alex usually shows up with Brynna and a wonderful home-cooked meal around 7:00. The wonderful thing about pediatrics is that this is totally normal behavior—the kiddos of the on-call residents often come for dinner to visit with their moms or dads. This would be totally bizarre on most other services in the hospital. I take some time then to eat and feed Brynna in person, and to hand off the bottles of milk that I have pumped earlier in the day and get empties back from Alex.

Overnight, the intern and I continue to alternate admissions. I get much more sleep than he does, though, because he has the pager, and the nurses call fairly frequently with questions and updates on patients. I haven't had much in the way of middle-of-the-night admissions yet, since the doctors in the peds ED downstairs do a great job of stablizing kids to send them back home. This is another nice thing about doing the sub-I in peds versus in medicine—more sleep on an average night in the hospital. I sleep in a call room, quite comfy, in a hallway with a bunch of other call rooms. There's a kitchen that is stocked with not particularly nutritious goodies, but also has boiling water for tea and oatmeal, and a freezer where I can recharge the ice pack that keeps my milk bottles cold. I head up to the call room around 10 or 11 and study or read up on patients' conditions for a little while before pumping one more time and going to sleep.

Day 2: "post-call." Up in time to be back in the residents workroom by 6:30 or 7. Check in on patients, repeat morning routine from day before. Run downstairs to pump while reviewing the information about each of my new patients, prioritizing what I need to tell the rest of the team. Rounds at 8:30, giving longer presentations introducing the team to each new patient and their issues. After the initial burst of post-rounds work, the team re-gathers for "sign-out," the daily transfer of responsibility from the post-call person to the new on-call resident. We "run the list," going through what needs to be done for each patient, which by that point is usually following up on tests and consults ordered earlier in the day. After sign out, I get to leave! Hurray! This is accomplished by noon, sometimes a bit earlier, ending about 30 hours in the hospital. I head home, shower, and settle in to nurse Brynna quite often all afternoon. We usually end up taking a nap together too.

Day 3 and Day 4: Normal, non-call days. Arrive by seven, do morning work and rounds, go to lunchtime conference. After conference, help the on-call resident with anything that needs to get done. Often, that means helping out with patients who are leaving the hospital—they need follow-up appointments arranged, prescriptions written, and a summary sheet of everything that we have done while they were with us. In pediatrics, the residents and medical students who are not on call often leave by 2 PM. This was also a big attraction of doing my sub-I in peds, as that is often 6 PM on the medicine wards. (Medical students, incidentally, are not subject to the 80-hour-workweek rule, and at other medical schools, they are sometimes left to complete work when their residents have to go home to avoid violating work hour regulations. That doesn't happen much here, though.)

Then repeat for one month. The day-off arrangement in peds is that if you are not on call or post-call on a weekend day, you don't come in, and the on-call and post-call people divide up your patients and see them. My first weekend on the service was a "black weekend": I was on call Saturday into Sunday and thus did not have a day off for two weeks. This weekend, however, is my "golden weekend": I was on call Thursday into Friday and have both today and tomorrow off! We are treating Thanksgiving as a weekend, too, so I will have the day off for the holiday as well, since my call days this coming week are Monday into Tuesday and Friday into Saturday. (My rotation was scheduled to end Friday...I just happen to have the much dreaded "terminal call" on Friday night. But I'm doing much better than my intern, who is scheduled to start a new rotation ON SATURDAY MORNING, post-call from pediatrics, in which he will be on call every fourth night for another month. The family med residents here have every-fourth-night-call for 10 out of their first 12 months of residency. Yikes.)

I am having a great rotation. The team is really treating me like an intern, and I have felt very much as if I am the primary doctor for my patients. I love establishing a good relationship with families and helping to explain the overall plan of care. I am usually able to answer whatever questions they have, which is very satisfying. The other students, residents, and consultants have been great. And I am learning a lot! This was definitely the right choice for my sub-I, as I get all of these educational benefits AND a chance to spend good time with Brynna. I miss her like crazy on those overnights, but having her come visit in the evening is fantastic, and I try to take advantage of downtime at the hospital to study, so that I don't have to do as much studying when I am at home with her.