Feb 10 2012

How to Excel on an Internal Medicine Sub-Internship Rotation

Once you have decided that you want to match into an internal medicine residency, you should try to schedule as many sub-internship or “audition” rotations as possible. Definitely schedule these at your top program choices, and then try to do more at other programs that you are interested in knowing more about. The optimal time to schedule these will vary with program availability and your schedule, but there are a couple of important points to keep in mind.

Initially, make sure to contact the program to find out when their interview season is, and then make sure to schedule your audition rotation during that period. This is important because the majority of the time you can also interview at the program while you are there for your sub-internship rotation. It is also a good idea to try to schedule your interview near the end, or at least half-way through, your rotation so that the residents, attendings and program director have a chance to get to know you. The programs are usually very happy to work with you to schedule your interview while you are already there, especially if you have traveled from out of town. How to excel on an Internal Medicine residency interview will be covered in a future post. I will update this post when that article has been posted.

Below I have described my tips on how to perform well during your internal medicine sub-internship (audition) rotation, so that you can impress your team and increase your chances of getting an interview and then a residency position at the program of your choice. Since I have had personal experience in doing several audition rotations in different parts of the country, and I will (hopefully) match into an internal medicine residency very soon, I hope that these strategies will be useful to you. These points are arranged in order of preference, but they are not that difficult so you should be able to perform all of them!

Update (2/13/11): I have successfully matched into my #1 choice for Internal Medicine residency, proof that these strategies do work!

1. Make the Intern’s Life Easier. Your primary job while on this rotation is to do everything you can to make life easier for the intern. Pretty much all of the other rules follow after this one. The things you will be doing to fulfill this rule will vary individually from intern to intern, and more specific things you can do are discussed below. However, be sure to ask the interns and residents on a daily basis if there is anything you can do to help, without being a pest. Always be actively looking for jobs that you can do, whether that is gathering charts, keeping a to-do list, or re-examining patients. Keep this rule in mind during your time on the floor and you will do very well.

2. Prove You Can Do the Intern’s Job as Well or Better than Him/Her. This is another rule that encompasses all the others, but is important to keep in mind at all times. There are really not any other specific things you can do to fulfill this rule other than what is listed below. Always be sure to work your hardest, don’t complain, and give 100% every day. Show that you are interested and have enthusiasm about what you are doing, because this is what you want to do for the rest of your life, right?

3. See All Patients and Write All Notes Before Rounds. Nothing shows more that you are not ready for rounds when you are furiously scribbling on your progress notes as the team is about to begin. Arrive to the hospital early enough so that you have plenty of time to see all of your assigned patients and complete all of your notes before rounding. It is also helpful to print out any imaging study reports, EKGs, culture results, etc. to give to the attending to review. Be on time to rounds with your notes ready, having reviewed the chart, and with a good assessment and plan in mind. This brings us to our next point.

4. Write Excellent Progress (SOAP) Notes. Hopefully you will already be familiar with how to do this from your third year medicine rotations. Remember the basics of the SOAP note format, and don’t put things in the wrong section. The overview of how to write a SOAP note is the topic of another post, but there are some extra ways to make your note great. Write down a list of the patient’s medications in the margin. For antibiotics, make sure to include the start date and/or the current day of treatment. Make sure your handwriting is legible. Don’t use pencil or marker as it may smear, and don’t use different colored ink on your notes. Sometimes nurses, case managers, and other staff write in the chart with alternate colored ink, so get in the habit of only using black pen. For abnormal labs, also put the previous day’s value off to the side so you can keep track of trends. Talk to the patient’s overnight nurse to see if any acute events happened during the previous night. The interns, residents and attendings all look at your note even if it does not become a permanent part of the patient’s chart, so don’t skimp on the details. Include a differential diagnosis in your plan for your assessment. Write out your thought process including what labs you want to order, what medications to start/stop/continue, consults you want to ask for, and imaging you want to obtain. Don’t worry about being 100% accurate. The main thing you want to focus on is your thought process for your plan and providing evidence and justification for it. Writing an exceptional progress note will give you a step-up for the next point.

5. Actively Participate in Rounds and Morning Report. Active participation means that you are presenting your own patients during rounds to your attending physician. Hopefully you have had a lot of practice with this before your audition rotations, and it will be no sweat. It can be nerve-racking the first time you present to a new attending, but if you have an excellent progress note you can get through it. In addition, make sure to answer pimp questions during rounds and morning report. Just sitting in the background will not help you stand out and be rememberable. Don’t be afraid to speak up and show that you are smart, just be careful not to come across as too confident or that you think you are the smartest person in the room.

6. Post-Round with the Intern. Post-rounding is when you go back through all the patient’s charts and take care of the loose ends. This mostly includes writing orders, discharging patients and dictating. Make sure that you are present for this every day and are available to help in any way that you can. During rounds you should have also been taking notes on what needs to be done for your patients, and you can also help make sure that all of this gets done. The interns will be grateful if you remind them of something they may have missed. You can also help by writing prescriptions and, if students are allowed, even dictating.

7. Be Professional. This should go without saying, but your behavior and appearance should always be a priority. Always follow the dress code. Don’t wear scrubs when everyone else is wearing a shirt and tie. Treat everyone with respect that you come into contact with. Remember that you are in the hospital to learn and that they are allowing you to be there. Do not ever ask if you can go home, and only leave when you are told you can. Never decline when you are asked to do something and always be willing to do little tasks.

8. Present a Lecture, Morning Report, or Journal Article. If there is a practice of students presenting a PowerPoint or an article on their rotation, make sure that you are able to do so before you leave. You can always offer to present a 5-10 minute summary of an interesting subject to your medicine team. It might take a little bit of time to prepare a lecture, but it is a good way to get up front, show your face, impress others, and be rememberable. You want to be able to be recognized come interview time.

9. Take Call. If students are able to take overnight call in the hospital, sign up. This will give you an opportunity to get to know more residents, gain a lot of experience, and show how much of a hard worker you are. Plus, the next day you will be post-call and get to go home early.

10. Eat breakfast. This may seem trivial, but I think it is vitally important. How are you supposed to take care of others if you don’t take care of yourself? This does require waking up earlier in the morning, but it will make the rest of the day smoother. If your brain is low on glucose you won’t be thinking as clearly and your mind will be on your stomach come mid-morning. On my medicine rotations, I liked to finish up my notes while eating breakfast before rounds. Eating breakfast will be especially important once you become an intern and your decisions will be directly affecting patient’s lives.

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