Internal Medicine Sub-I
Before we speak about the elective itself, you should be aware that as of now FMG's/IMG's are not always able to do medicine Sub-Internships at Montefiore, Columbia, Cornell, and Mount Sinai in Manhattan (you can do it at affiliates but I would advise against it). Therefore, Most Sub-Is are done at one of the following hospitals: Beth Israel, Lenox Hill, or Long Island-Jewish/Northshore. I did my sub-I at one of these hospitals. However, from what I heard electives at most of the above hospitals are organized in a similar way.
Things you will need: Short white coat, stethoscope, pen light, Pocket pharm book (or on iphone/blackberry).
The first day is mostly orientation. You go and pick up your beeper, sign some documents and than get fitted for a TB mask. This is usually mandatory so you will just have to stick through it and finish it. As soon as you finish with all the protocols, you will begin working with your team. A team at my hospital consisted of 1 resident, 2 interns, 1 sub-I and a teaching attending (notice that you will begin on the same day the interns switch rotations, so you will be with the same interns all month. Your resident will change 2 days after the first day). You belong to 1 floor although at times you may cover patients on other floors (depending on whether the hospital is geographical or team based). At my hospital the teaching attending was separate from the floor attending who actually takes care of the patients
Arrive around 6:15-6:30 to pre-round on patients. You must come to pre-round! You are expected to know what happened during the night (so look in the pt chart), all new lab values and anything needed to get done for the day. Also, you can do a quick physical exam to make sure everything is fine.
7-9 Round with team (resident and intern). Here you will present your patients and discuss further treatment plans for the patients.
9-11 Round with Teaching attending. Sometimes these are work rounds but usually you sit and go over one of the more complicated patients and examine the patient more in depth.
11-12 Work on your own, write notes, call consults. For notes, buy Maxwell's and go along. Basically ask one of the interns for one of their notes and copy the format which is usually: SOAP
S-Subjective: what the patient told you during pre-rounds, how the patient feels today.
O-O-Objective: Vitals, Physical exam, Labs, Radiology/diagnostic tests. Also add a section with drugs and allergies
A- Assessment: Possible diagnosis and what tests you are doing to rule them out. Any ongoing problems and what meds are being given.
P- Plan: treatment plan/discharge plan etc.
If your resident is nice, they will go over it with you to see if its good. Generally, you can also copy the assessment plan from the admission note and continue to follow that plan while updating it.
12-13 Lunch + noon conference. At my hospital they provided a Kosher lunch for you as well as a lecture. Make sure you pay attention and don't fall asleep as the program director is nearly there every day.
13-17 Work on your patients, talk to the attending on the floor about your patient, check to see if any consults arrived and wrote in the patient's chart. Once a week there is a lecture for the sub-I's and also once a week there is a lecture for the interns. You should go to all the lectures if you can. Most of the time you will not have too many patients. Once a week you will have Grand Rounds in the morning. It's a lecture for all of internal medicine, usually by someone doing some sort of famous research.
Also, do not wait around for consults. Continue to call them until they let you know exactly when they will be there. Also, if they need imaging done, call the radiologist and see where they are on the list. If it's urgent explain to them and try to move them up the list.
16-17- Hand patient over to night float. You must write what's called a "sign-out". Basically, it's a summary of what has happened to your patient through out the stay, important contact info, exam results, allergies etc. Most important to write are the things needed to be done for your patient overnight (i.e. Check blood cultures as soon as they are in, make sure sodium in tact, etc.). Also, you must write if a patient is DNR (do not resuscitate).
Sometimes you will have to stay on long call where you will admit patients until 21:00. That means you can receive a patient at 21:00 and you will have to stay till you finish the admission. Also when you are on short call, you have to admit until 3 or 4. These call schedules change in between hospitals so ask your intern exactly what happens where you are. At my hospital, you must do 1 overnight which is one of the 4 Fridays of your sub-I. You get one Golden weekend, meaning Saturday and Sunday off. Even on your golden weekend you have to come in and write a note on your patient at some point (most people come Sunday night). Admitting may be a bit of an issue at first so go with your resident or intern if you can. When a patient is admitted you have to go to the E.R., take the history and do the physical exam, the resident has to enter all the orders and make sure the patient is being cared for until they come up to the ward.
Words of Wisdom: In America, generally it is not wise to complain about things. Even if the interns/residents are complaining, please smile politely and keep your mouth closed. People who are working in that hospital are allowed to bitch, but people who are trying to get into that hospital have to make sure everyone around them knows they are excited and eager to work. Help your team out as much as possible. It is always a good idea to make a list with check boxes of everything you need to get done for your patients, including ordering labs and meds on the computer for the next day. Its also a good idea to write everything you need to do for the next day before you leave to go home, you will most likely forget in the morning. Something I learned from the army as well, is never be afraid/embarrassed to write down your tasks. If anything, it shows that you are responsible and people will know you will not forget. If an attending says to you, "It may be a good idea to get a vanco trough," write it down immediately so you don't forget. Be proactive, never wait for people to tell you what to do but also make sure to run your ideas by your resident. After all, you aren't a doctor yet and you may not know that particular protocols for that hospital. Most important, volunteer to present. Get a list of topics before the sub-I lectures and learn them before hand.
One last piece of advice, make sure to meet with the program director in every place you do an elective/sub-I. Let him/her know how much you enjoyed the program, who you worked with and what makes you want to be a resident there. Make sure to get a recommendation letter from the teaching attending and if that attending is unavailable, ask your floor attending.
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