The Internal Medicine Subinternship—Now More Important than Ever
For decades, the internal medicine (IM) subinternship has served as a critical interface between undergraduate and graduate medical education. As such, the vast majority of U.S. medical schools offer this rotation to help students prepare for post-graduate training. Historically an experiential rotation, a formal curriculum with specific learning objectives was eventually developed for this course in 2002. Since then, graduate medical education (GME) has changed significantly with the regulation of duty hours, adoption of competency-based education, and development of training milestones and entrustable professional activities. In response to these and many other changes to residency training and medical practice, in 2010, the Association of Program Directors in Internal Medicine (APDIM) surveyed its members—with input from the Clerkship Directors in Internal Medicine (CDIM) Subinternship Task Force—to determine which core skills program directors expected from new medical school graduates. The results of that survey helped to inform a joint CDIM-APDIM committee’s decision to re-evaluate the goals of the IM subinternship in an effort to enhance the transition from medical school to residency. This joint committee defined the minimum expectations of what constitutes an IM subinternship rotation, proposed recommended skills for IM subinterns, and discussed challenges and future directions for this crucial course.
The internal medicine (IM) subinternship is a longstanding pillar in undergraduate medical education (UME) that arose out of necessity in response to intern shortages during World War II, rather than a perceived educational need. This rotation for senior medical students to serve as acting interns was a logical extension of the “progressive graded responsibility” concept already in place for residency programs, and became widely adopted after the war.1 Since then, medical specialization evolved and changed residency education, which in turn gave rise to subinternships in other specialties.2,3 Although the IM subinternship has remained an integral component of medical education and is offered at most medical schools, it has largely been an experiential rotation without clearly defined curricular goals.2 In 1992, Federman was the first to specifically address the IM subinternship’s role in the continuum of IM education.4 Subsequently, Fagan and colleagues outlined more specific recommendations regarding the IM subinternship structure and experience.3
In 2002, the Clerkship Directors in Internal Medicine (CDIM) Subinternship Task Force published its core curriculum for the IM subinternship.5, 6, 7 This curriculum’s specific objectives were based upon a needs assessment from IM residency program directors, subinternship directors, and interns.5 Since that publication, graduate medical education (GME) and medical practice have changed significantly with the Accreditation Council for Graduate Medical Education (ACGME) regulations on duty hours and supervision; development of competency-based education, training, and evaluation; increased emphasis on transitions of care, patient safety, and quality improvement; and the widespread adoption of electronic health records (EHR). These changes have impacted clinical teaching and learning at the UME level. Duty-hour regulations have resulted in faculty and residents perceiving less time to teach students, reduced continuity of patient care, and decreased volume and variety of patient exposures for students.8, 9, 10, 11, 12, 13 Billing and medico-legal concerns have resulted in many institutions prohibiting students from using EHRs.14
EDUCATIONAL ORGANIZATIONS RESPOND
Recognizing the changes to GME and their effects on UME, in 2010 the Association of Program Directors in Internal Medicine (APDIM) surveyed its members about the IM subinternship. The survey items were developed with input from the CDIM Subinternship Task Force and included skills across several domains reflecting the current CDIM subinternship curriculum6 and primer.15 Program directors ranked the skills, knowledge, and behaviors they believed were most important for new interns to possess. Those results16 prompted a re-examination of the IM subinternship, particularly in the context of internship preparation. In July 2012, the Alliance for Academic Internal Medicine (AAIM) formed the joint CDIM-APDIM Committee on Transitions to Internship (CACTI), whose charge included updating the goals and objectives of the IM subinternship. More recently, the Association of American Medical Colleges (AAMC) has turned its attention to residency preparation with the publication of 13 core entrustable professional activities for entering residency (CEPAER) that define a core set of behaviors and skills expected of all medical school graduates.17 Capitalizing on the timely formation of CACTI and the AAMC’s CEPAER, this paper aims to update the goals and objectives of the IM subinternship, mapping them to specific core EPAs to reflect the many changes to GME, while promoting a standardized language that bridges the transition between UME and GME.
MINIMUM EXPECTATIONS OF WHAT CONSTITUTES AN INTERNAL MEDICINE SUBINTERNSHIP ROTATION
be developmental, consolidating and refining the knowledge and skills acquired during third-year clerkships
insure increased responsibility in the evaluation and management of acutely ill, hospitalized medical patients in directly supervised patient-care settings
promote development of effective interprofessional teamwork and communication skills.
the setting and length of the clinical rotation
level of supervision
duty-hour regulations and clinical workload
care transitions and cross-coverage responsibilities
access to EHRs
opportunity for evidence-based, high value care practice.
The IM subinternship must be an inpatient rotation that gives the subintern primary responsibility for providing care to medical patients. This experience may occur on the general medicine wards, medical intensive care unit (ICU), or a medicine sub-specialty service (e.g., cardiology, oncology, etc.), as long as the subintern is part of a team bearing primary responsibility for the care of its patients. To enable adequate and meaningful clinical exposure as well as optimal contact time with clinician-educators, the duration of an IM subinternship rotation should be a minimum of 4 weeks in length, mirroring the typical length of most residency program rotations.
Direct supervision throughout the rotation is essential, and the design of the medicine inpatient units and the nature of the hospital (e.g., academic or community-based) will determine the specific model. Teams may incorporate senior residents or involve direct supervision only by hospitalists or specialty attendings without any house staff. Ultimately, whichever model is used, an attending physician will have overarching responsibility for the supervised education of the subintern. Direct observation and feedback are the primary means for evaluating the subintern’s clinical performance and his/her ability to integrate feedback into subsequent performance.
While strict duty-hour regulations do not exist for subinterns, it is expected that clinical workload and duty-hour limitations appropriate for resident-led teams be adhered to by the subintern. The number of continuous duty hours for a subintern can mirror that of an intern or that of an upper-level resident, depending on the specific nature of the rotation and team structure and the discretion of the subinternship course director. Whereas ACGME program requirements state that an IM intern must not be responsible for the ongoing care of more than ten patients,18 there are no similar guidelines to inform decisions about the appropriate number of patients for whom a subintern assumes the primary caregiver role; the consensus of the CACTI Group is that providing ongoing care for three to five patients is ideal, with adjustments made based on the level of competence demonstrated by the subintern.
Important care transitions for hospitalized patients include admission, transfer between services, sign-outs between physicians, and discharge from the hospital. These care transitions leave patients especially vulnerable, and subinterns must actively participate in these critically important care transition activities to learn common patient safety principles and develop effective communication skills. In particular, discharge management provides rich opportunities for subinterns to work in multidisciplinary teams and learn to engage community resources during the discharge process. Likewise, subinterns should participate in cross-coverage roles similar to those of interns; this can include night and/or weekend work. The goal is to have subinterns develop skills in acute diagnostic and management strategies, and enhance their ability to recognize sick patients requiring higher levels of care. These cross-cover responsibilities, which may be assessed during the day or on night call depending upon the structure of the rotation, should be deliberately built into the clinical responsibility profile. It may be logistically unfeasible to build night-float roles for subinterns into a predominantly daytime subinternship rotation, so some institutions may need to create a separate required fourth-year night-float experience.
To fully engage as the principal patient caregiver, subinterns must be allowed full access to patients’ medical records and be given the ability to document in these records and to write orders with built-in mechanisms for physician co-signature before orders are implemented by the nursing staff. This level of engagement enables subinterns to demonstrate patient care ownership and provides them with valuable hands-on practice experience.
The IM subinternship provides ideal grounds for practical application of a medical school’s evidence-based medicine curriculum, and this should be an objective of the subinternship with clearly defined opportunities for assessment. The IM subinternship curriculum should also incorporate education on quality and safety measures and understanding of high value care.19
RECOMMENDED SKILLS FOR INTERNAL MEDICINE SUBINTERNS
Recommended Skills for Subinterns with Corresponding IM Milestones and Core EPAs for Entering Residency (CEPAER)
Recommended Skill Set
APDIM Survey High Priority Skills
Example Skill and Corresponding AAMC CEPAER
Recognizing sick vs. non-sick patients
Information management (prioritizing skills)
Acquire accurate and relevant histories from patients in an efficiently customized, prioritized, and hypothesis-driven fashion (PC)
Effectively and efficiently collects relevant historical data (EPA-1)
Perform accurate physical examinations that are appropriately targeted to the patient's complaints and medical conditions. Identify pertinent abnormalities (PC)
Able to perform an appropriately targeted physical exam (EPA-1)
Recognize situations which need urgent or emergent medical care, including life threatening conditions (PC)
Immediately seeks enhanced medical care for deteriorating patients (EPA-10)
Understand the relevant pathophysiology and basic science for common medical conditions (MK)
Able to interpret changes in vital signs, signs and symptoms of potential cardiovascular or respiratory collapse (EPA-10)
Coordinating care with other health care workers
Deliver appropriate, succinct, hypothesis-driven oral presentations (ICS)
Conveys a sense of urgency; asks questions of senior team members and other team members (EPA-6)
Work effectively as a member within the interprofessional team to ensure safe patient care (SBP)
Notifies all team members of changes in patient’s condition; involves ancillary staff in care of patient (EPA-9)
Knowing when to seek assistance
Recognize when to seek additional guidance (PC)
Knows when higher level of care is needed; recognizes when situations are beyond his/her own capabilities (EPA-10)
Recognize when it is necessary to advocate for individual patient needs (P)
Time management skills
Organization, Prioritization, and Time management
Respond promptly and appropriately to clinical responsibilities, including but not limited to calls and pages (P)
Answers phone calls and pages promptly (EPA-9)
Ensure prompt completion of clinical, administrative, and curricular tasks (P)
Maintains organized checklists of daily patient care tasks (EPA-4 and EPA-5)
Carry out timely interactions with colleagues, patients and their designated caregivers (P)
Maintains organized schedule of rounding times, clinic start times, and conferences
Recognize and address personal, psychological, and physical limitations that may affect professional performance (P)
Maintains open channels of communication with peers and supervisors to enable optimal receptiveness to feedback about effective teamwork (EPA-9)
Recognize the scope of his/her abilities and ask for supervision and assistance appropriately (P)
Appreciate the variety of health care provider roles, including, but not limited to, consultants, therapists, nurses, home care workers, pharmacists, and social workers (SBP)
Appropriately enlists timely assistance from team’s social worker to facilitate discharge planning process (EPA-9)
Knowing when to ask for assistance (and from whom)
Knowing when to seek assistance
Recognize when to seek additional guidance (PC)
Immediately call senior resident to come assist if patient clinically deteriorating (EPA-10)
Asks colleague (intern, resident, attending, nurse, etc.) for help with completing an unfamiliar task (e.g., placing an IV, drawing labs, completing discharge paperwork, getting informed consent, etc.) (EPA-9)
Enlists the help of senior resident or attending in cases where patient and/or family becomes upset about their care (EPA-9)
Seeks oversight from a senior resident or attending for discussions about end-of-life, DNR, or withdrawal of care (EPA-9)
Communicating effectively within healthcare teams
Provide legible, accurate, complete and timely written communication that is congruent with medical standards (ICS)
Generates a thorough discharge summary that effectively communicates the hospital course, the current plans, and follow-up for the patient (EPA-8)
Writing discharge/ transfer summaries
Providing a prioritized and organized verbal and written sign-out
Manage and coordinate care and care transitions across multiple delivery systems, including ambulatory, subacute, acute, rehabilitation and skilled nursing (SBP)
Communicates with past and future care providers to insure continuity of care (EPA-8)
Deliver appropriate, succinct, hypothesis-driven oral presentations (ICS)
Delivers accurate and focused bedside presentations (EPA-6)
Requesting a specialty consultation
Request and provide consultative care (PC) Request consultative services in an effective manner (ICS)
Asks meaningful clinical questions that guide the input of consultants (EPA-9)
Weighs consultant recommendations in order to effectively manage patient care
Communicating in a culturally sensitive manner
Actively seek to understand patient differences and views and reflects this in respectful communication and shared decision-making with the patient and the healthcare team (ICS)
Quickly establishes therapeutic relationships with patients and caregivers from all different socioeconomic and cultural backgrounds (EPA-9)
Coordinating care with other health care workers including nurses and triage
Effectively communicate plan of care to all members of the health care team (ICS)
Engages in collaborative communication with all members of the team (EPA-9)
Acts to facilitate collaboration with the team to enhance patient care (EPA-9)
CHALLENGES AND FUTURE DIRECTIONS
The IM subinternship’s brief yet pivotal role highlights some educational challenges of preparing 4th-year students for postgraduate training. Although academically and clinically rigorous, a typical subinternship is only 4 weeks in length and is usually taken early in the academic year to “audition” for residency programs, leaving the remainder of the year vulnerable to potential “decay” in knowledge and skills. These two issues argue strongly for medical schools to require more than one subinternship. Yet, increasing class sizes present logistical challenges to this proposal, both in terms of available training sites and numbers of prepared faculty, potentially decreasing the value of these subinternships.
Likewise, as health care systems move toward adopting EHRs, medical students’ ability to document and write orders are at risk of becoming diminished, which may further lessen the rotation’s educational value.14 The Alliance for Clinical Education has published a statement providing guidance to medical educators on expectations for medical students documenting in EHRs.22
As the economic climate has prompted re-evaluation of the cost and duration of medical education,23,24 IM faculty should strive to offer flexibility and adapt the subinternship curriculum to current and future changes in medical education. While these new guidelines aim for closer alignment of subinternship and residency expectations, we recognize that any curricular reform may limit flexibility, and thus, we have left many suggested requirements adaptable to specific institutions and situations.
Despite these challenges, we must prepare graduating students to transition into GME. While other 4th-year courses, such as capstone courses, can contribute,25 we believe that the subinternship, as defined in these guidelines, provides the most realistic preparation for patient care. We suggest that medical schools critically review their subinternship curriculum and construct “subintern milestones” that align with the AAMC’s published CEPAER and program director expectations as outlined in Table 1. Likewise, the content of each school’s subinternship curriculum and each student’s attainment of competency in each curricular element should be communicated to program directors, perhaps as part of the department chair’s letter.26 This would allow program directors to anticipate experiential gaps and develop appropriate orientation activities for new interns accordingly.
The medicine subinternship is a cornerstone of the final year in medical school. GME has changed in terms of duty-hour regulations, milestones, EPAs, and competency-based education, with increasing emphasis on team work, quality improvement, and patient safety. Thus, the subinternship experience also must evolve to align with the new learning environment. Program director expectations of new interns provided a logical framework for these updated subinternship goals and objectives. Adopting clearly articulated curriculum guidelines across schools may help insure that starting residency, graduates possess the knowledge, skills, and attitudes necessary for success in the next phase of their medical training.
This paper was commissioned by the Councils of both CDIM and APDIM and was reviewed prior to publication.
Contributors: The authors would like to acknowledge the support of the Alliance for Academic Internal Medicine staff members (Ms. Sainabou Jobe, Ms. Consuelo Nelson, Ms. Margaret Breida) and Ms. Amy Chmielewski in conducting this project.
Funding: This project did not receive any external or internal funding.
Prior presentations: This paper has not been presented at any conference.
A full listing of the CACTI Group Membership is available electronically (see Appendix).
Conflict of Interest
The authors declare that they do not have a conflict of interest.
- 1.Ludmerer K. Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care. New York: Oxford University Press; 1999.Google Scholar
- 6.CDIM Subinternship Curriculum and Training Problems. Available from: http://www.im.org/p/cm/ld/fid=373. Accessed 12 Feb 2015.
- 15.Harrell H, Aiyer M, Appel J, Gliatto P, Sweet M. Primer to the Internal Medicine Subinternship. MedEdPORTAL; 2012. Available from: www.mededportal.org/publication/9277. Accessed 12 Feb 2015.
- 17.Core Entrustable Professional Activities for Entering Residency. Available from: www.mededportal.org/icollaborative/resource/887. Accessed 12 Feb 2015.
- 18.ACGME Program Requirements for Graduate Medical Education in Internal Medicine. Available from: https://www.acgme.org/acgmeweb/Portals/0/PFAssets/2013-PR-FAQ-PIF/140_internal_medicine_07012013.pdf. Accessed 12 Feb 2015.
- 21.The Internal Medicine Milestone Project: A Joint Initiative of the Accreditation Council for Graduate Medical Education and the American Board of Internal Medicine. Available from: http://acgme.org/acgmeweb/Portals/0/PDFs/Milestones/InternalMedicineMilestones.pdf. Accessed 12 Feb 2015.
- 22.Hammoud MM, Dalymple JL, Christner JG, et al. Medical student documentation in electronic health records: a collaborative statement from the Alliance for Clinical Education. Teach Learn Med. 2012;24(3):257–66.Google Scholar
- 23.Dzau VJ, Cho A, ElLaissi W, et al. Transforming academic health centers for an uncertain future. N Engl J Med. 2013;369:991–993.Google Scholar
- 24.Abramson SB, Jacob D, Rosenfeld M, et al. A 3-Year M.D.—accelerating careers, diminishing debt. N Engl J Med. 2013;369(12):1085–1087.Google Scholar
- 25.Teo AR, Harleman E, O’Sullivan PS, Maa J. The key role of a transition course in preparing medical students for internship. Acad Med. 2011;86:860–5.Google Scholar
- 26.Lang VJ, Aboff BM, Bordley DR, et al. Guidelines for writing department of medicine summary letters. Am J Med. 2013;126(5):458–63.Google Scholar