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.5–7 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.8–13 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

Building on earlier work and the previously published CDIM subinternship curriculum,3,5–7 the new subinternship curriculum should:

  • be competency-based

  • 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.

To achieve these goals, the subinternship must contain rigorous expectations that define:

  • 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

Previous work showed that students from different schools do not enter internship with a ‘standard’ set of skills and that gaps exist between the skills new interns can perform and what is expected of them by program directors.20 The IM subinternship is a well-suited rotation that can address many of the core skills that IM program directors would like their new interns to possess. Results from the 2010 survey of APDIM members provide the most recent core skills program directors expect from new medical school graduates. There was high uniformity among program directors’ responses to this survey, which served as the starting point for the recommended set of skills that all students completing an IM subinternship should possess. The survey responses broadly defined four major skill sets: patient evaluation skills (e.g., recognizing sick patients), time management skills, knowing when to ask for assistance, and communicating effectively within healthcare teams.16 Each of these broad skills and the associated items from the APDIM questionnaire can be linked to the published IM milestones21, most of the ACGME clinical competencies, and the AAMC’s core EPAs for entering residency (CEPAER) (see Table 1). Additionally, example behaviors or skills that would allow the subintern to demonstrate achievement of competence in each milestone are included to help operationalize the milestones. Many of these behaviors could be developed through caring for patients as a subintern, while others could potentially be accomplished through selective use of the training problems contained within the CDIM subinternship curriculum, which include common inpatient scenarios and cross-coverage situations. Using the IM milestones as a framework for competencies in the medicine subinternship facilitates bridging of the educational continuum from UME to GME and establishes greater uniformity in the education and evaluation of students.

Table 1. Recommended Skills for Subinterns with Corresponding IM Milestones and Core EPAs for Entering Residency (CEPAER)
Full size table

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.

CONCLUSION

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.