“The Environment Fostered True Growth”: Harnessing Coaching on an Innovative Medicine Sub-internship

Abstract

Background

Medicine sub-internships aim to prepare students for residency. However, the traditional sub-internship structure, with multiple learners at varied levels, poses obstacles to providing the clinical exposure, learning environment, and direct observation and feedback necessary to develop essential skills.

Aim

Investigate the educational experience of learners on a coaching-centered sub-internship (CCSI) on a resident uncovered ward service.

Setting and Participants

From 2017 to 2022, 73 sub-interns and 39 hospitalists participated in the rotation at a community-based university-affiliated urban hospital.

Program Description

Sub-interns rotated on a CCSI with teams comprised of one attending, one physician assistant, and one student. Students cared for patients across the continuum of hospitalization with frequent coaching by trained attendings. Students engaged in workshops targeting clinical skills essential for internship.

Program Evaluation

Students (n = 67/73, 91.8% response rate) rated the quality of the course significantly higher on the CCSI than the traditional sub-internship rotation (mean [SD]) 4.87/5 [0.49] vs. 4.63/5 [0.61]; p < 0.001. Students and faculty found the CCSI fostered coaching, autonomy, accurate assessments, professional development, growth mindset, and readiness for internship.

Discussion

Our model demonstrates that a CCSI can cultivate the skills and mindset to prepare students for internship. This coaching model can benefit students in other settings.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11606-024-08928-y.

INTRODUCTION

Internal medicine sub-internships aim to prepare students for residency by asking a senior medical student to assume many responsibilities of an intern. The traditional structure of medicine sub-internships have sub-interns integrated into large teaching teams. However, with multiple team members responsible for patients, sub-interns may not experience the full responsibility of patient care, as interns and residents may take over tasks to expedite patient care. Opportunities for high-yield learning, including independently assessing new admissions, are often distributed amongst many learners. Furthermore, the number of learners limits the time and attention available for attendings to directly observe the sub-intern, generate accurate assessments, and provide coaching and feedback on clinical skills.

As an alternative to the traditional teaching team, on resident uncovered ward services (RUWS), medical students work with an attending physician without interns or residents. An Alliance for Academic Internal Medicine (AAIM) national survey of clerkship directors found that nearly half place students on RUWS, with the vast majority being sub-interns.¹ Despite this, the literature is sparce in describing existing curricula and identifying best practices to provide optimal experiences for sub-interns on RUWS rotations.

We designed a sub-internship experience on a RUWS which harnesses coaching to address the limitations of the sub-intern experience in a traditional team structure.² We used the theories of growth mindset and deliberate practice to guide development of the rotation.^3,4 In a growth mindset, abilities can be developed with effort, whereas in a fixed mindset, aptitude is static.³ Thus, people with a fixed mindset tend to avoid challenges and feedback due to fear of criticism, whereas those with a growth mindset embrace them as a path towards mastery.³ Coaching can foster a growth mindset, since its hallmarks include mutual engagement in reflecting, discussing vulnerabilities, and using failure as a catalyst for development.⁵ Coaching is central to deliberate practice, the iterative process of setting goals, performing, and receiving feedback, to achieve expertise.⁴ Here we describe a sub-internship curriculum which combines a clinical skills curriculum with a coaching model, capitalizing on the one-to-one attending-to-learner ratio which allows time for direct observation and collaborative feedback, to prepare students for residency.

SETTING AND PARTICIPANTS

Fourth year medical students rotated on an inpatient medicine sub-internship at a community-based university-affiliated urban hospital. Attending physicians were academic hospitalist faculty, most of whom also attend on the traditional ward service at the tertiary care center.

PROGRAM DESCRIPTION

Rotation Structure

This 4-week sub-internship took place on a general medicine service comprised of one hospitalist attending, one physician assistant (PA), and one sub-intern, caring for up to 15 patients. Sub-interns worked with two attendings who alternated weeks. In comparison, the traditional ward service team at the affiliated university hospital was typically comprised of a sub-intern, four housestaff, two clerkship students, and one hospitalist attending who rotated every 2 weeks.

Sub-interns carried three to five patients. They were responsible for all aspects of patient care including presentations on rounds, order entry, communication with consultants, allied health professionals, and outpatient providers, patient counseling, clinical documentation, discharge planning, and sign-out.

The PA had first call responsibilities for patients not covered by sub-interns and acted as second call on the sub-intern’s patients. The PA provided students with logistical support for executing care plans. They cosigned sub-intern orders when the attending was unavailable and cross-covered the sub-intern’s patients during student conferences or after sign-out.

The hospitalist attending supervised all patient care, completed advanced patient care tasks when not appropriate for the sub-intern or PA, wrote daily progress notes, addended discharge summaries, and cosigned sub-intern orders. Attendings directly observed students during bedside rounds, interdisciplinary rounds, procedures, goals of care conversations, and sign-out.

Growth Mindset and Coaching

Attending physicians were selected to attend on the rotation based on their desire to refine educator skills and serve as sub-intern coaches. Like at many academic hospitalist groups, time to attend on the traditional ward service was limited; thus, this rotation was an attractive opportunity to work with learners.⁶ Most faculty had previously completed the Stanford Faculty Development Clinical Teaching Program or similar training in clinical teaching skills.⁷ Many faculty engaged in a longitudinal peer observation of teaching program (Appendix Table 1). Additionally, course directors delivered workshops for faculty and PAs on feedback, growth mindset, and leading educational and efficient rounds.³ Orientation introduced faculty and students to Dweck’s growth mindset as the cornerstone of the rotation.³ The course director shared expectations for students to make mistakes while taking on new challenges. Attendings were introduced as coaches, and students were primed to receive frequent real-time feedback. Attendings and students met during orientation to set specific, measurable, achievable, relevant, and time-bound (SMART) goals.⁸ Attendings had ample opportunity to directly observe and provide feedback within the clinical workflow. Students and attendings met weekly to review student self-reflection on their progress towards achieving their goals and set new goals for the following week, guided by a collaborative feedback form (Appendix Table 2), which also was a learner sign-out for the oncoming service attending. In comparison, on the traditional ward service, students met with their service attendings for mid-course feedback without a structured standardized format.

Clinical Skills Curriculum

Sub-interns participated in a biweekly workshop-based clinical skills curriculum led by sub-internship faculty which targeted skills required for intern year. Curriculum development was informed by a national survey of internal medicine residents and the AAIM Sub-Internship Curriculum and included sessions on admissions, discharge preparation, calling consults, sign-out, time management, and resiliency training (Appendix Table 3).^9,10 Attendings gave feedback and coached students on these skills within the context of daily clinical care.

Student Grades and Assessments

Both the coaching-centered sub-internship (CCSI) and traditional rotation were pass-fail. Attendings completed the institutional sub-internship student evaluation which included both quantitative and qualitative measures of students’ clinical skills, medical knowledge, and professionalism.

PROGRAM EVALUATION

Program evaluation included surveys of both students and faculty. Students completed the institutional course evaluation which consisted of quantitative (Likert scale) and qualitative questions. Quantitative data was compared, using the Wilcoxon signed-rank test, between the CCSI and traditional sub-internship rotation at the institution’s academic center. Qualitative data included student responses to three open-ended questions which explored the learning environment and aspects of the course which fostered or hindered learning. A pilot group of students who participated in the rotation in 2017–2018 completed a post-course survey used to optimize it. Faculty who remained at the institution at the time of publication were surveyed to “compare your experience working with a sub-intern when attending on the CCSI versus attending on a traditional ward service with a sub-intern on it.” Authors (SK and AT) performed a thematic analysis of qualitative data by independently coding responses then meeting to reconcile codes and identify themes and representative quotes. Approval from the Weill Cornell Institutional Review Board was obtained.

Results

Over 6 years (2017–2022), 73 students and 39 attendings participated in the CCSI. In pilot data (n = 15/15, 100% response rate), students noted high scores for perceived autonomy (mean [SD]) 4.87/5 [0.52], coaching and mentorship 4.93/5 [0.26], and observation and feedback 5.00/5 [0.00]. Retrospective pre- vs. post-rotation confidence in starting internship (Likert 1–5) was significantly improved from a mean 2.20/5 to 4.30/5 (p < 0.001). Students reported completing an average of 13 new admissions during the rotation.

Quantitative data from the institutional course evaluation was compared between students who rotated on the CCSI (n = 67/73, 91.8% response rate) to students who rotated on the traditional sub-internship (n = 196/238, 82.4% response rate). Students rated the overall quality of the course significantly higher on the CCSI than the traditional rotation (mean [SD]) 4.87/5 [0.49] vs. 4.63/5 [0.61]; p < 0.001. Students similarly reported significantly higher supervision in patient care 4.78/5 [0.55] vs. 4.60/5 [0.66]; p = 0.03, observation of clinical skills 4.58/5 [0.61] vs. 4.19/5 [0.97]; p = 0.006, amount of informal feedback 4.67/5 [0.61] vs. 4.37/5 [0.85]; p = 0.01, and quality of formal feedback 4.82/5 [0.39] vs. 4.58/5 [0.73]; p = 0.03 on the CCSI.

Qualitative analysis of student (n = 67/73, 91.8% response rate) and faculty (n = 14/33, 42% response rate) free responses identified strengths and challenges of the CCSI (Table 1). Strengths identified by students and faculty included coaching, supported autonomy, improved assessments, role modeling and professional development, fostering a growth mindset, and improved readiness for internship. Challenges included didactics conflicting with clinical care, loss of near peer learning and support, difficulty in supporting struggling learners, and the need for adequate PA support.

Table 1.

Student and Faculty Perspectives on a Novel Coaching-Centered Sub-Internship Rotation

Major domains and themes	Representative quotes
Strengths of the rotation
The 1:1 team structure fostered coaching	“Each attending directly observed each sub- intern’s work and could provide the attention needed for growth and mentorship…It helped me fall in love with medicine all over again.” -Student 41 “Working one on one with a SubI gives you a much more meaningful opportunity to establish a coaching relationship and help the student improve through repeated coaching and feedback.” -Faculty 8
Supported autonomy in patient care fostered skills development	“This was truly a formative experience for me—I got to be first call for 5–6 patients and felt like I had enough support to do so and gradually work up to that autonomy.” -Student 9 “I think students on the [CCSI*] are pushed and challenged in a supportive environment that is ideal for the sub-I experience. As an educator, it is an incredible opportunity to work longitudinally with a student and have enough bandwidth to truly focus on skill development.” -Faculty 12
Ample opportunities for direct observation allowed attendings to generate more accurate assessments and generate stronger letters of recommendation	“On [the CCSI*], there is much more contact with the MS4 and therefore I am able to more fully evaluate their knowledge base, their clinical acumen and their communication skills.” -Faculty 5 “I am able to write them more personalized and thoughtful/meaningful letters of recommendation because of the increased face time.” -Faculty 7
Students and attendings felt the rotation fostered role modeling and professional development	“Working closely with an attending gave me a better idea of what I’m working towards, and I was lucky enough to rotate with two attendings who really embodied the type of doctor I hope to be one day.” -Student 28 “It gives you a better sense of the efforts of the student and also gives you a better idea of your effectiveness as an educator.” -Faculty 11
The environment fostered a growth mindset	“[The Rotation] built a culture of ‘growth-mindedness’ where mistakes were seen as growth opportunities rather than times to feel bad and punished.” -Student 1 “Incredibly well-designed. The environment fostered true growth.” -Student 61
Clinical skills training enhanced readiness for internship	“I think didactics that focused on foundational, practical issues—frameworks for approaching admissions, calling consults, etc.—really helped bring me up to speed during the first week of the sub-I.” -Student 51 “I think their clinical skills and readiness for internship are accelerated compared to someone doing a subi [on a traditional team structure].” -Faculty 7
Challenges posed by the rotation
Didactics can conflict with patient care duties	“It was hard to focus on lectures. Even when signed out of [chat], we were constantly getting messages.” -Student 4
Students may miss out on learning opportunities from near-peers (residents)	“I felt I would have learned more by being part of a team and being able to talk through ‘stupid’ questions with the residents to form a gestalt of clinical reasoning for a variety of problems.” -Student 22
Struggling learners may need more support	“However, the [CCSI*] only works when students are ready to be working without a senior resident, otherwise it ends up being much more work for the attending to sign orders that are often incorrect and need tweaking.” -Faculty 10
PA† support is essential for learner supervision and support	“On days where there is no PA†, it is more challenging to work with the sub-Is and I think things get missed more easily.” -Faculty 6

Major domains, themes, and representative quotes of student (N = 67) responses to the following prompts: “Describe anything during the course that you believed fostered an exemplary learning environment of professionalism and mutual respect that should be used in other courses,” “Please comment on aspects of the course that had a positive impact on your learning,” and “Please comment on aspects of the course that had a negative impact on your learning” as well as attending (N = 14) responses to the question “How would you compare your experience working with a sub-intern when attending on [this rotation] versus attending on a [traditional team structure] with a sub-intern on it? Please consider the impact on the student and your own professional development or fulfillment as an educator.” All quotes are followed by unique numerical identifiers which were given to each participant

^*CCSI, coaching-centered sub-internship

^†PA, physician assistant

DISCUSSION

Students who completed the CCSI reported high satisfaction with the rotation, significantly improved perceived readiness to start internship, and meaningful mentoring and coaching from their attendings. Students assumed a high level of patient care responsibility, attendings noted improved assessments of students without intervening residents, and both parties reported rapid growth in students’ clinical skills. The CCSI was rated superior to the traditional sub-internship in multiple domains including observation of clinical skills, supervision in patient care, quantity of informal feedback, quality of formal feedback, and overall course quality. These findings support our belief that a coaching-centered sub-internship on a RUWS can overcome challenges experienced on a traditional sub-internship. Our rotation, in which the attending role is centered around being a coach to a sub-intern within the clinical care setting, is novel in the literature. Additionally, our innovation illustrates what a successful sub-internship curriculum on a RUWS may look like, which is underexplored.

Based on this data and our lessons learned, success of the rotation relied on four core tenets, which we highlight as best practices for developing a CCSI: (1) create a learning environment prioritizing growth mindset, (2) use high-quality coaching to drive growth, (3) target rapid clinical skills development, and (4) provide supported autonomy (Fig. 1).

Figure 1.

Best practices for implementing a coaching-centered sub-internship rotation. SMART, specific, measurable, achievable, relevant, time-bound.

A learning environment emphasizing growth mindset lays the foundation for a rich and productive coaching relationship. Priming students and attendings to normalize mistakes cultivates the psychological safety necessary for students to share vulnerabilities. Attending coaches can then guide and nurture student self-reflection, goal setting, and development of action plans to advance skills. In addition to frequent observation and real-time feedback, the use of structured tools, such as our collaborative feedback form, encourages students to self-assess their performance and prioritize areas for development. As coaches and students iteratively engage in deliberate practice, accurate assessment of student’s abilities enables a rapid increase in student autonomy to meet their learning edge. As one student described, “even though I was given more responsibility than I’d ever had in medical school, I never felt unsafe…It was like riding a bicycle with invisible training wheels that I only discovered were there when I faltered a bit.” Selection of faculty attendings who are outstanding clinical coaches is requisite to a successful CCSI, and ongoing faculty development in best practices of creating a safe learning environment and a collaborative coaching relationship is incredibly valuable.

Our innovation was limited by taking place at a single site. The CCSI was compared to the traditional sub-internship at our institution, but both sites, patient population, and rotation structure were unique. Cross-over was not possible since students completed only one sub-internship. Most of the program evaluation regarding student clinical performance was self-reported and did not include patient experience metrics, quality of care metrics, or validated assessments of clinical skills. Access to faculty development programs may be variable at other institutions and may affect local outcomes.

Future studies could examine whether the CCSI fosters the development of master adaptive learners by studying the frequency in which students engage in deliberate practice and their mindset using validated growth mindset tools.¹¹ Direct comparison of clinical skills, residency experience, and performance of students completing the CCSI versus those on a traditional sub-internship service may also be undertaken. Exploration of attending professional satisfaction and improvement of educator skills when attending on an CCSI compared to the traditional ward service would be valuable.

Our experience demonstrates that a CCSI can foster the skills and mindset to prepare students for internship. Through harnessing an environment fostering growth, clinical coaching, supported autonomy, and clinical skills development, a CCSI creates self-reflective and motivated learners. Sub-internship directors can and should think outside of the traditional team structure when developing sub-internship rotations.

Supplementary Information

Below is the link to the electronic supplementary material.

Data Availability

The datasets generated during and/or analyzed during the current study are not publicly available but are available from the corresponding author on reasonable request.

Declarations:

Conflict of Interest:

The authors have no conflicts of interest to disclose.