Abstract
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.5–7 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)
| Recommended Skill Set | APDIM Survey High Priority Skills | Curricular Milestone | 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 | Transition periods: | 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) | |
| Oral presentations | 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) |
Legend:
PC = Patient Care
MK = Medical Knowledge
P = Professionalism
SBP = Systems-Based Practice
ICS = Interpersonal Skills and Communication
EPA-1: Gather a history and perform a physical examination
EPA-2: Prioritize a differential diagnosis following a clinical encounter
EPA-3: Recommend and interpret common diagnostic and screening tests
EPA-4: Enter and discuss orders/prescriptions
EPA-5: Document a clinical encounter in the patient record
EPA-6: Provide an oral presentation of a clinical encounter
EPA-7: Form clinical questions and retrieve evidence to advance patient care
EPA-8: Give or receive a patient handover to transition care responsibility
EPA-9: Collaborate as a member of an interprofessional team
EPA-10: Recognize a patient requiring urgent or emergent care and initiate evaluation and management
EPA-11: Obtain informed consent for tests and/or procedures
EPA-12: Perform general procedures of a physician
EPA-13: Identify system failures and contribute to a culture of safety and improvement
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.
Acknowledgements
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.
APPENDIX
The CACTI* Group: Authors and Affiliations
Richard L. Alweis, MD
Program Director
Department of Medicine
Reading Hospital
Steven V. Angus, MD
Program Director
Department of Internal Medicine
University of Connecticut School of Medicine
Jonathan S. Appelbaum, MD
Education Director and Core Faculty
Department of Internal Medicine
Florida State University College of Medicine
Paul B. Aronowitz, MD, Ex Officio
Clerkship Director
Department of Internal Medicine
University of California, Davis, School of Medicine
Alexander Carbo, MD
Assistant Professor
Department of Medicine
Harvard Medical School
Beth Israel Deaconess Medical Center
Hospital Medicine Program
Allison Ferris, MD
Assistant Professor of Medicine
Medicine Sub-Internship Director
Department of Internal Medicine Drexel University College of Medicine
Eric Goren, MD
Hospitalist
Department of Medicine
Raymond and Ruth Perelman School of Medicine at the University of Pennsylvania
Laurence C. Hood, MD
Assistant Professor of Medicine
Division of General Internal Medicine
Department of Medicine
University of Florida College of Medicine
Michelle Horn, MD
Assistant Professor; Director, Medical Education
Departments of Internal Medicine and Pediatrics
University of Mississippi Medical Center
Nadia J. Ismail, MD
Clerkship Director
Department of Medicine
Baylor College of Medicine
Ben Taub General Hospital
David F. Jacobson, MD
On-site Clerkship Director
Department of Internal Medicine
California Pacific Medical Center
Mark A. Levine, MD, Committee Vice Chair
Associate Chair for Education and Residency Program Director
Department of Medicine
University of Vermont College of Medicine
Diana B. McNeill, MD, Ex Officio
Assistant Program Director
Department of Internal Medicine
Duke University School of Medicine
Neha Mittal, MD
4th Year Clerkship Director, Assistant Professor
Department of Internal Medicine
Texas Tech University Health Sciences Center
Heather Tarantino, MD
Clerkship Director
Department of Internal Medicine
West Virginia University (Charleston Division)
T. Robert Vu, MD, Committee Chair
Associate Clerkship Director
Department of Medicine
Indiana University School of Medicine
Sean Whelton, MD
Associate Professor of Medicine
Division of Rheumatology
Department of Internal Medicine
Georgetown University School of Medicine
Meenakshy K. Aiyer, MD, Ex Officio
Associate Dean for Academic Affairs
Department of Internal Medicine
University of Illinois College of Medicine at Peoria
Maria L. Cannarozzi, MD
Associate Professor, Clerkship Director
Department of Medicine
University of Central Florida College of Medicine
Saumil M. Chudgar, MD, MSEd
Associate Director, Undergraduate Medical Education
Division of General Internal Medicine
Department of Medicine
Duke University School of Medicine
D. Michael Elnicki, MD
Director, Ambulatory Medicine Clerkship
Division of General Internal Medicine
Department of Medicine
University of Pittsburgh School of Medicine
Susan J. Gallagher, MD
Associate Professor
Department of Medicine
State University of New York at Buffalo School of Medicine and Biomedical Sciences
Heather E. Harrell, MD, Ex Officio
Clerkship Director
Department of Medicine
University of Florida College of Medicine
Dan A. Henry, MD
Clerkship Director
Department of Medicine
University of Connecticut School of Medicine
Gregory C. Kane, MD, Ex Officio
Division of Pulmonary and Critical Care
Interim Chair, Department of Internal Medicine
Thomas Jefferson University Hospital
Chad Stephen Miller, MD
Clerkship Director
Department of Internal Medicine
Tulane University School of Medicine
Marty D. Muntz, MD
Clerkship Director, Associate Professor
Department of Internal Medicine
Medical College of Wisconsin
Cori Salvit, MD
Director of Medical Student Education
Department of Internal Medicine
Memorial Sloan-Kettering Cancer Center
Alwin F. Steinmann, MD
Chief of Academic Medicine
Department of Graduate Medical Education
Exempla St. Joseph Hospital
Emily Stewart, MD
Assistant Program Director
Department of Medicine
Jefferson Medical College of Thomas Jefferson University
Laura Rees Willett, MD
Associate Program Director
Department of Medicine
Rutgers Robert Wood Johnson Medical School
* The CACTI Group is the CDIM-APDIM Committee on Transitions to Internship.
CDIM is the Clerkship Directors in Internal Medicine, while APDIM is the Association of Program
Directors in Internal Medicine.
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