Last updated: Sep 2024

What I Wish I Knew: Sub-Is / Acting Internships (AI)

The AI will be the most amount of responsibility you’ve been given in medical school. The stakes are a bit higher because they are Honors/Pass/Fail and many times you are doing AIs in the field you are applying into. That being said, many medical students enjoy the AI a lot more because you actually feel like a doctor! There is no secret to doing well on AIs, many of the same principles of being a good MS3 are the same as being a good MS4 (care about your patients, have a good attitude, be humble and eager to learn, etc.). Here are a few pieces of advice from graduating MS4s on doing well in AIs:

1. Learn the system: a key difference between the AI and MS3 rotations is that in an AI, you are really trying to advance the patient’s care. Thus, learning to navigate the hospital system (know who to call to expedite procedures, which tasks need to be done in advance to facilitate for easy discharge, how follow up with interdisciplinary team members on requests etc.) can really go a long way. Each hospital system is its own landscape. If you can, it helps to do an elective in that same hospital before your AI. However, this definitely is not required nor always possible, so try to ask other students who’ve done AIs or even rotations at that hospital. Any bit of knowledge can help.

2. Communication is key: communicating with your team, especially senior resident is imperative. It’s always better to overcommunicate than undercommunicate. However, you want to be a bit mindful of how you communicate—don’t bring up every little thing without first taking a moment to think through what you propose to do. E.g. “Hi [senior resident], pt X’s nurse just paged me asking about Y. I took a quick look on update date and I think it’s okay to implement Y, do you agree?” This is a much better response than “Hi [senior resident], nurse asked me about Y, what do I do?”. Of course there are scenarios that are more time-sensitive and you may not have as much time to think, especially in urgent scenarios, in those cases you may need to prioritize speed of communication and totally okay to say “this felt urgent, so I haven’t had time to think through it yet and just wanted to let you know”.

• Another piece around communicating is to make sure you “close the loop”. Write down all the tasks you’re supposed to do, if you’re uncertain what the ask is, okay to speak out loud: “okay so order confirmation for Mr. X, we’ll order him 40 lasix IV to start this AM and page cards to see if we need to restart GDMT before dispo, is that right?” Your resident/senior can jump in if something was incorrect—this is an easy way to safe time and prevent errors!

3. Take ownership of your patient: depending on the AI you are in, you may be “first-call”. This means you are the primary point person for your patient whenever anyone has a question (consultants, nurse, pharmacy, family, social workers, OT/PT/SLP/nutrition). Think proactively—think about what are the steps that are preventing them from getting their surgery, discharging, etc. and try to take steps proactively to mitigate that. Are they still awaiting an MRI? Try calling down to the MRI scheduling to prioritize the patient. Do they need to have their chest tube taken out prior to their transportation arriving? Flag that to your senior and offer to take that out. Did the consult service drop some recs? Pend those orders and let your senior know. This is a lot of what being an intern and you can start doing that on your AI!

4. Ask interns for help: interns can be your best friend on an AI. They are the closest to remembering how new/difficult everything is. Often times, they are not directly evaluating you so it feels a little easier to ask them for help. You can bounce things off of them like “hey, is this the fastest way to do XYZ?” “Can you show me your pre-rounding or task-tracking methods?”

5. Solicit feedback and be honest: ask for feedback early and often and show that you can implement it! Also a huge thing on AIs—and in general—is to always, always be honest. Never lie. This seems like it should go without saying, but sometimes, students feel pressure on AIs (where the stakes feel higher) to try to always present themselves in a positive light or fail to acknowledge mistakes. Please, please, don’t do this. It’s not good for you, the patient or the team. Everyone will make mistakes on AIs. It’s part of learning. Everyone makes mistakes in medicine, period. Your interns/residents/attendings have all made numerous mistakes in their training. What you don’t want is to be seen as the dishonest medical student, because once your team loses trust in you, it can really be hard to gain it back. Totally okay to say “oh, no I forgot to do XYZ, I feel really badly and will make sure it doesn’t happen again” or “oh shoot, I accidentally entered the wrong dosing for XYZ, thank you so much for catching that, I will be sure to be extra careful and double check things going forward”. As the saying from Warren Buffett goes, “It takes 20 years to build a reputation and five minutes to ruin it". This is especially true in the medical field where mistakes can have repercussions for human lives—better to be honest than to hide things under the rug and actually hurt another human being.