How to Excel on a Sub-Internship

by Lily Mundy, MD, PGY-3
Duke University, Durham, NC

Sub-internships, or visiting clerkships, have become a rite of passage for medical students pursuing a residency in plastic surgery. Succeeding on these rotations can be a daunting task.  Medical students often have limited clinical exposure to plastic surgery prior to the fourth year and are further challenged by traveling to a new city and hospital system for the rotation.

Plastic surgery continues to be one of the most competitive residencies in the Match, and a strong performance on a sub-internship with a resulting letter of recommendation can significantly improve a medical student’s chance at matching in the field1. In a recent survey of plastic surgery program directors, the most important factors contributing to a favorable rank were associated with the sub-internship. Performance on a sub-internship was the most valued subjective factor, followed by interview performance, personality, maturity and leadership potential. The two most valued academic factors were the content and author of letters of recommendation2.   

What factors are you evaluated on during a sub-internship and how do you excel? The American Council of Academic Plastic Surgeons has identified the following attributes to be important, which recommendation letter writers will rank you on: work ethic, conscientiousness, technical ability, self-initiative, communication skills, academic skills, team player, and overall impression3. How do you achieve high rankings on these? Below is some advice to help you be your best self and maximize your chances of having a successful experience on service.

Situational awareness.

A strong medical student is often described as “knowing how to be helpful without being told,” “someone who anticipates what the next step is,” and “a self-starter who does what needs to be done.” The key to becoming someone who is described this way is to develop a sense of situational awareness. Pay attention to what is happening around you; consciously and continuously ask yourself what you can do to contribute to the task at hand. If a dressing is being changed on rounds, anticipate: open supplies, hold up the extremity, raise the bed height, etc. The first time that you see something you are not usually able to predict the next step, but the more you focus on this the better at it you will become. Your team won’t always ask you to help, so don’t wait to be told what to do. Learn to connect tasks together both on the floor and in the operating room. When a resident or attending asks for a suture, you can ask for scissors. When someone asks for irrigation, you ask for suction or a lap sponge. Anticipate the next steps in the operation and be prepared to help or ask the appropriate questions. This demonstrates that you are engaged and are interested in contributing to the team in a meaningful way. 

Be prepared.

Once you achieve baseline technical skills, plastic surgery is all about preparation and planning. A common mantra is poor planning leads to poor results. The program wants to see your ability to prepare, as this reflects your ability to be a successful learner in residency. Read for your cases and for clinic. Know the patient’s history, the indications for surgery, anatomy, and the basic steps of the operation. Your team is not looking for you to be an expert (residency exists for a reason), however this is your opportunity to demonstrate your clinical knowledge, technical skills and work ethic. To this end, be prepared for rounds. Show up early, ensure the dressing bag is well stocked, know your patients, and give informative and concise presentations. Morning rounds is your time to shine as a student and demonstrate that you are an essential member of the team.

Don’t be weird.

Frequent comments in letters of recommendation center around “I won’t find Jennifer annoying when I receive a phone call from her at 3am,” or “I found Matthew to be pleasurable even at the end of a 12-hour case.” Surgery means long hours, middle of the night phone calls, and spending more time with our colleagues than we do with our families. Programs want to match residents that will make these hours seem shorter, not longer. While you should always allow your personality shine through, you want to show that you have the emotional intelligence to read situations. You should demonstrate that you are capable of connecting with others, that you know when to be lighthearted and when to be serious. These skills will not only be important as a sub-intern, they will allow you to be a successful resident, form productive clinical and research relationships with others, and better connect to your future patients. Another important component of this is maintaining a sense of professionalism in all of your interactions. Respect personal boundaries. While residents or attendings may be casual in their interactions with you, be aware of how causal you are in return. These are not your friends; they are your senior colleagues. Learn to navigate the delicate balance of being social in a professional way. Do not make fun of residents, and be mindful of physical interactions. If you are a “close talker” or find yourself putting your hands on friends’ hands or shoulders during conversation, limit these activities in the professional setting.

Don’t complain.

The month is demanding and there are a lot of external and internal stressors. Vent to your fellow medical students, family, and friends. Avoid complaining to individuals more senior to you. While it is always okay to bring up an issue or wrong-doing in a mature and constructive way, complaining about the day-to-day minutia can give others the impression that you are unable to cope with external stressors. Think how you would feel listening to a first-year medical student complaining about the minutia of first year. If you do find yourself wanting to complain all of the time, reflect on this: Your feelings may be a sign that this is the wrong type of training environment for you or possibly the wrong field of practice.  If so, that’s okay – but you should try to determine that before the Match. You have a limited time on service. You want to leave a positive impression and make it easy for others to want to be around you. 

Don’t lie.

Always be truthful. People entrust their lives in physicians. Residents who are found to consistently lie are often terminated. If you do not know a piece of clinical information or did not do something be honest. Tell your team that you will look it up, you will perform the task now, or that you will do a more thorough job next time. Do not think that you will get away with lying.

Play nice in the sandbox.

Do not engage in conflict with your team. This is especially relevant to your interactions with other sub-interns. Demonstrate that you work well with others and can have a team-based attitude.

Know your audience.

While the key people evaluating you are residents and faculty members, you are on a one-month interview with the entire hospital. Successful residents and attendings are capable of having professional and appropriate communication with all members of the team in all circumstances, and you need to demonstrate that as a student you can do the same. We know that the operating room scrub may treat you differently than everyone else in the room, but keep your cool. Demonstrate that this does not rattle you. As an intern, and throughout your career, your patience will be tested in much greater ways, so start practicing your equanimity now.

Be yourself.

In addition to adding to clinical education and being evaluated by the program, a major goal of the sub-internship process should be to determine the training environment that best fits you. Identifying a training program where you can be comfortable and successful while being yourself will be key to success in residency. You will find that other people respond better to your genuine self than to a façade of who you think others want you to be. You will be more at ease and fun to be around, qualities that are valued in a resident. Allow your excitement for the specialty to show through and have fun.

  1. National Resident Matching Program: The Match. Advance Data Tables. Accessed March 2018.
  2. Janis JE, Hatef DA. Resident selection protocols in plastic surgery: a national survey of plastic surgery program directors. Plastic and reconstructive surgery. 2008;122(6):1929-1939; discussion 1940-1921.
  3. American Council of Academic Plastic Surgeons. Plastic Surgery Residency Recommendation Form. Accessed March 2018.

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