What is a sub-internship?

Sub-internships (sub-Is), audition rotations, and acting internships (AIs) are common names for the same thing: a required clinical rotation completed during your last stretch of medical school. Though difficult, the seasoned medical student is expected to function at an intern level under the supervision of senior residents and attending physicians.

Depending on your desired specialty, you will complete either a medical or surgical sub-I. The hours and clinical cases are demanding, but this rotation also provides a unique educational experience with greater responsibilities that will provide a taste of life as a resident, as well as a strong letter of recommendation if you play your cards right. 

Most U.S.-based medical students complete their sub-Is at their local institution, though it is not uncommon to audition at other academic institutions where they want to apply for residency. Regardless of where you complete it, your audition rotation grants you a chance to demonstrate your interest to residency directors.

Here are some tips to ace your sub-I, arguably the most important rotation of your medical school career.

Five Tips for Sub-Internship Success

1. Start out on the right foot

To start, maintain professionalism during your interactions. Whether it’s talking with patients, families, team members, or faculty, remember to be respectful and keep patient confidentiality in mind. Not only do you represent yourself on an audition rotation. but also your medical school and fellow classmates.

Display professionalism by arriving at your rotation prepared and on time. Adhere to rules and standards set by your team or institution including work hours, deadlines, and dress codes. Be aware of your own shortcomings and biases, and be willing to take feedback or criticism with humility and grace.

In 21st-century medicine, your patients and fellow staff members expect a certain degree of polish from medical providers. It’s easy to spot any lack of professionalism. Think back to your medical school interviews and how you were on your best behavior. Your sub-I is essentially a one-month-long interview! Faculty and residents evaluating you will notice your patient interactions. If you treat patients or families poorly, it will reflect poorly on you and your home institution, so don’t ruin it for yourself or the next rotating student.

2. A little preparation goes a long way

Come to work prepared. Arrive a few minutes early with a plan for the day. Once you have built a routine, this will get easier. For instance, arrive at the team room, print the patient handoffs, chart review, and then receive a sign-out from the night team. It’s often useful to read up on the patients under your care in case the attending has a question. For example, if your sub-I is in medicine, and one of your patients has a kidney stone, read up on it before rounds. Learn the common calculations, renal pathologies, and management. In doing so, you will be prepared and impress your attending and teach your team. Similarly, for my budding surgical colleagues, if asked to tie a suture, do not hesitate to get your hands dirty. 

By the time your sub-internship begins, you will have a basic fund of knowledge regarding clinical medicine. Use your time on the audition to solidify this knowledge and expand it further. Work not only to understand the basics of clinical medicine, but also to comprehend why certain diagnostic or treatment modalities are utilized. Take the time to integrate evidence-based medicine into your management decision to impress your team.

3. Be authentic

Your goal during your sub-I is to learn as much as you can while taking on increased responsibilities. Show enthusiasm in helping the team, and the stellar letter and positive evaluations will come naturally by the end of the month. Throughout my experience as a rotating sub-I and as faculty supervising sub-interns, I recognize several traits and behaviors that help students stand out.

Just as you did during your core clinical rotations, you should continue to convey your enthusiasm for learning medicine during your sub-internship rotation. Your overall attitude should be one that prioritizes patient care, and you should demonstrate your commitment to your medical training by approaching work with a positive mindset. 

Program directors often express that a lack of authenticity can negatively affect an applicant because there is uncertainty as to which type of resident they would end up working with. In general, it’s easy to identify if someone is not being authentic, especially over the course of a month-long rotation. Just remember, you don’t want to be stuck in a program for years where you can’t just be yourself.  

4. Learn the practical side of inpatient work

As a sub-intern, you are a veteran with experience working in the hospital setting. Instead of learning where the cafeteria is, you can instead learn about the ins and outs of the practicalities of patient care, as well as serving the primary care role for the patient. Learn how a hospital functions, who to call to follow up on specific tests or studies, where key supplies for bedside procedures are kept, and how to navigate multidisciplinary care with poise and good communication.

These skills may not be directly medically related, but they are just as important to master in order to properly care for your patients. Updating families and gathering additional information from families, calling consults and providing pertinent details, cross-covering for patients you may not be as familiar with, arranging medications and follow-ups for discharging patients, and working as part of a team are just some examples of practices that you will familiarize yourself with on your sub-internship rotation. Do this, and you’re guaranteed to impress your residents and attendings. 

5. Teach!

As a sub-intern, you have the opportunity to play an active role in teaching medical students on your team. In addition, you should seek opportunities to teach your entire team about medical topics relevant to patients. Make sure to check with your team for a time to do a brief, five-minute chalk talk.

The sub-internship is also a great time to start forming habits you would like to have as a resident. These rotations are an excellent time to start learning your teaching style. Teach medical students on your team and update residents with the latest clinical recommendations. You can even ask to write a case report if you happen to come across a zebra (a rare and interesting medical case)!

Finally, remember your role. You are a sub-I, and you will do better as well as enjoy your rotation more if you embrace your role as an active member of the team. As a third-year core medical student, most follow the herd while hoping to learn bits and pieces from watching. However, sub-interns have the chance to learn from more first-hand experience, similar to interns, by taking direct ownership of patients. Make sure to check with your supervising residents often, but take these opportunities to practice acting as an intern. Be an active participant in patient care. Your team will be happy for the helping hand and will hopefully be eager to train you. Remaining enthusiastic and integrated with the service will really help you shine.

Bonus tip: Shift your perspective

Try on the shoes of a program director, think about what kind of resident are you looking for? Most directors I’ve spoken with are not looking for someone who only focuses on work. Instead, they are after a colleague. A colleague is dependable and approachable, who is smart and hardworking but is also receptive to feedback. This is someone they know their current residents can work well with.

Aside from grades, test scores, and recommendation letters, program directors in most specialties mention that there is also significant weight given to team chemistry and fit. Programs are looking for potential residents that will be well-rounded colleagues. A sub-internship or audition rotation provides an opportunity to show other residents and faculty that you could be a great boon to the program.

Remember that a good fit goes both ways. Your sub-I is a chance for you to see if the program is a good fit for you. How is the resident-faculty relationship, how involved is the patient care, and how is the work-life balance and residency wellness? These are all questions you can ask and things you can experience firsthand during your sub-I to determine if, ultimately, they are people you would like to work with.  

Further Reading

• How to Get the Most Out of Your Sub-Internship
• How the Residency Match Algorithm Works
• Residency Interview Questions: What to Ask and How to Prepare
• Tips to Succeed in Your Final Year of Medical School