Are Sub-Internships Beneficial?

I was recently asked to speak to students at my former medical school and give advice on succeeding in the clinical years of medical school and the residency application process. In speaking with them, the subject of sub-internships (sub-I’s) came up and garnered much attention. I am always shocked when people tell me that someone advised them against doing a sub-I in their specialty and/or program of choice. Whether planning to enter surgical or medical specialties, I have heard from multiple students that they have been told that doing a sub-I is a bad plan. They say they are told that they can only hurt their chances. They are advised that if they screw one thing up during the rotation that they will never get into that program. Is this really true? Or is it yet another medical myth that needs to be discounted?

A quick Google search reveals multiple program websites espousing the benefits of doing sub-I’s and several journal articles that describe the role of the sub-I and what they can contribute to a team. There is minimal mention of any negative result from completing a sub-I in your specialty or program of choice. But does completing a sub-I benefit students? I think in order to understand whether a sub-I has value, we have to know what the goal of a sub-I is. When taken literally, the term “sub-internship” implies that the fourth year medical student is acting as an intern—entering orders, writing notes, rounding on patients, and (on certain rotations) participating in procedures. They are intended to be an extension of the intern. They should know about the patients—their history, their labs, their plans. They should be contributing to patient plans. They should be working the hours of a resident. The sub-I is meant to be a flavor of what residency is like, and I would strongly advocate that without it, students cannot truly understand the daily grind that is being a resident. With high attrition rates in certain specialties (like surgery) a major concern and physician dissatisfaction and burnout becoming hot topics, I would be inclined to think that a real-world view of what your job is going to be like in a certain specialty prior to committing to it would be of great value.

Sub-internships also give students the opportunity to spend more time with residents and faculty within their chosen profession. This allows students to determine whether they fit well at a program that, on paper, looks great. It also allows students the opportunity to see whether the residents and faculty at a particular program seem to enjoy their work or are plainly unhappy. Spending time at a program you think you might be interested in offers insight into the daily workings of that particular program—like how the PD interacts with the residents, how the residents interact with staff, and how the residents interact with one another.

A sub-internship is also an incredible opportunity to showcase what you know and what you can do. Say you don’t have the best board score or class rank. If you show up for your sub-I and work your tail off, know about your patients, have some handle on procedures, and demonstrate a willingness to learn, you can easily overcome your deficits on paper. I have witnessed people jump many spots on a rank list because the residents and faculty at a program advocated for their work ethic and fund of knowledge (that their application was not able to adequately convey). In addition, many programs like the idea of a known entity sitting higher on their rank list than someone with similar scores, standing, and letters that they are not familiar with on a personal level. 

The cons of doing a sub-internship? If you don’t show up, don’t have a baseline level of knowledge, or have difficulty getting along with others, then it is not rocket science to think that you might not come out of the rotation with improved chances. But not knowing the answer to one question or taking a little too long to tie a knot is not going to destroy any chance you had of matching into that program in the vast majority of cases. So, my advice and the advice of most of the people I interact with, is to do a sub-internship and get as much as you can out of the experience.