Summary

Dr. Animesh, a young doctor-in-making shares his first hand experience of a sub-internship in the USA where he picked up ; 

• the rigmarole of rotation protocols  
• keeping abreast of the latest medical updates  
• importance of staying mentally healthy for a doctor

America, known as the land of opportunities offers an elective for medical undergraduates, especially immigrants which is known as “Advanced Medicine Sub-internship” rotation. This internship is known for its more than usual involvement in patient care.

As a Sub-Intern, one gets to learn all the skills, that a first-year resident executes in his/her term at the hospital, working daily from 8 am to 5 pm on regular days and 8 am to 5 pm on-call days.

The team involves 1 PGY-2 Internal Medicine resident, 2 PGY-1 Internal Medicine Resident, and 2 PGY-1 Resident of a different speciality doing his/her preliminary year in medicine.

The doctor-patient ratio in the U.S. is roughly about 1:10; which is a comfortable one, compared to the rest of the world. This allows for better quality in treating the patient and maintains the progression of knowledge in doctors.

Daily working protocol

8 am: Every resident is at his work station before time and immediately logs into their computers. The hospital network owns a software which is used for documenting a patient’s daily activities- lab reports, manoeuvres performed, vitals, urine output, diet and medications given. After having a look at respective patients and updating handwritten notes, all interns visit patients for follow up rounds  addressing patient concerns.

9 am: Morning documentation is updated, and the progress is tracked. Important changes in the patient’s disease processes are noted and that information is kept ready for the “Attending Physician” (AP) to review.

Between 9-11 am: Morning rounds with the AP starts and the entire team presents their respective patients to the AP. Brief additions are made in the management plan of each patient and then patients are visited for interpersonal connection, observation, and to procure some new information regarding their health.

11 am to 12 pm: Afternoon notes are made, and all the relevant details are added.

12 pm to 1 pm: A quick conference takes place between hospitals. It is mandatory for all the residents to attend and have their lunch during this time. The conference covers all the latest research done and guidelines updated for specific diseases.

1 pm to 3 pm: Patients are seen once again by the residents and their management plans are revised and checked. All the blood workup, radiological tests are tracked and looked upon.

3 pm to 4 pm: Afternoon rounds take place with the AP. But this one in particular is a short one, where minor adjustments are made.

4.30 pm: The residents prepare to leave and put together their personal notes, which they hand over to the on-call residents for the day.

Mental health of a medical professional is of utmost importance

A general rule followed in America is that ‘you never bring your work home’.

The hospitals have frequent Mental Health Seminars for doctors, where they emphasise on turning off the pagers and not receiving any calls from the hospital during off duty hours. The consensus is that, if the doctors treating the patient are not in sound mental health, it directly affects the patient's treatment; and as a whole, patient mortality.

Personal tasks in the hospital

1. Presentations: It was mandatory for all the residents to present one research paper a day. The paper should pertain to any of their patient’s conditions and the talk should approximately be 5 to 10 minutes. This kept the knowledge flowing and updated.
2. Patient Interactions: Each of us were given 3 to 5 patients per day to follow, which were strictly ours. This put doctors out of their comfortable spots and allowed for pure interpersonal connections with the patients where the goal was to build a rapport and acquire as many details of their conditions as was possible.
3. Conference: Mandatory involvement in the afternoon conferences along with an active discussion.
4. Handling Respiratory Distress: “CODE BLUE”. Whenever a patient began to gasp or started coding; the medical alert team was called. This included, Internal Medicine on Call Residents, Pulmonary Medicine residents, Anesthesiology Residents, Cardiac Critical Care residents. The hospital speaker announced about the place where the patient was coding and the team on call. One to two personnels from each department would rush to the room and start resuscitating the patient. Cardio-Pulmonary Resuscitation was started and maintained by a number of people, till there a pulse was detected. Intubation and injecting the patient with Atropine and Epinephrine was done by the Anesthetists. The ventilation was maintained and monitored by the pulmonary care residents.
5. Research Work: It was mandatory for all first- and second-year residents to indulge themselves in research; mostly in the branch they wished to opt for fellowship, so as to stay updated.

Learnings from the experience

The elective offers immense potential to anyone who aspires to enter Internal Medicine. It gives real learning and insight into the workings of the health system in a developed nation. 

The various procedures, conferences, patient interaction skills, critical patients-handling skills, update of knowledge every day made it one of the most challenging yet enthralling electives especially for international students, a different ball game altogether.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.