Inpatient Rotation for Sub-Interns

Welcome to the Family Medicine Inpatient Sub-Intern rotation! This rotation provides a great opportunity to see disease processes and illnesses from a different perspective than our usual one in clinic. Not only will you get to see the natural progression of common illnesses, but you will also have the opportunity to talk and think about how we can try to limit or prevent hospitalizations for our patients in their future. Just as importantly, this rotation will help give you a taste of functioning “as an intern,” and we will try our best to support any specific educational objectives you may have.

We’ve created this page to help transition you onto our teams as quickly as possible.  Info like this is always a work in progress, and is only meant to be helpful.  We realize that roles for students can vary a lot from rotation to rotation, and we’re trying to give you an idea of what we expect on this rotation. Please let us know if there is any way we can improve your experience, or the experience of future students.

We look forward to working with you!

Kali Graham, MD

Director of the Family Medicine Inpatient Service

I. “Intern-like” Experience

The goal for an inpatient sub-internship should be for a sub-intern to ease into the role of an intern, and that means starting to take a more active role in the care of inpatients with more responsibility. More concretely, sub-interns should able to carry 3-4 patients, serving as the functional intern for those patients. Usually the upper-level resident will co-follow the sub-i’s patients, answering questions and helping along the way, but sometimes the interns will help as well.

II. Work Hours, Days Off, Call

Our service has two teams which alternate daytime call, while we share the overnight admissions. Overnight signout begins every day at 7am, and you will usually get about 15 mins after morning report to finish pre-rounding, so come in the morning at the appropriate time to do all your pre-rounding.  Being efficient will help.  The work day goes to 5pm on weekdays, you don't need to stay with the late intern.

The sub-intern schedule is modeled after the current schedule of our interns.  We expect you to abide by the same duty hours that we use for our interns, which translate to working about 60 hours a week- 6 days with one day off. Duty hour rules you will need to abide by include no more than 80 hours in a week and at least 10 hours off between shifts.

Weekends: You will work on average one weekend day per week, and have one full weekend off during the month. Please refer to the Sub-Internship Schedule. On the weekend you can leave when you are done with your work, you don't need to stay late.

III. Schedule Requests, Extra Days Off

Additional days off that sub-interns need, or specific requests for their schedule should be discussed with the resident on the team first, then the attending. 

IV. Daily Progress Notes

 Sub-interns should write daily progress notes for the medical chart. Unfortunately, student notes can’t be used for billing, which complicates things a little. Our service handles this by having the student write a complete note and forwarding the note to the senior resident to review. The senior resident edits the note and cosigns it, and then sends it to the attending to sign. 

Other Note Writing Tips 

• Do not cut and paste the assessment and plan section.  People can always look at your note for the day before if they want to read that again
• Don't cut and paste things like radiology reads into your note- briefly summarize the radiology read in your own words.
• On morning rounds, you should have a thought out, prioritized assessment and plan for your patients.
• Sub-intern progress notes tend to be too short in the “assessment and plan” sections. Include all problems, including hypertension, blood sugar issues, etc. Explain your thought process as well in the note.
• Include disposition in daily assessment and plan for patients. Always think about the question, “What’s keeping this patient in the hospital?”
• All orders from med students and PA students need to be co-signed.

V.  H&Ps

There is a written template for History and Physicals here. Please use this while you take a patient's history to make sure your process is complete. Documentation for Powerchart will be done by the resident or PA, but you will be required to present to the attending. 

V. DC Summaries

For discharge summaries, we recommend that you type out a dc summary and give it to the attending and upper level resident for review and feedback. Documentation for Powerchart will be done by the resident or PA.

VII. Shared Information

PBWorks Site

This is the pbworks site!  There's a lot of info here, and maybe you'll have more ideas on things that we should add.  Be sure to check out the articles page for some hand-picked articles that are important.

Team List

Our team patient list is kept on powerchart CACHE. Our residents can show you how to set up the team lists when you start. Please keep your patient's information updated daily as the Night Float team uses this to cross cover.

VII. Inpatient Teaching Schedule

Please refer to the Inpatient Educational Schedule

VIII. Basic Expectations for Our Teams

• your expectations are similar to those of our interns, so please refer to this page

Specific Expectations for Sub-Interns

• Sub-interns should be completely on top of the details about their patients. They should know the trends of the labs and the plan of care.
• Sub-interns can’t write orders without an electronic co-signature, and can’t give verbal orders.
• On rounds, know the amount of prn medications (ativan, morphine, etc.) your patients received in the last 24 hours (look in the electronic MAR).
• Be able to competently carry 3-4 patients.
• Be especially aware of these issues: amount of IV fluids a patient is receiving and why, whether the patient’s foley can come out, if the patient is receiving DVT prophylaxis, if they need to be on telemetry, what the patient’s code status is, and if there have been two blood sugar readings greater than 180 in the last 24 hours. 
• Help keep the handoff list up to date on your patients (see above). For example: take off lasts week’s “follow U/S results.” 
• Try to write most of the orders on your own patients- this helps you know what’s going on.
• Before going home, sign out your patients to the resident.
• Interim summaries should be done on selected patients (the resident can tell you which ones) before transferring off the ward service.
• Try to help “tuck in” your patients as much as possible before leaving the hospital- including making sure any needed am lab orders are written for, communication has happened with family members if needed, and prn orders are written for things that can be anticipated.

Additional Miscellaneous Tips

• Get social work, speech therapy, PT/OT involved early.  
• Order home O₂ the day before discharge if you can anticipate that it will be needed.
• Get appointments and medications ready on Friday for anticipated weekend discharges. 
• When pre-rounding, talk to nurses about 24 hour events, concerns, etc., and keep them in the loop on the plan.

06/2023