key: cord-0771912-tbtpn3tn
authors: Giantini-Larsen, Alexandra M.; Norman, Sofya; Pannullo, Susan C.
title: Interns Without Subinternships
date: 2021-11-24
journal: J Surg Educ
DOI: 10.1016/j.jsurg.2021.10.017
sha: 02fafba11dc953ba197d69020910d691e5192244
doc_id: 771912
cord_uid: tbtpn3tn

Surgical interns who have completed medical school in the era of Covid-19 will not have the same experience gained through the traditional multi-month fourth-year surgical subinternships. During subinternships, medical students learn relevant anatomic and radiographic features of surgical pathologies, hone technical skills, and gain exposure to surgical consults and procedures. This lack of intensive exposure will have this cohort starting at a lower comfort and knowledge level compared to years prior. Residency programs, especially subspeciality programs, should review and utilize national resources to facilitate the transition to intern year, such as the American College of Surgeons Entering Resident Readiness Assessment and American College of Surgeons/ Association of Program Directors in Surgery/Association for Surgical Education Resident Prep Curriculum. We recommend the use of a specialty-tailored intern boot-camp and longitudinal curriculum that focuses on learning procedural skills and surgical conditions, anatomy, pathology, clinical examination, radiographic findings, surgical approach, and postoperative complications. These steps will help address knowledge gaps and promote intern readiness in this cohort of individuals.

Surgical interns who have completed medical school in the era of Covid-19 will not have the same experience gained through the traditional multi-month fourth-year surgical subinternships. During subinternships, medical students learn relevant anatomic and radiographic features of surgical pathologies, hone technical skills, and gain exposure to surgical consults and procedures. This lack of intensive exposure will have this cohort starting at a lower comfort and knowledge level compared to years prior. Residency programs, especially subspeciality programs, should review and utilize national resources to facilitate the transition to intern year, such as the American College of Surgeons Entering Resident Readiness Assessment and American College of Surgeons/ Association of Program Directors in Surgery/Association for Surgical Education Resident Prep Curriculum. We recommend the use of a specialty-tailored intern bootcamp and longitudinal curriculum that focuses on learning procedural skills and surgical conditions, anatomy, pathology, clinical examination, radiographic findings, surgical approach, and postoperative complications. These steps will help address knowledge gaps and promote intern readiness in this cohort of individuals. ( In July, new classes of surgical interns begin around the country. Current interns, as well as future classes of graduating medical students in the era of Covid-19, will experience a disrupted final year of medical school. One unique aspect of this cohort is that most will begin intern year without the usual set of subinternships geared toward fourth-year medical students applying into surgical residency programs. For students who have access to home subinternships, these experiences likely vary depending on the operative case volume, status of elective cases, and restrictions on medical student involvement in the operating room. Prior to current restrictions, students applying to surgical specialties would often engage in up to four months of specialty-specific subinternships. On these rotations, medical students learned relevant anatomic and radiographic features of surgical pathologies as well as developed an understanding of pertinent clinical history and physical exam findings of common surgical consults.

The subinternship is also a period where surgical skills, such as knot tying and suturing, are mastered under the direction of a resident or attending and experience is gained in specialty-specific procedures. 1 While the subintern generally partakes in morning rounds and bedside related procedures, rotational exposure is currently weighed heavily toward participating in cases in the operating room. In contrast, during the intern year, the floor duties often outweigh the intern's ability to participate in operative cases. For example, in neurosurgery, a subintern may help place an external ventricular drain, drill a burr hole for a craniotomy, or master the one-handed knot. In urology, a subintern may learn difficult Foley catheter placement, or basic cystoscopic skills. In addition, most subinterns are embedded into the, rounding and consult system that is representative of junior residency. A lack of this intensive exposure over a multi-month period during the final year of medical school risks having interns starting at a lower comfort and knowledge level than in years prior.

The benefits of surgical subinternships and pre-residency preparatory courses have been well established. These include building technical skills, gaining familiarity with surgical procedures, understanding postoperative care pathways, and developing competence in team-based communication. [2] [3] [4] According to a position paper prepared by the Subcommittee for Surgery Subinternship and the Curriculum Committee of the Association for Surgical Education (ASE), the goals and objectives of the surgical subinternship include an emphasis on developing the ACGME core competencies of patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and system-based practice. 5 The American College of Surgeons has launched multiple educational resources focused on preparing graduating medical students and interns for surgical residency. With the change in medical student exposure to surgical education through a restrictive subinternship experience, these programs are more essential than ever before. The American College of Surgeons (ACS) Division of Education developed the "Entering Resident Readiness Assessment" Program that identifies the strengths and weakness of new residents with regards to decision-making skills. 6, 7 This assessment focuses on decision making for clinical scenarios that are commonly experienced during intern year. We propose that all surgical training programs should have residents take the assessment between June and July of intern year and use these results to tailor the curriculum to address gaps in knowledge. The ACS in conjunction with the Association of Program Directors in Surgery (APDS) and ASE developed the ACS/APDS/ASE Resident Prep Curriculum for fourth year medical students focused on patient care and medical knowledge, technical skills, professionalism, interpersonal skills and communication, practicebased learning and improvement, and systems based practice to prepare graduating medical students for internship and reduce variability in skill. 8 This program takes the burden off individual medical schools and residency programs to develop a unique curriculum and helps to standardize the readiness and preparedness of interns across the country.

During the final year of medical school and first year of residency, graduating medical students and interns often participate in surgical boot camps that focus on exposure to common pathologies, consults, and surgical skills to promote readiness for residency. [9] [10] [11] [12] These programs help address the deficiencies that may arise from a lack of intensive surgical subinternship experience. Institutions during the COVID pandemic have demonstrated the benefit of short intensive courses on subintern preparedness, such as virtual subinternship programs and one-day courses. Recent evidence supports that participants demonstrate improved preparedness for elective rotations, as well as increase in self-perceived knowledge and decrease in anxiety regarding subinternships. 10-12 A recent publication on orthopedic intern virtual boot camp highlighted the use of take-home kits with surgical instruments that allowed interns to practice procedural skills and promoted skill retention with longitudinal practice. 9 Surgical subspecialities should focus on development of national hybrid boot camps that contain an element of in-person procedural skill training supervised by more experienced residents or attendings. Incorporating longitudinal surgical skills sessions in the skills laboratory and providing early exposure into the operating room will also help promote their development and retention of these skills and improve their confidence in performing procedures. 4 To prepare future classes of interns, we propose that medical schools and residency programs develop a dedicated period of time focused on early preparation that include utilization of ACS resources including ACS Entering Resident Readiness Assessment and ACS/APDS/ASE Resident Prep Curriculum, involvement of medical students and interns in surgical boot camps, longitudinal skill sessions, early exposure to the operating room, and faculty mentorship throughout intern year.

Technical skills acquisition in surgery-bound senior medical students: an evaluation of student assertiveness

American College of Surgeons; Association of Program Directors in Surgery; Association for Surgical Education

Medical school training for the surgeon

A surgical skills elective can improve student confidence prior to internship

Surgical subinternships: bridging the chiasm between medical school and residency: a position paper prepared by the Subcommittee for Surgery Subinternship and the Curriculum Committee of the Association for Surgical Education

The American College of Surgeons Entering Resident Readiness Assessment Program: development and national pilot testing results

ACS Entering Resident Readiness Assessment

ACS/APDS/ASE Resident Prep Curriculum

Boot Camp: orthopaedic intern education in the time of COVID-19 and beyond

Neurosurgery training camp for sub-internship preparation: lessons from the inaugural course

Democratizing access to neurosurgical medical education: national efforts in a medical student training camp during coronavirus disease 2019

Adapting to the educational challenges of a pandemic: development of a novel virtual urology subinternship during the time of COVID-19