INTRODUCTION

The subinternship (also referred to as acting internship) is an essential rotation, which typically occurs in a medical student’s final year, and is required by over 90% of US allopathic medical schools.1, 2 During the subinternship, students assume the responsibilities of first-year medical graduates to develop and refine the clinical skills needed for post-graduate training. Recent graduates report that the subinternship is a key experience for residency preparation and nearly 75% of all students complete a subinternship in internal medicine (IM).3, 4 Residency program directors from a wide range of specialties also regard subinternships as critical clinical experiences that best prepare students for the transition to residency.5

In response to the concerns about intern readiness and the variability in the subinternship experience, members of the Alliance for Academic Internal Medicine (AAIM; a nonprofit professional association that includes academic faculty and leaders responsible for third- and fourth-year undergraduate medical education) published guidelines in 2019 detailing expectations, objectives, and assessment of the IM subinternship curriculum.6, 7 These guidelines promoted subinternship redesign to ensure that students are better prepared for residency. Many schools restructured the subinternship to meet these expectations. For example, some schools transitioned student assessments to include core entrustable professional activities for entering residency (CEPAERs) and others developed specific asynchronous learning experiences to target other advanced competencies, such as high-value care.8,9,10,11 Appropriate oversight and intentional support for the subinternship are required to implement the changes suggested by the AAIM guideline.

The role and support of the clerkship director (CD) are well defined from previous publications, which suggest that CDs should receive support up to 50% full-time equivalent (FTE).12 Although the roles and responsibilities of the subinternship director are also described in the literature, there are no formal recommendations to guide medical schools and internal medicine departments on appropriate FTE allocation.13 Moreover, data from the 2017 Annual Survey of Clerkship Directors in Internal Medicine (CDIM) demonstrated that 52.8% of IM CDs oversee one or more subinternships suggesting that medical schools may not have dedicated faculty for the subinternship leadership role.14

The subinternship director’s critical role is highlighted by the need for a structural and curricular redesign that better prepares medical students for residency.7 This paper seeks to describe the current roles and responsibilities of the IM subinternship director, their FTE and salary support, and reporting structure.

METHODS

On September 14, 2017, Clerkship Directors in Internal Medicine (CDIM; a charter organization of AAIM) launched its annual research survey of CDs at all LCME accredited U.S. medical schools with CDIM membership. Altogether, 131 CDIM members designated as “clerkship director” received a personal email invitation to complete the voluntary web-based survey. One individual per member school received the invitation. Ninety-three percent of LCME-accredited schools were represented in CDIM as of the survey period.

The survey was administered via Qualtrics Surveys (Qualtrics, Provo, UT) and included five email reminders to non-respondents. During fielding, the population size was adjusted to 129 possible respondents, due to medical schools whose CDs were in transition. The survey protocol was granted full institutional review board exemption from the University of North Carolina Office of Human Research Ethics (Study #: 17-1954). Only MK of AAIM Surveys staff (who served as project personnel) had access to the survey population and survey software during fielding.

The survey questions were reviewed and modified through several iterations by the CDIM Survey and Scholarship Committee (representing faculty and faculty leaders with extensive experience in medical education and clerkship and/or fourth-year student training). Concurrently, AAIM Surveys personnel randomly selected eight CDIM faculty members with experience as medical educators in the IM clerkship, who pilot-tested the Web survey. The committee further revised the survey instrument following the pilot test and content review by the elected CDIM Council in July 2017. The final survey consisted of 79 questions, including multiple-choice, numeric-only, and open-text response options, with conditional logic and display patterns as needed (Supplementary Appendix). The results presented in this analysis are based primarily on the section “Required Post-Core Clerkship Experiences.”

DATA ANALYSIS

Data analysis was performed in Stata 14.2 (StataCorp 2015), and included descriptive statistics; Pearson’s Chi-square statistic or Fisher’s exact test (alpha level: 0.05 for statistical significance) was used to conduct bivariate tests for associations between categorical variables. Cronbach’s alpha was used to confirm the internal consistency of items used to measure the many responsibilities reported by subinternship directors (α=0.87). Upon survey closure, a variable to denote medical schools as “public” or “private” for all survey-eligible schools was merged into the dataset, from publicly available data (LCME 2017). Data from AAIM membership files, for respondents’ and non-respondents’ (e.g., gender, U.S. Census region of their school, and a proxy for school size), were also merged into the dataset. The dataset was then de-identified to ensure confidentiality. Due to item nonresponse or survey conditional logic, some denominators will vary and not sum to 107.

RESULTS

The survey response rate was 83% (107/129). There were no statistical associations between respondents and non-respondents based on key variables that defined the population: medical school type (public/private), U.S. Census Bureau region, proxy for size, or gender (Supplementary Appendix Table I).

Roles, Responsibilities, Reporting, and Resources of Internal Medicine Subinternship Directors

Oversight Roles

Fifty-four of 107 respondents (50.5%) reported overseeing core clerkship inpatient experiences and/or one or more subinternship(s). For experiences offered during the fourth year of medical school, the most frequently reported rotations by respondents were inpatient internal medicine at 98.2% (53/54) and ICU at 92.6% (50/54). Additional experiences included inpatient cardiology at 79.6% (43/54), outpatient internal medicine at 74.1% (40/54), inpatient hematology/oncology at 74.1% (40/54), and inpatient gastroenterology at 63.0% (34/54). An additional 44.4% (24/54) reported “other” with additional comments.

Oversight for the fourth-year experiences varied, with 52.8% (28/53) of CDs reporting that they were also the subinternship director, 26.4% (14/53) that another faculty member directed all of the medicine subinternships, and 18.9% (10/53) that each subinternship had its own director. One respondent reported “other” (specifically, that a department director of undergraduate medical education was responsible) (Supplementary Appendix Table II).

Oversight Responsibilities

The most frequently reported responsibilities for the subinternship directors were administration, which includes the development and re-adjustment as needed of schedules (83.0%, 44/53), and course evaluation, which includes review and response to feedback from students, faculty, and the curriculum evaluation committee (81.1%, 43/53). Grade determination for the rotation was the next most frequently reported at 79.2% (42/53). Additional responses are included in Table 1.

Table 1. Responsibilities of Directors of Post-Core Clerkship Required Experience (Subinternships): 2017 CDIM Annual Survey of Internal Medicine Core Clinical Clerkship Directors
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Full-time Equivalent Support

Of the 54 respondents who reported to oversee core clerkship inpatient experiences and/or one or more subinternships, 48 reported the estimated FTE per course provided to the course director for subinternship oversight (six reported “I do not know”). The modal response for estimated FTE per course was 10–20% FTE, with 33.3% of respondents (16/48) reporting this level of support while 29.2% (14/54) reported receiving no FTE support. The remaining responses are displayed in Figure 1.

Figure 1
figure 1

FTE support to subinternship directors. n=48. Questions were presented to 54 respondents who reported that they oversee one or more sub-internships and/or one or more elective experiences. Six additional respondents reported, “I do not know.”

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Reporting Structure

Of the 54 respondents who reported to oversee core clerkship inpatient experiences and/or one or more subinternships, 52 responded to a question about whom they reported to (respondents were allowed to select multiple responses. See Appendix). Forty-six percent (24/52) of subinternship directors reported to the CD (i.e., themselves), 32.7% (17/52) to the dean of curriculum, 32.7% (17/52) to the department chair, and 28.9% (15/52) to the department education leader (or vice-chair). Nine respondents (17.3%) reported “other” (e.g., division chief, director of UME).

Administrative support

Of the respondents who reported overseeing one or more subinternships, 79.6% (39/49) reported that administrative support is designated for subinternship directors. An additional five reported that they were not sure.

DISCUSSION

In this study, one-third of the respondents reported 10–20% FTE support for the subinternship director role while 29.2% reported no FTE support. In contrast, 30.1% reported greater than 41% FTE for the clerkship director role while only 15% reported less than 20% FTE support.14 Our findings demonstrate that the subinternship director role is less supported than the clerkship director role, despite similar responsibilities. The subinternship is increasingly recognized as a critical rotation to prepare students for residency and to assess competency in clinical skills of graduating students.7, 15 As the United States Medical Licensing Examination (USMLE) Step 1 transitions to a pass/fail scoring system in 2021, program directors in all specialties are likely to rely on subinternship performance to identify students who will thrive at their program. Recommendations for increased focus on the UME-GME educational transition through the joint identification of a common set of competencies, the use of robust assessment strategies, development of individualized learning plans for graduates, and other initiatives were put forth in preliminary form by the Coalition for Physician Accountability, which includes membership from numerous stakeholder groups.16 As UME-GME transition initiatives take root, it will be important for medical schools to cultivate and support leaders who can implement the new initiatives. Such support would include training in instructional design, specifically assessment and development of individualized learning plans, professional development via involvement in local and national committees, and the time and financial resources required to accomplish the tasks above. In return, subinternship directors may benefit their institutions not just by improving the learning and skill development of their graduates, but also by serving in leadership roles as liaisons between the UME and GME communities within their institutions.

A variety of workplace assessments in coordination with appropriate oversight and faculty development are critical to accurately represent student abilities across a variety of domains. Whereas assessment during clerkships often focuses on basic clinical skill attainment and medical knowledge, assessment of subinternship performance should encompass a broader skillset.17 To be successful interns, graduating students must develop the knowledge, skills, and attitudes that allow them to effectively communicate, accurately evaluate patients, efficiently prioritize multiple tasks, and recognize when to request help.6 Program directors have advocated for increased focus on the development of characteristics such as self-reflection and improvement, organization, reliability, and responsibility in the fourth year.5 CEPAERs have been proposed as a framework for the assessment of skills that are necessary for success.18, 19 However, the adoption of CEPAERs has been limited to date.20 Medical schools need subinternship directors who are well versed in competency-based assessment and receive the necessary support and resources to successfully implement workplace-based assessments. More robust student assessment methods will benefit the institution, the students, and the subinternship director, as they will inform program evaluation and may provide a basis for professional development in teaching, both for the subinternship director and their teaching faculty.

Challenges around resourcing the subinternship may result from a medical education system in which clerkships are inextricably linked to the accreditation process. The structure, function, and quality of clerkships often figure prominently in LCME accreditation visits; and thus, the outcomes of the clerkships have understandably been the primary focus of clinical education leadership.21 Also, the required nature of clerkships makes them an appealing target for curricular updates and innovations that are intended to affect all students. CDs may be provided with more protected time than subinternship directors because of their critical role in designing and implementing rotations that are crucial for LCME accreditation.12 In some institutions, if clerkships adapt to fit the changing needs of the healthcare system, there may be less impetus for change in subinternship rotations.

Finally, the role of the subinternship as an “audition” for residency placement cannot be overlooked. Specialties, such as emergency medicine and internal medicine, have developed explicit expectations around the number and type of subinternship experiences required for consideration for residency positions.22, 23 Although less explicitly stated, other programs often recommend a specialty-specific subinternship experience both as a means of additional clinical experience and letters of recommendation. Furthermore, residency programs have called for subinternship performance to be included in a “shared evaluation platform” to highlight a residency applicant’s strengths and weaknesses.24 It will be important to provide the support necessary for subinternship directors to develop both high-quality educational experiences and implement assessments that accurately convey a student’s strengths to residency program directors.

This study is not without limitations. Although the overall survey response rate of 83.0% was high and there were no statistical associations between respondents and the survey population, most but not all accredited medical schools were CDIM members as of fielding. Additionally, this was not a study of subinternship directors per se. Rather, it was based on core CDs who reported to oversee one or more subinternships or one or more elective experiences. However, the item response rates to key questions generally were high, as was the content validity of those questions. Furthermore, the reported FTE support for subinternship directors may not apply to those who do not serve as CD. CDs in this study reported the FTE support for their subinternship role and for subinternship directors of other courses. The CD may know the FTE support and reporting structure of other subinternship directors in their department but the estimation of responsibilities and administrative support is subjective. This highlights the need for future studies that survey all subinternship directors, not only those who also serve as the CD.

To our knowledge, this study is the first to describe the roles, responsibilities, reporting structure, and support of the IM subinternship director. As the subinternship becomes increasingly important for the transition to residency and the residency selection process, future studies are needed to determine essential roles and responsibilities, and the appropriate level of support for subinternship directors.