How to Use Your Sub‑I to Confirm or Reject an Internal Medicine Future

Your internal medicine sub‑I should decide your future, not just pad your CV.

Most students waste it. They treat sub‑I like another core rotation with slightly more notes and a fancier title. That is a mistake. Your internal medicine sub‑I is the single best simulation you will get of what your life could look like for the next three years. You either walk out thinking, “Yes, I can do this for a decade,” or, “Absolutely not.”

You are not there just to impress an attending. You are there to run a controlled experiment on your own future.

Here is the step‑by‑step way to use your internal medicine sub‑I to confirm or reject an IM career.

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1. Set the Right Goal Before Day 1

Showing up “to work hard and keep an open mind” is vague and useless. You need a concrete decision target.

By the end of this sub‑I, you should be able to say one of three sentences:

1. “I want to apply categorical Internal Medicine.”
2. “I do not want to apply to Internal Medicine.”
3. “I could see IM as a backup, but I will first pursue X specialty, and here is why.”

Everything you do on this month should be aimed at answering which of these is true.

Define what you are really testing

You are not testing:

• Whether you can do Internal Medicine. You can. Almost any competent MS4 can survive an IM residency.
• Whether you enjoy every minute. You will not. Every specialty has unpleasant parts.

You are testing:

• Can I tolerate the worst parts of IM enough to enjoy the best parts?
• Do I like the workday of IM, not just the “idea” of IM?

Write this down the night before you start:

• Three specific reasons you think you might like IM
• Three specific things you are worried you will hate about IM

Keep this in your phone. You are going to revisit it.

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2. Understand What an IM Sub‑I Should Actually Simulate

On a good internal medicine sub‑I, you are not “just a student.” You are a junior intern.

If your sub‑I is being run correctly, your role should approximate this:

Aspect	Strong Sub‑I (Intern‑like)	Weak Sub‑I (Shadow‑like)
Patient load	4–8 patients you follow closely	1–3 patients, often pre‑rounded by others
Order entry	You write most orders (co‑signed)	Residents place all orders
Notes	Daily notes on all your patients, used for real care	Occasional “student notes” no one reads
Call/night	Some exposure to cross‑cover/admissions	Daytime only, no sense of true workflow
Responsibility	You are expected to “own” patients	You are expected not to be in the way

If your sub‑I looks like the right column after the first week, you will not get real data on whether IM fits you. You need to upgrade your role (we will talk about how in a bit).

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3. Build a “Career Hypothesis” You Can Actually Test

Before week 1 ends, translate your vague feelings into testable criteria. Otherwise, you will leave with “I kind of liked it” which is useless on Match day.

Break it into four buckets:

1. Cognitive fit – Do you like the thinking in IM?
2. Workflow fit – Do you like the daily rhythm?
3. Team and culture fit – Do you tolerate/like the IM personalities and hierarchy?
4. Long‑term identity fit – Can you picture being “the internist” in 10 years?

For each, define 2–3 concrete signals you will track.

3.1 Cognitive Fit: Do you like how IM uses your brain?

You are testing:

• Do I enjoy undifferentiated problems?
• Do I like managing 10 simultaneous diseases and medications?
• Does longitudinal thinking excite me or drain me?

Signals to track for yourself:

• On rounds, do you feel drawn to figuring out “why” (diagnostic reasoning) vs. just “fixing the obvious”?
• When a complex patient is discussed (e.g., cirrhotic with AKI, GI bleed, infections), are you:
  • Leaning in, sketching pathways
  • Or mentally checking out after the first 3 problems
• After an exhausting day, could you still talk about an interesting case for 10 minutes without wanting to throw your pager?

If you consistently feel mentally flattened by the type of thinking, not just the hours, that is a red flag.

3.2 Workflow Fit: Do you like the shape of the day?

IM days are relatively predictable: pre‑round, round, notes, orders, family calls, discharges, admissions, repeat.

You are testing:

• How much does the multitasking and interruption bother you?
• Do you hate the computer work so much that it poisons the clinical work?

Signals:

• Do you get into a “flow” state at any point (admitting, rounding, discharging), or does the entire day feel like scattered chaos?
• How do you feel about the ratio:
  • Face time with patients
  • Time at the computer
  • Time coordinating with consultants, nurses, social work
• On your commute home, are you:
  • Mentally replaying interesting cases and thinking what you missed
  • Or only fantasizing about specialties with procedures and no notes?

3.3 Team and Culture Fit

Internal medicine culture is different from surgery, EM, anesthesia. More talking, more deliberation, more “why.” Sometimes more passive‑aggressive. Often very academic.

You are testing:

• Do you feel comfortable with internist personalities?
• Do you like long discussions about marginal benefits of therapies and guideline minutiae?

Signals:

• How do attendings argue? Does that style fit your temperament?
• How do residents respond to uncertainty? Do you like that model?
• Do you find your best‑fit role on the team quickly, or do you feel off‑tempo the whole time?

3.4 Long‑Term Identity Fit

This is the one most students ignore. They pick a specialty that fits their MS3 personality, not their likely 40‑year personality.

Questions to quietly ask yourself:

• Can I imagine being the person other services call when they are lost?
  (“Can you help manage this heart failure in my surgical patient?”)
• Does being known as “the complex medical problem person” feel satisfying or exhausting?
• When you meet an attending who has been in IM 20+ years, can you imagine wanting their life?

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4. Structure Your Month to Get Real Data (Not Vibes)

Now to the practical part. Here is how you should run your sub‑I to maximize what you learn.

4.1 Week 1: Go All‑In and Ask for Real Responsibility

Day 1, after orientation, say something very close to this to your senior resident:

“I want this month to feel as close to an intern month as is safe. I am seriously considering Internal Medicine, and I need to find out if this work fits me. Please push me and treat me like a junior intern.”

Then actually behave like that person.

Concrete actions:

1. Volunteer for admissions

   • Take first call when a new patient is assigned.
   • Go see them immediately, present a structured plan, write the note, and prep orders.

2. Own your patients

   • Know every lab, every imaging result, every consultant note before rounds.
   • Anticipate next steps. If you are waiting for a lab, decide now what you will do when it comes back high, low, or normal.

3. Call people yourself

   • You call the family with your resident listening on speaker.
   • You talk to the consulting service with a proposed question and plan.

You are intentionally pushing yourself to the IM intern experience. You want to feel the real cognitive and emotional load.

4.2 End of Week 1 Checkpoint: Quick Reality Scan

One evening after week 1, sit down and answer these in writing (not in your head):

• Energy level from 1–10 (1 = “I am dead,” 10 = “I could do another week like this”)
• Enjoyment level from 1–10
• Anxiety level from 1–10

Then answer:

• What surprised me about the work?
• What part of the day feels best?
• What part of the day makes time crawl?

Do not decide your career after week 1. But do start to notice patterns.

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5. Use Targeted Experiments During the Rotation

Once the basics are under control, you need to deliberately sample different flavors of IM life, not just float through a generic ward month.

5.1 Push for a Variety of Cases

Ask your senior:

“If there are especially complex or ‘classic IM’ patients, I would like to take them, even if it is more work. I am trying to see if that side of IM fits me.”

Target:

• One patient with complex multimorbidity (e.g., COPD, CHF, CKD, DM, prior stroke, depression)
• One patient with new, undiagnosed systemic problem (fever of unknown origin, weight loss, night sweats, weird lab pattern)
• One patient where goals of care and serious illness conversations are central

Pay close attention to which type of case you find draining versus energizing.

5.2 Shadow the Intern Explicitly

Pick a day and tell the intern:

“Today I want to follow exactly what you do, task for task, as much as possible. I am trying to decide if I want this job next year.”

Then measure:

• How much “overhead” work (pages, pharmacy clarifications, bureaucracy) feels tolerable?
• Does the chaos feel like a fun puzzle or just noise?

If you hate the intern’s job even on a relatively good day, that is data.

5.3 Sample an On‑Call Night or Admitting Shift

If your sub‑I does not formally include it, ask:

“Could I join you for one of the evening admissions shifts this week? I want to experience that part of IM.”

On that night, focus on three questions:

1. How do I feel about rapid‑fire problem solving when tired?
2. Does admitting feel like a fun diagnostic sprint or a slog of data entry?
3. How do I emotionally process sick, unstable patients?

You are not judging yourself for being tired. You are judging how much you hate that tired version of yourself.

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6. Talk to the Right People, and Ask the Right Questions

Hallway conversations during a sub‑I are career gold if you use them correctly. Most students waste them on vague “Do you like it here?” chatter.

You want targeted, future‑oriented questions.

6.1 What to Ask Interns

• “If you could go back to M4, would you still choose IM? Why or why not?”
• “What part of your day feels most medicine and least paperwork?”
• “What surprised you the most about intern year that you never saw as a student?”
• “On your worst day, what keeps you from regretting IM? Or do you regret it sometimes?”

Listen especially for regret patterns. You will hear themes like:

• “I wish I had considered radiology more.”
• “I actually like ICU and want to do critical care fellowship.”
• “Honestly, I should have done EM; I hate clinics.”

Use these as stress tests for your own preferences.

6.2 What to Ask Senior Residents

You are testing long‑term fit and trajectory, not just intern misery.

Sample questions:

• “At what point in residency did you know IM was or was not right for you?”
• “How has your view of IM changed since intern year?”
• “What parts of your job got better with seniority? What parts got worse?”

The answer to that last one matters. If the parts that get better are the ones you care about, good sign. If your favorite parts (e.g., acute inpatient care) shrink over time while billing and admin grow, you need to know if you can live with that.

6.3 What to Ask Attendings

Here you are probing identity and lifestyle.

• “What do you like about being an internist that you did not appreciate as a resident?”
• “What made your happiest colleagues stay in IM, and what made others leave or burn out?”
• “If your own child was choosing a specialty and had a similar personality to me, would you steer them toward or away from IM?”

You will get blunt answers behind closed doors. Pay attention.

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7. Systematically Compare IM to Your Alternative Specialty

You probably have at least one other serious contender: EM, anesthesia, neurology, surgery, something. Use your sub‑I to directly compare.

Do this on paper. Not in your head.

Dimension	Internal Medicine	Your Alternative (e.g., EM)
Type of thinking	Longitudinal, complex, multi‑problem	Acute, rapid decisions, shorter episodes
Daily workflow	Rounds, notes, discharges, coordination	Shifts, rapid turnover, procedures
Patient contact	Repeated, ongoing	Intense but brief
Documentation	Heavy, detailed, multi‑problem	Episodic, focused
Future options	Hospitalist, primary care, many fellowships	[List key paths]

During your sub‑I, every time you think “I wish I was doing X instead,” write it under the alternative column.

Then ask yourself two questions at the end:

1. When I am happiest on this sub‑I, what am I actually doing?
2. Is there a specialty where I would do more of that and less of the stuff I hate?

If the answer is yes and that specialty is realistic for you (scores, letters, timeline), you should not ignore that.

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8. Guard Against the Two Big Biases

You are not a robot. Your judgment during this month is going to be influenced by things that have nothing to do with IM as a field. Recognize them so you do not let one bad attending derail your entire career.

8.1 The “Team Halo” and “Team Hell” Effects

If you have a phenomenal senior and attending, you may think, “IM is amazing.” If you have a malignant one, you may swear off IM forever.

Fix: Ask yourself:

• “If I transplanted this exact work into a neutral, functional team, how would I feel about it?”

Also, actively sample other teams:

• Eat lunch with residents from another team and ask about their experience.
• If possible, spend a half‑day with another attending’s rounds.

You are trying to separate “I hate this team” from “I hate this work.”

8.2 The “I Am Good at This, So I Must Love It” Trap

Some students are naturally good at IM tasks:

• Organizing data
• Writing clear notes
• Remembering medication names and side effects

They get praised constantly. And then they confuse competence with passion.

Ask yourself:

• If I stopped getting praise tomorrow, would I still enjoy this work?
• Am I excited to read about IM topics on my own time, or am I just chasing honors?

Being good at something is not enough. You need at least a neutral to positive emotional reaction to doing it every day.

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9. Week‑by‑Week Debrief Plan

Do not wait until the end to “reflect.” Force yourself into structured check‑ins.

Week 1: Shock and Adjustment

• Write one paragraph: “What surprised me most about IM work?”
• List: Top 2 things I enjoyed, top 2 things I disliked.

Week 2: Pattern Detection

• Track: For three days, each evening, rate (1–10)
  • Mental fatigue
  • Emotional fatigue
  • Sense of meaning

Look for patterns like:

• High fatigue but also high meaning → possibly a good long‑term fit.
• Low fatigue, low meaning → job feels trivial or boring.
• High fatigue, low meaning → bad combination.

Week 3: Future Projection

This week, deliberately visualize your PGY‑2 self:

• You are cross‑covering 40 patients at night.
• You are triaging multiple admissions while handling a rapid response.
• You are supervising interns and students.

Ask yourself each day: “Do I want to grow into that role?”

If the answer is consistently no, listen to it.

Week 4: Forced Decision Draft

Three days before the rotation ends, force yourself to write a draft decision, even if you are unsure:

• “Right now, my best guess is that I do / do not want to pursue Internal Medicine because…”
• “If I ignore fear, prestige, and inertia, I would choose…”

You are allowed to revise this later. But forcing yourself to articulate it will surface what is really driving you.

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10. Use Your Attendings to Pressure‑Test Your Decision

The last week is when you should finally ask attendings and seniors directly for help with your decision. Do not waste this on “Do you think I will match?” nonsense. You want career‑level feedback.

Here is how to do it quickly and not awkwardly:

“Dr. X, do you have 5 minutes sometime this week? I am using this sub‑I to decide about IM and would really value your honest perspective.”

When you sit down:

1. Share your self‑assessment in 2–3 sentences:
   • “Strengths I have noticed here are X, Y, Z. Challenges I struggle with are A, B.”
2. Share your draft decision:
   • “Right now, I am leaning toward / away from IM because of [specific reasons].”
3. Ask two pointed questions:
   • “Based on how you have seen me work this month, do you think IM fits my strengths?”
   • “If you were in my shoes with my personality and performance so far, what would you do?”

Then be quiet and let them talk.

You are not asking them to decide for you. You are getting external calibration.

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11. When the Month Ends: Make a Clean Call

You are going to be tempted to punt the decision, especially if you are a “maybe.” That is how people drift into a specialty they are lukewarm about.

At the end of the sub‑I, you should force a binary decision, using this simple rule:

• If you are actively excited about IM ≥ 60% of the days, and your concerns are mostly about training pain (hours, notes, call), then:
  • Call it “Yes, I will apply IM,” even if you are nervous.
• If you are neutral or negative about IM ≥ 60% of the days, and the things you dislike are core to the job (type of thinking, patient population, culture), then:
  • Call it “No, I will not apply IM,” even if you did well and got praise.

The sub‑I is not the time for cowardly maybes. It is the time for controlled testing followed by a decision.

If you still cannot decide, that is its own diagnosis:

• You either:
  • Did not push yourself hard enough to simulate intern work, or
  • Are avoiding a difficult truth about your preferred specialty (e.g., competitiveness, lifestyle, prestige)

In that case, your next step is not “apply broadly and hope.” It is book another high‑intensity experience in your alternate specialty and run the same process there.

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12. A Simple Decision Flow You Can Use

To make this even more mechanical, here is the rough internal flowchart I have seen work for students:

Internal Medicine Sub-I Decision Flow

Step	Description
Step 1	Start Sub I
Step 2	Ask for intern like role
Step 3	Week 2 reflection
Step 4	Identify disliked elements
Step 5	Confirm alternative not better
Step 6	Reject IM, pursue alternative
Step 7	Consider program or team issue
Step 8	IM as backup only
Step 9	Apply IM with confidence
Step 10	Enjoy IM work most days?
Step 11	Disliked elements core to IM?
Step 12	Alternative specialty clearly preferred?

You do not have to draw this out. Just remember:

• If you hate the essence of IM, walk away.
• If you like the work but hate your specific rotation, reconsider the environment.
• If you like IM but love something else more, be honest and pursue the thing you love.

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13. One Concrete Step You Can Take Today

Open your calendar and block 30 minutes on the evening of Day 3 of your sub‑I. Title it:

“IM Sub‑I: Reality Check.”

During that block, write:

• Three moments you felt “this is interesting”
• Three moments you thought “I would hate doing this forever”
• A one‑sentence gut answer: “Right now, do I want to be an internist? Yes / No / Unsure.”

Do that, and you will already be far ahead of the average MS4 sleepwalking through their sub‑I and hoping the Match figures out their life for them.