Tips to Excel on an Otolaryngology (ENT) Sub-I
Written by Lauren Howser, MD
Preparing for a sub-I is both a scary and exciting time! Let’s address some of the more intimidating topics so you can focus on the excitement and learning that comes with this added responsibility.
Refresh Your ENT Knowledge Base
Coming out of the third year you likely aren’t an expert at head and neck anatomy and all the other intricate details that arise in otolaryngology – and that’s okay! Don’t feel overwhelmed. There are a few resources I like to help streamline the process of beginning to understand ENT topics.
- ENT Secrets (sub-I level)
- Pasha’s Otolaryngology-Head and Neck Surgery: Clinical Reference Guide (slightly more in-depth, junior resident level)
- Headmirror’s ENT in a Nutshell podcast
- Otomatch (has additional resources and FAQ from years prior)
I want to stress that you will likely not feel completely confident in most ENT topics before your sub-I, that’s why it’s a 5-year residency!!
2. On the Job: Rounding
Your morning routine will start with pre-rounding, list-making, and rounding on your patient list with the team. Every hospital does this a little differently, but the overall idea is the same. You will likely round with a team of residents spanning from intern to chief, and sometimes an attending but this is much less common. A sub-I responsibility changes depending on this team's makeup and specific goals – so my main piece of advice is open communication. Ask your team on the first day what the expectations are (sometimes best to ask the intern) and do your best to exceed them!
- The List: Preparing the patient list can be one of the most helpful things a sub-I can do, and teams are very thankful for your due diligence in this task. Your team will teach you how they like it done, but make sure you are alert and focused to record lab values, room numbers, and other information correctly. Be ready to print copies of the list for your team (hint: always print an extra in case someone misplaces it throughout the day). On rounds, an elite sub-I will keep track of who patients are and why they are there. Take notes on your list and use them to help you keep patients and treatments straight.
- What to Carry: Often a sub-I can be useful by carrying rounding supplies and having them ready for the team. This can take some time to pick up on so ask your intern for help in the supply closet.
- Be adaptable and aware of your surroundings. There is a fine line between being proactive and coming on too strong. Be aware of your limitations but be positive and willing to do whatever helps the team.
3. On the Job: OR
- Chart Searching: Always look up the patient for a case you know you will be in. You don’t have to memorize every detail, but always look at the corresponding clinic note, H&P, and imaging. Keep in mind any questions you have (how a diagnosis was made, odd presentation, etc.) and discuss it in the OR with the resident or attending. Hint: this also shows that you have been doing your nightly preparation!
- Surgical Steps: Again, don’t memorize each surgical step, but do read over a trusted resource explaining relevant anatomy and the general idea of the case. I like to use the Open Access Atlas of Otolaryngology, Head & Neck Operative Surgery website. You can also refer to textbooks like Bailey’s or Cumming’s.
- Surgical Skills: Make sure you are comfortable suturing, hand tying, and instrument tying.
- OR setup: Be proactive in setting up the OR, getting warm blankets, throwing your gloves and gown, etc. Introduce yourself to the OR nurses and ask them how you can best help!
4. On the Job: Clinic
- H&P: Oftentimes the sub-I will enter the patient room first and get a brief H&P. Be prepared to ask ENT-relevant questions and perform a solid head and neck exam. It’s okay if you aren’t an expert at looking in ears or using a microscope. Those are things you will keep practicing even as an intern!
- Presentation: You likely will present your H&P to the attending. Have a solid order you always use and stick to it! When in doubt, do a more formal presentation and make it more casual if an attending requests. The biggest change in this for a third-year medical student is the expectation to come up with a reasonable assessment/plan. This is where your reading and resources help you! Don’t be afraid to open your ENT Secrets book or look up a disease process before your formal presentation. And discuss your plan with a resident if available!
- Writing Notes: Each clinic is different but is prepared to write concise and accurate notes. Touch up on ENT verbiage and pertinent positives/negatives. I like to read the attendings’ notes from previous visits to see an example format.
5. Grand Rounds Presentation
You likely will give a Grand Round style presentation towards the end of your rotation. It can be beneficial to collaborate with an attending perhaps after seeing a patient in the clinic or OR and using it as inspiration for your presentation. Choose a topic that a medical student can reasonably understand and discuss in usually around a 10-minute presentation. Choose something that interests you! Another option is to present a research topic you’ve been working on. When in doubt, go more formal (don’t forget to pack your suit). Start thinking about this at least a week or two before the presentation date – it is an impression you make on the entire department, so you want to put in the time and effort to make it great.
6. Letter of Recommendation
Most sub-I’s want a letter of recommendation from a rotation, either home program or away. There are many ways to go about it, but I like asking early to middle of the rotation to give ample time for letter writers to get to know you, yet still have time to observe your skills after knowing they might write about you. Ask residents for advice on who to get a letter from and be open about your desire to get a strong letter (and deadlines) with the attending. Open communication is the key again!
Take a deep breath, you are going to be an excellent sub-I!
