The COVID-19 related cancelation of away rotations for medical students in urology has been devastating to many prospective applicants and residency programs alike. It is widely acknowledged that sub-internships are a critical part of the application process. Students rely on sub-internships to learn urology and understand the culture of various residency programs, while programs use these rotations to assess the potential applicant's personality and fit.

When virtual sub-internships were first announced by the Society of Academic Urologists, I must admit that I was a little skeptical. How could programs incorporate students virtually to teach them, evaluate them and expose them to the culture of their program? Casting these doubts aside, I decided to jump in and became the first virtual sub-intern at the Zucker School of Medicine at Hofstra/Northwell, otherwise known as the Smith Institute for Urology (SIU). Going into the virtual sub-internship, I did not fully know what to expect. Little did I know what a phenomenal journey upon which I was about to embark.

Technology Involved

Figure 1. Amwell C250 Telemedicine Cart available on floors, in OR and at clinic.

The success of my virtual sub-internship owes a lot to the telemedicine carts at Long Island Jewish Medical Center (LIJMC; see figure). ¹ These carts were housed in the hospital and at outpatient offices. When I logged onto the cart I was able to control the 20× zoom camera and experience a 360-degree view. On a typical day, I participated in morning rounds and then either observed cases in the operating room (OR) or attended clinic. On rounds the residents brought the cart from room to room so I could meet patients and also learn the dynamics of the morning routine in the hospital. In clinic I was able to go into patient rooms, interview patients, present to attendings and discuss treatment options. In the OR I viewed various open and endoscopic procedures. The only drawback of using the carts was that the connection would sometimes disconnect due to poor Wi-Fi signal or the battery would run low. Fortunately for me, the residents, faculty and other staff were very attentive and were able to resolve these issues promptly.

My Experience

Each morning I put on my white coat, sat down at my desk and logged onto the cart. Through my Northwell remote electronic medical record access I was able to check overnight updates on patients and prepare for rounds. Participation in rounds was a phenomenal learning experience as residents went out of their way to answer my questions. I must acknowledge an intern who would contact me throughout the day with updates on patients I was following. During my rotation the residents went above and beyond by sharing slides from conferences and quizzing me in the OR and clinic. They even took time out of their weekends to help me with my grand rounds' presentation.

The virtual sub-internship also provided a great opportunity to observe the camaraderie among the residents. As we all adjusted to the virtual sub-internship setup, the residents began to include me in banter. I will never forget the day in clinic when a resident jokingly asked me to stand up to prove to him that I was wearing pants. Fortunately for me, I was!

When I was in the OR I observed the surgical autonomy that the faculty provided to residents. On a personal level I appreciated how many of the attendings, no matter how junior or senior, continually checked in to make sure that I had a clear view and also took the time to enhance my understanding by asking me questions.

My Education

Besides getting to know the residents, my schedule, which was developed by the program directors, allowed me to meet 17 of the 28 faculty members and exposed me to various subspecialties. In addition to attendance at rounds, cases and clinic, I was expected to watch recorded lectures on different core topics each week. These subjects were strategically matched with who I was assigned to work with that week.

To further enrich my experience most providers allowed me to see patients with them and involved me in outpatient procedures. I am especially grateful to those who took the time to walk me through the steps necessary to read renal ultrasounds, perform transperineal transrectal ultrasound/magnetic resonance imaging fusion prostate biopsies, and conduct and analyze urodynamics.

During my time at LIJMC I was assigned a faculty mentor. I worked with this mentor on numerous procedures in the OR and clinic. At the end of the rotation he took the time to discuss my self-reflection essay and my overall experience at LIJMC. During this meeting, much to my delight, my mentor also mentioned that even though this was a virtual rotation he felt very comfortable writing a letter of recommendation (LOR) based on his own interactions with me and feedback from others. Since obtaining LORs has historically been an important part of away rotations, the fact that I was offered a LOR without hesitation shows that a well-organized virtual sub-internship can work.

Conclusion

My experience as the virtual sub-intern at SIU was extremely rewarding and exceeded all expectations. By the end of my 4 weeks, I truly felt that I was part of the team and that I knew most residents and faculty on a personal level. I successfully learned about the culture of the program while faculty and residents were able to assess my strengths and capabilities at the same time.

I am now convinced that a well-structured virtual away rotation can be a phenomenal opportunity for medical students and residency programs. I would strongly recommend such an experience to my fellow medical students and would certainly do another virtual sub-internship if given the opportunity. I am hopeful that more urology departments and other medical and surgical specialties will consider creating virtual experiences as an effective alternative to in-person away rotations.

Acknowledgements

I want to thank Michael J. Schwartz, MD and Shannon Smith, MD for their advice and help with this article as well as Mubashir Billah, MD for motivating me to write about my experience.