Sub-internships completed during the fourth year of medical school are an important part of the residency application process in many specialties. In urology, the sub-internship experience is essential. Nearly all applicants complete a home sub-internship and two ‘away’ sub-internships at hospitals of interest 1. Applicants have cited these experiences as critical to their programme rankings in the match process 2. The sub-internship experience is also an opportunity for faculty to become acquainted with and assess potential candidates for their programme. While programme directors gave special consideration to their programmes' sub-interns in the past, due to recent changes in the residency application process including preference signalling and the pass/fail scoring of the United States Medical Licensing Examination (USMLE) Step 1 examination and many clerkships, sub-intern performance is now the most important factor evaluated by programme directors, along with letters of recommendation 3, 4. Prior research has found that academic relationships in higher education are influenced by social, geographical, and cultural dimensions, rather than strictly academic ones 5. These factors are known to play an important role in the evaluation of residency programmes and by extension sub-internships 6. Despite the importance of urology sub-internships, there is a dearth of knowledge about the current experience of sub-interns. In this study we sought to understand the goals of medical students, residents, and faculty in the sub-internship experience and determine if the reality of the current experience aligns with those goals. Our anonymous survey was distributed to urology residency programme directors via their publicly available e-mail. Medical students and residents were also contacted individually by e-mail if they had previously applied to the authors’ residency programme. Additionally, the survey was distributed on social media (X) using our residency programme's account and the authors’ personal accounts. As a result the number of individuals who received the survey is unknown, prohibiting calculation of a formal response rate. Survey questions were generated based on literature review and expert consensus among urology residency programme directors at two institutions. Respondents were given the opportunity to enrol in a raffle for a 50 gift card as an incentive for survey completion. Survey responses were collected from August 2023 to July 2024. The survey primarily assessed activity ranking and frequency, collecting the respondent's AUA section, but no other demographic information. Medical student respondents were asked to rank the six provided reasons why they completed a urology sub-internship. Residents and faculty were asked to rank the six provided aspects of a urology sub-intern were most important to evaluate. All respondents reported how often sub-interns at their programme participated in a provided list of activities. We also asked respondents to rank the three most important activities contributing to their reason for completing a sub-internship or for evaluating sub-interns. Percentages were calculated within each stakeholder group. The survey was created and data were collected using the Qualtrics on-line platform (Qualtrics, Provo, UT, USA). Descriptive statistics characterised stakeholder perceptions for hypothesis generation rather than testing. Data analysis was performed using R version 4. 4. 0 (R Foundation for Statistical Computing, Vienna, Austria). Respondents to our survey included 2321 respondents: 1885 medical students, 264 residents, and 172 faculty. The largest proportion of respondents were from the AUA New York Section (45% 1039/2321) and the smallest proportion were from the South Central section (3% 69/2321) (Table S1). ‘Confirm interest in urology’ was ranked as the most important reason for completing a urology sub-internship by 53% of medical students. The reasons most often ranked in the top three were ‘confirm interest in urology’ (83%), ‘prepare for residency’ (60%), and ‘interact with faculty’ (60%) (Fig. 1). While ‘confirm interest in urology’ was the top reason for nearly all regions, ‘obtain letter of recommendation’ was a top three reason for the Mid-Atlantic, South Central, and Western sections (Table S2a). The aspects most often ranked by residents and faculty among the top two most important to assess in a urology sub-intern were ‘work ethic’ (49%) and ‘medical knowledge’ (43%) (Fig. 2). Across most AUA regions ‘work ethic’ and ‘medical knowledge’ remained the top two most important aspects to assess. In the New England and Northeastern sections, ‘surgical skills’ was the second most important aspect 42% and 37%, respectively. ‘Cultural fit’ was the second most important aspect in the North Central (39%) and Western sections (57%) (Table S2b). The top three activities that medical students ranked most contributory to ‘confirm interest in urology’ were rounding (72%), operating room (OR) time (71%) and consults (48%) (Table S3a). For ‘preparation for residency’, medical students ranked rounding (75%), OR time (72%), and floor work (40%) as the most contributory. The activities ranked most important to ‘interact with faculty’ were rounding (67%), OR time (49%), and didactics (39%). The top three activities that residents and faculty ranked as most helpful to assess a sub-intern's ‘work ethic’ included were rounding (66%), OR time (51%), and floor work (48%) (Table S3b). For assessing ‘medical knowledge’, residents and faculty again ranked rounding (56%), OR time (61%), and floor work (35%) most frequently among their top three opportunities. Compared to medical students and residents, faculty consistently reported more frequent participation by sub-interns in all activities except for simulation laboratory, research, and call (Tables S4 and S5). Activity frequency also varied by AUA section. Sub-interns reported to participate in rounding everyday or a few times a week most frequently in the Western (67%) and Northeastern (66%) sections, while only 47% and 40% of sub-interns in the New York and Southeastern sections respectively engaged in rounding that frequently. The majority of sub-interns were reported to frequently participate in the OR in the Western (70% reported everyday or a few times a week) and North Central (61%) sections, but a minority of students participated that often in the New York (40%) and Southeastern (38%) sections. Our findings reaffirm prior research on the importance of the sub-internship experience and identified new insights regarding the motivations and priorities of each stakeholder group 6. The desire to ‘confirm interest in urology’ was unexpected as the top priority for medical students based on previous research finding resident culture and clinical experience as the most important aspects when evaluating residency programmes 1, 2. This may be due to differences in motivation to complete a sub-internship at a students’ home institution vs an away rotation, which were not captured in this study. We also identified potential geographical differences in the motivations of residents and faculty who evaluate sub-interns. These differences may reflect distinctions in regional culture or residency programme priorities, although future research can help elucidate reasons for these differences. This information can be used by sub-interns to better understand how they will be evaluated and adjust their efforts accordingly. These findings also shine a light on how sub-interns spend their time and how this may change based on programme geography. There appears to be a wide range in the frequency of reportedly important activities such as rounding and OR time; however, it is not clear if this is related to programme director priorities, residency culture, or logistical necessity. Interestingly, there appears to be a consistent overestimation by faculty of how often medical students participate in the most important activities, potentially representing an overly optimistic view of their sub-internship. Additionally, differences in reporting frequency of these activities suggests a potential area in which faculty can further align their sub-internship with shared goals. Other sub-internship activities, although reportedly participated in less frequently, may also have value. Urology simulation laboratory experience has been shown to increase medical student interest in the field and improve procedural knowledge 7. Call is also an important experience, with surgery residents who did not take call during their clerkship experience feeling less prepared for residency 8. Ultimately, programme directors must decide which activities serve their sub-interns, residents, and faculty best with the opportunities available to them. While these findings are specific to the structure of urology sub-internships in the United States, the broader themes may resonate internationally. Medical students undertaking advanced clinical rotations, electives, or clerkships can allow them to explore specialty interest, demonstrate clinical competence, and build mentorship relationships. Although the evaluation systems, licensing examinations, and residency selection processes differ across regions, the core principles of demonstrating professionalism, medical knowledge, and engagement in clinical activities are broadly applicable. Future work could explore how these themes manifest in different training systems to provide a more comprehensive, global perspective on optimising sub-internship or elective experiences. By identifying which activities stakeholders value most, these results can help guide the development of a more standardised national sub-internship curriculum that ensures consistent exposure to core clinical duties across programmes. Programmes may also use these data to refine faculty evaluation rubrics, prioritising competencies and behaviours that align with what students, residents, and faculty view as most meaningful during a sub-internship. In addition, greater clarity about activities that applicants find most helpful may inform advising and preparation strategies for medical students, enabling them to focus on experiences that best support career exploration and readiness for residency. This study is not without limitations. Regional representation was uneven, with a disproportionate number of responses from the New York section, which may limit the generalisability of regional comparisons; however, this was addressed by reporting stakeholder goals and sub-internship activities by region, and our survey respondents mostly mirrored programme location. Additionally, the geographical differences in these activities can help programme directors understand their sub-internship in the context of others in their region. Next, our survey did not assess satisfaction with the current sub-internship experience. Voluntary on-line participation may have introduced selection bias, and reliance on respondent recall—particularly among residents and faculty estimating student activity—raises the possibility of recall bias. Additionally, Qualtrics settings reduced—but cannot eliminate—duplicate responses, and we cannot be certain that all respondents were urology sub-interns. Finally, the absence of demographic variables such as year of training, institution type, and gender restricted our ability to perform subgroup analyses. Despite these limitations, our findings can guide programme directors to improve their sub-internships by aligning student activities with the primary goals of all stakeholders. Medical students can also use these findings as guidance to maximise their sub-internship experience, including the geography of the residency programme. The authors declare no conflict of interest. Table S1. Survey respondents by role and AUA section. Table S2a. Medical student rankings of top reasons for completing a urology sub-internship (percentage of respondents ranking item among the top three). Table S2b. Resident and faculty rankings of the most important aspects to assess in a urology sub-intern (percentage of respondents ranking item among the top two). Table S3a. Percentage of medical students ranking each activity among the top three that contribute most to each purpose. Table S3b. Percentage of residents and faculty ranking each activity among the top three most important to assess aspects in a urology sub-intern. Table S4. Reported frequency of sub-internship activities. Table S5. Frequency of sub-internship activities by AUA section reported by all survey respondents. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.
Adler et al. (Thu,) studied this question.