Following the completion of medical school junior doctors are required by the bodies responsible for the registration of medical practitioners to complete one year of supervised hospital-based practice, referred to as an internship, before they are eligible to receive their full medical registration. While medical students are exposed to the real life application of medicine through clinical placements during medical school, the first year following graduation provides the essential time needed for junior doctors to consolidate and build on the knowledge, skills and experience gained in their undergraduate years, with the dedicated oversight and supervision of senior medical staff.
The internship year is broken up into rotations (or terms) of generally 8-10 weeks each. In the majority of Australian states and territories there are compulsory terms (core terms) in medicine, surgery and emergency medicine. These core terms need to be completed by interns to meet the requirements set by the state medical boards for gaining full medical registration. These core terms provide interns with a balanced generalist experience that prepares them well for their future medical careers.
Despite the importance of the content of the internship year in the development of a junior doctor, the core terms are unfortunately coming under increasing scrutiny by health departments. This has been driven by the recent increases in the numbers of medical school students and the need to find additional intern places to accommodate these new graduates. While additional medical school places are needed to ameliorate the medical workforce shortage, the forward planning to ensure the students and graduates receive quality training has lagged well behind.
Quite simply, as it stands, there will not be enough intern places to accommodate the numbers of graduates who will be entering the system. The solution proposed by some jurisdictions for finding the additional intern places, has been to cut the intern experience by either substituting the required core terms or by reducing their duration. This has been met by opposition from many in the medical community who recognise that the core terms have been put in place for good reason. At present there is a real risk that the quality of intern training may be sacrificed in the interest of increasing capacity.
The Essential Core Terms
The core terms of medicine, surgery and emergency medicine provide an essential combination of experience during the internship year. This combination of experience cannot be replicated by using alternative settings. Nor can it be achieved by introducing a simplistic competency-based approach whereby the development of knowledge and skills is viewed as being independent of the setting in which they are being acquired. The experience obtained through spending time with patients and senior clinicians in the key areas of medicine, surgery and emergency medicine is unique and must be protected.
These core terms provide the intern with the knowledge and experience of how these key areas in medicine function. This knowledge is vital if our future doctors are to effectively communicate with their colleagues about the care of patients, and in turn, is essential in achieving the best possible patient outcomes.
The core term in medicine contributes significantly to the essential foundation of knowledge that is necessary for future medical training and practice. It places the intern in a managed clinical environment where they are given supervised experience in managing patients with complex, often chronic, medical conditions. Medical terms highlight the importance of evidence-based medicine; foster clinical reasoning and decision-making, as well as teamwork in a multi-disciplinary environment.
The surgical core term provides the intern with exposure to the surgically ill patient and experience in managing patients with a variety of surgical conditions. Importantly, interns develop the ability to recognise the signs and symptoms of acute complications of surgery and develop critical problem-solving skills in being involved in the management of these patients. Interns also have the opportunity to learn and practise basic procedural skills, and through time spent in theatre, gain experience in the field of anaesthetics and surgical assistance.
The emergency term provides exposure to a wide range of undifferentiated acute patient presentations, both physical and behavioural, that allows the intern to develop their clinical decision-making in a manner and environment that no other discipline can offer. The opportunity to conduct an initial assessment of a patient is hugely valuable in allowing the intern to formulate his or her own independent ideas on possible diagnoses and options for management. The emergency term also allows the intern to work through the stages of history taking, examination, investigation, diagnosis and initial management. The emergency term also provides the opportunity for interns to practice important procedural skills, and professional skills such as teamwork, time management, and the ability to prioritise tasks are also developed.
The knowledge of how an emergency department operates and interacts with the other specialty areas and services provided by a hospital is critical to an intern’s understanding the complex system of health care. The emergency term provides the understanding that is necessary to be able to successfully negotiate a patient through the system, and deliver the best possible care. This experience of how an emergency department functions is essential, regardless of the specialty field an intern intends to pursue in future, as ultimately almost all specialities at some stage have their patients interact with this service.
The core term in emergency medicine is the one that is most under threat due to the fact that available intern places are less plentiful than in medicine and surgery, and that the contribution of interns to an emergency department’s patient throughput is limited or negated due to their significant supervision and teaching requirements. Despite these acknowledged limitations it is vital that solutions are found to ensure that this irreplaceable term is made available to all interns. Past reviews of the emergency term have confirmed its value in the intern year. One such review conducted in Victoria in 2003 actually resulted in the core intern emergency term being increased in length from four weeks to eight weeks.1
A survey conducted by the AMA Queensland Council of Residents and Registrars in 2005 found that 95% of respondents rated the emergency term as beneficial or highly beneficial in terms of training and experience.2 This was also supported by a survey conducted by the Postgraduate Medical Council of Queensland in 2006, which demonstrated strong support for the value of the emergency term with the vast majority of respondents agreeing or strongly agreeing that the emergency term should be retained.3
There is an increasing tendency to use non-hospital environments for terms in internship. Experience in non-hospital settings, including general practice, can be hugely beneficial for interns and quality experiences should be supported. However these experiences must not be used as a substitute for the essential core hospital terms of surgery, medicine and emergency medicine, as is happening already in some states such as South Australia where general practice is assessed to be an equivalent substitute for an emergency medicine term. Whilst there are similarities between these two rotations, significant differences exist in terms of diagnostic and interventional resources available (including their timing of availability), interaction with other health professionals and most importantly severity of patient presentation. The latter in particular means that emergency medicine, where one learns the skills of managing critically ill patients including resuscitation, cannot be substituted.
If properly resourced, a term in general practice can provide interns with an experience, particularly in chronic care and involvement in diagnostic processes, that has been shown to contribute significantly to their professional and personal growth.4 An understanding of how this specialty of medicine functions and interacts with the broader health care sector is immensely valuable to their future careers and interns should be encouraged to complete a term in general practice during their internship.
The AMA has considered whether general practice should be a core term in its own right. Whilst this idea may have merit at present it is felt that there is not the capacity for this to take place. This may change in the future but would require a significant increase in allocation of resources to support teaching in this area, with these resources likely needing to come from government.
Structured training courses and simulated scenarios can be an effective supplement to real-life clinical experience, providing the intern with time for dedicated practice and an opportunity to receive immediate feedback on their performance. However, simulated teaching environments have their limitations; they cannot replace what a doctor learns through direct patient contact.5, 6, 7 They must only be used as a complement to real-life clinical experience and under no circumstances should they be used as a substitute for the essential core terms in internship.
The core terms must be of sufficient length to provide interns with the opportunity to gain the full potential of the placement and positively and productively contribute to the functioning of the unit team and patient care. A full-time core term of any less than eight weeks duration makes this extremely difficult to achieve and can be disadvantageous for interns and their supervisors.
It is essential that the core rotations of medicine, surgery and emergency medicine be maintained as part of the intern year. Having said this, in the case of a shortage of access to these core rotations, junior doctors should not be penalised. The granting of full medical registration must remain at the end of the internship year. A shortage of core terms should not be used as an excuse to introduce a two-year internship. Currently, the second postgraduate year provides junior doctors with an increased level of responsibility for patient care and greater freedom to explore a particular area of interest. Junior doctors have already committed many years to their medical training and to formally extend this by another year would be counterproductive and grossly unfair to junior doctors. Moreover, an extended internship will only delay the issue of access to core terms, and not actually solve the problem.
References:
1. Review of Intern Training in Emergency Medicine Departments in Victorian Hospitals, Postgraduate Medical Council of Victoria, 30 August 2006.
2. As cited in AMA Queensland, Council of Resident and Registrars, Submission addressing Internship to Queensland Health’s Additional Medical Graduates Project, 2006.
3. Researching a Flexible Model of Education and Training for PGY1 Doctors, Final Project Report, Postgraduate Medical Education Council of Queensland, 2006.
4. Martin A, Laurence C O, Black L, Mugford B. General Practice placements for pre-registration junior doctors: adding value to intern education and training. MJA 2007; 186 (7): 346-349.
5. Heaven C, Clegg J, Maguire P. Transfer of communication skills from workshop to workplace: the impact of clinical supervision. Patient Edu Couns 2006 Mar; 60 (3): 313-25.
6. Crotty B. More students and less patients: the squeeze on medical training resources. MJA 2005; 183 (9): 444-445.
7. Lake F, Ryan G. Teaching on the run tips 4: teaching with patients. MJA 2004; 181 (3): 158-159.