Keywords Internship orientation program - medical interns - skills - transition
INTRODUCTION
An internship is a delicate and yet essential transition phase for a medical graduate,
a period during which a medical student metamorphoses into a complete doctor. During
the period, an undergraduate student technically learns various disciplines in different
years as per the curriculum. Immediately after successful completion of his/ her final
year, they are posted as interns in various departments to undergo one year of rigorous
house surgeonship during which they participate in patient management and care. It
has been seen that often the interns are oblivious of what is expected out of them
and work aimlessly. Gaps in knowledge and suboptimal practical skills of fresh interns
have resulted in medical errors and have compromised patient safety.[1 ] In addition, team work, hospital guidelines and policies are subjects that are untouched
during medical schooling.[2 ] Therefore, it becomes essential that prior to fresh interns starting work in a hospital,
they should be primed about it. This training should ideally comprise sessions to
make them aware of their roles and responsibilities, to gain knowledge about hospital
policies and guidelines. They should also be made to do core procedural skills on
task trainers under supervision so that they become capable of working independently
in the future without compromising patient safety.[1 ] The focus should be on explaining to them the need or reason with logic to know
these facts, just like any other fresh recruit in the hospital.
Twelve months of training as an intern is important, as it poses challenges to these
bright young minds in terms of learning to work in a multidisciplinary team under
stressful conditions. They have to interact with various health-care workers and also
communicate with patients, which requires a good amount of interpersonal skills to
work effectively and empathetically even in complex situations. While working in the
hospital they are exposed to certain circumstances with variable ethical and legal
issues. An insight into real working conditions and day-to-day scenarios can prepare
these naive minds to deal with and respond to such situations in the future.[3 ] Besides exposure to patient care, it brings clarity to their minds and helps them
to discharge their duties to the best of their capabilities. This includes writing
prescriptions, patient progress notes, and discharge summary and following other hospital
guidelines.
In our institute, an internship orientation program is organized regularly for fresh
interns to acquaint them about hospital policies and goals as well as to enhance their
skills required for assisting in patient care. The current study was conducted to
determine the usefulness of the internship orientation program for the fresh batch
of medical interns. The objectives of this study were to:
Assess the effectiveness of the internship orientation module as an induction course
for fresh interns.
Evaluate intern perception and key learning points on the internship orientation modules.
Identify sessions that should become part of the undergraduate curriculum based on
feedback.
MATERIALS AND METHODS
A seven-day well-structured orientation program for freshly joined interns is held
every year at the Advanced Center of Continuous Professional Development (CPD) in
All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India [Tables 1 ] and [2 ]. The program includes brief lectures and active teaching learning methods such as
group discussions, role-plays, video demonstrations, and skill training on task trainers.
Interns are apprised of their roles and responsibilities. Adult learning principles
are used in a highly interactive and nonthreatening environment.
Table 1
Day-wise sessions covered during the internship orientation program
S. no
Day
Session
1
Day 1
Role and responsibilities of an intern
2
International patient safety goals
3
Rational use of drug and adoption of safety measures; essential drugs
4
Measures of safety in surgical procedures; How to avoid mishaps /Errors in medical-surgical
procedures
5
Hand hygiene and Biomedical Waste Management (universal safety precautions: Handwashing,
personal protective equipment; hospital infection control committee)
6
Day 2
Documentation records and maintenance of patient files/ record
7
The patient care-essential policy adopted currently at our institute
8
Pharmacy at our institute
9
Legal aspects in medical documentation, informed consent: Filling of death certificate
10
Pharmacovigilance—our responsibility
11
Occupational health hazard and vaccination
12
Day 3
Professional ethics in patient care
13
Doctor-patient relationship
14
Communication skills
15
Professionalism and alternative medicine
16
Confidentiality
17
Breaking bad news
18
Informed consent
19
Humanities in medicine
20
Day 4
The rationale of ordering investigations
21
Government Insurance Scheme—Ayushman Bharat
22
Filling of investigation request forms and critical alerts
23
Sample collection and transport—haematology clinical pathology, biochemistry; cytology
and histopathology
24
Sample collection and transport tests in microbiology
25
Know your attitude and perception for effective management of stress/ conflict and
interpersonal relationship
26
Day 5
Basic life support (BLS) American Heart Association certified
and 6
Procedural/examination skill training
28
Day 7
Request for blood products from the blood bank
29
Hemovigilance transfusion protocols
30
Dealing with work stress
31
Alumni—message from senior batches
32
Assessment
33
Feedback
Table 2
Skill Stations with a hands-on learning experience for participants in the internship
orientation program
Procedural/examination skill station
Gloving, gowning, and scrubbing techniques; aseptic techniques
Surgical knot tying
Male and female catheterization
Nasogastric (NG) tube insertion and tube feeding
Intravenous (IV) cannulation/ intramuscular (IM) injection
Arterial blood sampling
Abdominal paracentesis
Digital rectal examination (DRE) / prostate examination and breast examination
Hemorrhage control
Wound dressing
Evaluation of the overall program was done by a prevalidated structured Post-Course
Test through Multiple Choice Questions (MCQs) on each topic covered in the orientation
program. Pretest and post-test assessment was conducted for sessions on Hand Hygiene
and Biomedical Waste (BMW) Management as well as Occupational Hazards and Vaccination.
Only post-test was conducted for the rest of the sessions due to time constraints.
Interns were requested to fill the feedback form in which they gave their opinion
on the overall quality of the program, time given to each session, content of the
program, trainee and resource faculty integration, delivery of the content, and enhancement
of skills after attending this training program. A few open-ended questions were also
included, for which they were asked to give a descriptive response.
Skill stations [Tables 1 ] and [2 ] were arranged and delivered through small group teaching of six to eight interns
per batch. Procedural stations were delivered with good interaction by the instructor.
Emphasis was given to discussing real-life situations with complexities that can be
involved and how to deal with them. The five-step approach of psychomotor teaching
was practiced for imparting specific skills (Step 1, conceptualization; Step 2, demonstration
through visualization; Step 3, deconstruction; Step 4, comprehension through verbalization
by trainee; Step 5, performance by the trainee with correction and reinforcement).
Each intern was allowed to practice adequately until the competency was achieved or
until the intern himself or herself felt confident of performing the task independently.
RESULTS
The internship orientation program was conducted in January 2019 for 107 interns and
again in January 2020 for 128 interns.
Effectiveness of internship orientation program
Effectiveness of the internship orientation module as an induction course for fresh
interns was assessed by a post-test conducted at the end of the course by objective
assessment through MCQs. The distribution of questions as per topics covered in the
post-test is displayed in [Figure 1 ].
Figure 1: Distribution of topics in the post-test
The majority of interns scored between 65% and 85% in the post-test, with an overall
mean score of 74.13 ± 7.18 (Range of score shown in [Figure 2 ]). Topic-wise performance in the post-test is shown in [Table 3 ].
Figure 2: Histogram showing the frequency of total scores in post-test
Table 3
Post-test scores as per the topic distribution
Topic
Scores(%)
Patient safety
76
Patient registration/documentation/ADR monitoring
75
Humanities/communication skills, professionalism, interpersonal skills, and ethics
82
Ordering investigation and blood products
69
Procedural/examination skill training
84
Post-test scores were found to be highest for the procedure skills and communication
skills, including medical ethics followed by documentation and medical records and
patient safety. They scored lowest in the topic of ordering investigation and blood
products [Table 3 ].
Analysis of training on occupational hazards showed a statistically significant improvement
in post-test scores, 12.83±1.63, compared with pretest scores, 6.70±1.84 (P < 0.001), as shown in [Figure 3 ].
Figure 3: Pretest and post-test scores for training on occupational hazard (n = 232)
Analysis of training on hand hygiene and BMW showed statistically significant improvement
in post-test scores, 18.26±1.57, compared with pretest scores, 13.3±2.48 (P < 0.001), as shown in [Figure 4 ].
Figure 4: Pretest and post-test scores for training on hand hygiene and BMW management (n = 232)
Interns’ perception of orientation program
On analysis of interns’ perception about the internship orientation module and key
learning points learnt, 225 (96%) interns expressed that the time allotted for training
was adequate. According to 221 (94%) interns, content of the program and delivery
of content was excellent to good for the majority. The method used for training was
considered appropriate by 228 (97%), and the integration of trainee and resource faculty
was scored as very good by 223 (95%) of interns. Overall, 232 (99%) of interns felt
that there was skill enhancement after training and considered the training content
very useful [Table 4 ].
Table 4
Feedback of interns on training accorded (N = 235)
S. no.
Items
n (%)
1.
Time accorded for training
225 (95.7%) Adequate
2.
Content of program
115 (48.%) Excellent
106 (45%) Good
14 (6%) Average
3.
Delivery of relevant content
94 (40%) Excellent
124 (52.7%) Good
14 (6%) Average
3 (1.2%) Poor
4.
Method used for training
228 (97%) Appropriate
5.
Trainee and resource faculty integration
134 (57%) Excellent
89 (37.8%) Good
12 (5.1)% Average
6.
Enhancement of skills after attending this training
232 (99%) Yes
7.
Usefulness of training content
232 (99%) Yes
About 89 (37.8%) felt that basic life support was the most useful session, whereas
50 (21%) considered surgical and hands-on skill training as the most useful. Other
sessions that the participants found useful were soft skills, ethics, stress management,
and BMW management [Figure 5 ].
Figure 5: Most useful sessions according to interns during orientation program
In their feedback, a few questions were open-ended and interns expressed their views
and opinions, as depicted in [Table 5 ].
Table 5
Concise qualitative feedback given by participants on take-home messages on internship
orientation
•
‘Hand hygiene is a powerful tool’
•
‘Patient safety, priority along with self-care and motivation’
•
‘Be a good human, see the patient as yourself’
•
‘Good communication is important’
•
‘Affective skills and ethics are equally important as are cognitive skills and knowledge’
•
‘Medicine is a combination of science and art and this art in the form of soft skills
helps you deal with situations in a better and more successful way’
•
‘There is a lot beyond books’
•
‘Try to treat the person, not the patient and try to cure the person, not the disease’
•
‘A very beautifully structured program included every topic that is going to be an
integral part of our training as an intern. Besides, I am looking forward to putting
all of it into practical use’
•
‘Maintain professionalism, the internship is all about practicing under supervision,
ask seniors if any problem occurs’
•
‘Interpersonal relationship and soft skills are very important’
•
‘Learn to balance work life and personal life’
New skills learnt by interns
Interns documented that there were few new skills acquired by them through this program
module and they expressed that these should be included as a part of the undergraduate
medical curriculum. The newly acquired skills enumerated by them included:
DISCUSSION
During the medical undergraduate teaching and clinical postings, students are taught
the nuances of history taking and examination; however, their training occurs in a
controlled environment and the focus of the students while learning is to attain passing
grades (assessment-driven learning). Freedom to perform without the stressful influence
of being assessed at each step is a major attributable factor in differentiating an
undergraduate student’s performance from that of an intern. The clinical approach
of a student needs to be perfected with other attributes, culminating their transition
into a practicing clinician with professional competence, good communication skills,
stress-coping strategies, and ethical practice. It is imperative to sensitize these
interns during the orientation program to bridge the gaps left during medical school
teaching as well as enhance other required skills so that they become competent and
are motivated to serve as able members of the health-care delivery system.[1 ]
The medical education has taken its skyrocketing development with a scaffold increase
in medical graduates passing out every year as junior doctors. However, knowledge
of performing basic procedural skills still receives widespread criticism.[4 ] A study conducted by Hanson in Ireland revealed that 91% of newly graduating doctors
were not prepared for the skills needed as an intern and training in personal characteristics,
competence, and formal education during the internship period were found to be insufficient.[5 ] It has also been a general observation that internship is a time utilized by interns
to prepare for postgraduate entrance examinations at the expense of clinical work
and hospital-based training, which is another concern requiring attention. The results
of our study emphasize the valuable need to conduct an orientation program for interns
before their clinical postings start to familiarize them with their roles and responsibilities
regarding patient care.
A comprehensive orientation program prepares young graduates to work with confidence
and contribute toward patient care while practicing patient safety goals, medical
ethics, and communication skills, which were appropriately delivered to them through
this program. The results of our study favor the need for structured pre-internship
orientation and such programs can evoke further interest, increase efficiency, and
hone communication skills. The findings of our study are in agreement with the results
of the study conducted by the University of New South Wales, which evaluated a “Preparation
for Internship” course.[6 ]
“There is a lot beyond books,” a comment received from a participating intern sums
up the importance of our internship orientation program. Open-ended feedback received
from interns reveals the attainment of key learning points envisioned in this preinternship
training program. The response of interns as main stakeholders on the content, quality,
duration, and usefulness of the program reflects a good acceptance to the training
modules. An overwhelming positive feedback for procedural stations, basic life support,
and soft skills indicates their interest toward interactive and hands-on skill-based
learning. The self-reporting of interns by feedback forms, pre- and post-test helps
the teachers to predict deficiencies in educational opportunities and professional
behavior of interns. It can help in drawing the attention of the policymakers for
needful changes.[7 ]
Intervention through such tailored training programs on interns have been tried by
a few educators, with encouraging results.[1 ],[8 ] These interventions are effective educational strategies to hone clinical skills
and improve confidence in them.[9 ] Satisfactory feedback and improvement in skills were reported by Mckenjee et al ., who conducted a three-day training course of pre-interns on practical procedural
skills, and Laack et al ., who delivered a one-week simulated training course during internship.[1 ],[3 ] In contrast to these studies, our orientation course was a comprehensive program
comprising many skill assets, ranging from documentation, patient safety policies,
procedural skills to communication and team dynamics. Inconsistencies in educational
content can be a possible threat to its total functionality, hence a uniformity in
such programs is essential to ensure standard content and quality of training.[1 ]
A major concern in recent times is lack of knowledge of soft skills and this has escalated
disrespect to the profession among the public, which has led to an increase in physical
attacks on doctors in India.[10 ] Thus, social and emotional skills are inseparable from cognitive skills and they
are crucial for an effective thought process and decision making.[11 ] Emotional intelligence (EI) skills such as communication, self-awareness, empathy,
control on impulsiveness, the elevation of stress threshold, flexibility, and optimism
are ways to cope with challenges and these essential abilities are required in the
field of medicine.[12 ],[13 ],[14 ] Educators have also emphasized that EI development should be included in medical
school curricula.[15 ],[16 ] Hence, the emphasis has to be given not only to improve cognitive skills but also
in developing good soft skills to improve Emotional Quotient (EQ) along with Intelligence
Quotient (IQ). The Medical Council of India (MCI) has recommended the Attitude, Ethics
and Communication (AETCOM) Module and its implementation in all medical colleges in
India.[17 ]
Stress management is another area that is often overlooked in the undergraduate curriculum.[18 ] This should be included in the curriculum as well as pre-internship orientation
to help the interns to cope with their mental strengths and to balance professional
as well as personal life in this phase of transition. Basic life support, Humanities,
interpersonal skills, ethics, and stress management are topics that should be included
in the medical undergraduate curriculum, as expressed by interns in our study. Early
acquisition of these skills would prime the medical students to be a better professional.
The MCI has made a Foundation Course mandatory for first-year medical undergraduates
as soon as the students join the Medical College regardless of which Medical Institute
they join.[19 ] Along the same lines, we recommend that all medical institutions adopt a holistic
and comprehensive internship orientation program such as ours, to prepare the medical
graduates for their assigned roles as interns.
Limitations
A pretest was not conducted for all delivered sessions due to time constraints in
the seven-day training program and, hence, baseline knowledge and improvement in knowledge
could not be evaluated for all content delivered. We could not take Faculty, Interns,
Residents, and Patient feedback on their performance after attending this program
to assess the real impact of this program.
CONCLUSION
The Internship Orientation Program acts as a seed initiative to sensitize fresh interns
to the working environment of functioning as a qualified doctor. This program endows
fresh interns with knowledge, skill, and confidence, which would support them in their
transition from that of a student to professional life. It empowers them with a positive
attitude toward patient care and improves their attitude toward the doctor–patient
relationship as they step into the next phase, which is full of responsibilities and
commitment. The inclusion of a comprehensive intensive transition course, prior to
the commencement of internship is strongly recommended for an effective internship.
