The Internship of 2015-2016

Introduction

Changes in the Life of an Intern

Life as an Intern was pretty simple in the past.  As recently as 2005 a typical internship in the British Isles and other Commonwealth countries consisted of 6 months of medicine and 6 months of surgery.  

You’d be working for a ‘firm‘ – part of the same team for 6 months… You would also be expected to work a horrendous number of on-call shifts, sometimes 24 hours on call with minimal recovery.  

This sentiment is graphically and somewhat cynically dramatised in the controversial 1990s BBC television show ‘Cardiac Arrest’ (worth watching a few episodes if you have time):

To comply with patient safety concerns as well as the European Union’s Working Time Directive and other legislation, the working system for Junior Doctors has been changed to keep interns away from most after hours duties (e.g. night shifts).  There has also a movement towards a shift pattern type of working week with either 8, 10, 12 or 14 hour shifts.

The changes in the working hours of Junior Doctors in most developed countries has the advantage of limiting burnout and maximising educational and day time training opportunities.  There are also perceived service provision benefits when out of hours ward cover is provided by more experienced practitioners.   Unfortunately the disadvantage of changing working hours is a relative lack of exposure to emergencies and overall experience in the first year of working as a doctor.  Some of this lack of exposure may be offset by Training in Simulation but it cannot be ignored as a potential issue.

The Intern of 2013 can expect to work around 75-90 hours a fortnight depending on local regulations.  In the UK an Intern will do 4 different 3 month jobs in their first year whereas in Australia Interns usually do 5 terms lasting 10 weeks in their internship.   With increasing numbers of graduates there are also multiple supernumerary jobs.  Interestingly, United States Interns are still expected to work much longer hours that those described above.

Old Training System Features  (A Historical Picture)

• Living on Site and a focus on Social Activities
• After-hours On-call
• Working Weeks of over 50 hours/week
• Working on a single ward and with the same people for up to 6 months
• Nights incorporated into every term
  • e.g. one week of nights every 8 weeks on rolling roster
• No paid overtime
• Less Supervision
• Non-specific Curriculum for Junior Doctors
• Subjective Workplace Assessments (WPA)

New Training System Features (The Future)

• Assessment and Appraisal
  • May include 360 degree feedback (Multi-source Feedback)
  • Teaching and Education for Adult Learners
• High Level of Competition for Training Jobs (this is not new but is increasing)
• Working Weeks of 40 hours/week or less
• Mix of during hours and after hours
• Use of alternative training methods (the end of “see one do one teach one”)
• Objective Workplace Assessments (WPA)
• Managing Emergencies less on your own –If you do encounter an Emergency due to “MET Call” Systems are early detection of the deteriorating patient the Intern or Resident is likely to be in secretarial or minor medical role.
• Age at graduation is higher – issues with work-life balance
• Less after hours cover (when not doing a relief term)
• Less pay (due to less working hours)
• More stress due to various factors including time pressures and government targets

Tips for the New Junior Doctor

Safe Prescribing

It is essential to think about a safer approach to prescribing.

Recognition that this is a high risk activity in the day of the Junior Doctor is important.

Summary

Elements of Good Teamwork

• A Clear Team Structure
• Adequate plan and preparation
• Skilled Members – (recognition of extra needs is part of good team work – call for help early)
• Effective Team Leadership
• Good Team Communication
• Full utilization of resources
• Wise management of people
• Share Common Goals
• Collaboration
• Regular Education and Training

When managing an Emergency Share your goals with the team (rather than a list of tasks).

Communicate using names and closed loop communication.

Debrief after Difficult cases and Emergencies and reflect on what went well and what could go better.

Try to share your thoughts and learning points with seniors as well as Interdisciplinary Team Members e.g. Nurses).

You should never feel completely isolated at a big hospital – there’s support available.

Graded Assertiveness

Raising a concern about a Senior’s actions in an Emergency can be very difficult and can feel like an impossible task.  One suggested method of bringing to attention a potential error is Graded Assertiveness – we suggest you gently “Cuss your Consultant”:

• C – CONCERN – I am concerned that we haven’t checked for allergies
• U – UNSURE – I am uncertain that this Augmentin duo forte medicine can be given to someone with a possible penicillin allergy
• S – SAFETY – I am really worried it is UNSAFE to give this patient a penicillin like drug given his known allergy.  I think this is a patient safety issue…
• S – STOP – Please stop – we need to take a timeout and discuss this further…

Recent Issues in the Medical Training System

The year in the life of an intern in 2013-2014 has changed a lot compared to twenty years ago when many of our hospital specialists and GPs graduated from Medical School.  The first year as a doctor has even changed significantly compared to 5 years ago when most registrars and trainees became interns.

The large number of graduating medical students has increased the number of interns significantly.   This pattern has occurred in Australia as well as many other developed countries.  A full list of statistics for Australia can be found if you Click Here.

As a result of problems with similar transitions in the UK system some Australian authors predicted there may be problems with increasing number of students and that early planning would need to occur to avoid the problems seen in the UK.

Increasing the number of graduating medical students should theoretically (at least in the government’s eyes) meet the demand for doctors both in urban and rural settings. However, the financial and logistical costs of training the increasing number of interns is very high. This has lead to a shortfall of places for the increased number of medical students to work and this in turn has lead to a great deal of stress for supervisors and applicants.

Some have labelled this mismatch as a crisis – and it certainly mirrors my memory of the UK system between 2005 and 2007 where there were similar stresses for medical students and junior doctors.

The Effects of changes in Training

Having noted some of the current issues with the training system that have recently taken place, it is highly likely, as was the case in my own experience of the UK system that ‘things tend to work out‘ for the individual.   Even though the process is competitive, we have not tended to see the majority of medical students or junior doctors left out of desirable and fulfilling jobs in their training.  Having said this, we do see and experience a lot of stress in getting to these goals.   In some cases the stress of the application process has lead to doctors in training filing legal action due the perception of unfairness in the system.  As long as the system is fair and has a degree of transparency hopefully we won’t see the same problems here in Australia over the next 5 years.

Finding your Career Path

Medicine holds an amazing number of “careers within a career” fitting a range of interests and lifestyle choices.  Our main tip in choosing a career is to take advice from multiple sources including both trainees in that speciality and more importantly consultants in your chosen field of practise who are less likely to be burned out and more likely to reflect your long term career.  You are likely to spend more time as a consultant than a trainee even if you change between specialties a few times or start late.  We suggest inviting doctors in your area of interest to talk about themselves and their career.  Most human beings won’t say no to this type of invitation.  It’s simply a quick meeting where you ask them about their career and why they chose it – most people like to talk about themselves to some degree so don’t be scared to ask questions about why the consultant chose their career.

If you are not sure about what you want to specialise in you should be reassured that this is common – we advice you look at multiple options and take into account where you want to be in 10 years time in terms of both career and your home life.

Jesse Spur from Injectable Orange blog and podcast has an excellent 10 minutes spiel about being a great intern (well worth a listen) – CLICK HERE

Conclusions

In conclusion, being a new intern is one of the most exciting times of your life in medicine and while it required both stamina and patience it is a truly rewarding experience.  Furthermore, the Junior Doctor has the opportunity to spend time with and learn from patients at the coal face of healthcare.   The learning curve is steep in the first year as a doctor but the leaps forward that are taken in a short time are always apparent.  The future holds ongoing and new challenges for the aspiring intern but none of these are insurmountable to the enthusiastic new doctor.

Good luck with your first year as a Doctor!!