In Conversation with a Newly Graduated Intern
For educators and clinical supervisors, July is a stressful time when final year medical students transition to their first year of clinical practice, referred to most commonly as internship.The transitioning gap between medical school and internship is well described internationally and surveys and research consistently demonstrate a lack of prepareness for clinical practice amongst interns.
There are specific areas that new interns find particularly challenging: performing procedural skills, prescribing, acute care, decision making and working as part of a team. Errors pose a significant threat to patient safety and the impact of this lack of preparedness on the intern manifests as stress and burnout.
In the WNW Intern Training Network we have just completed 3 weeks of intern induction and bootcamp – an intensive simulation based programme for new interns, focusing on procedural skills training using task trainers, decision making around acute care using our virtual patient platform Medical Exam Tutor and team based training using hi-fidelity manikin based simulation. This programme aims to rapidly upskill the interns for safer practice in the clinical workplace. During the 3 week period, the interns do not work in the hospital at night but rather are encouraged to settle into their roles and perform skills and tasks new to them, fully supported during the hours of 8am to 5pm. They commence night duty in August.
Whilst this bootcamp programme goes some way towards helping the newly graduated doctors to be more confident and safer, it is not sufficient. New interns suffer from high stress and burnout levels and are often unable to do their job. Increasing, or in some cases introducing, this type of training in the undergraduate curriculum would go a long way towards improving levels of preparedness and in helping newly graduated doctors to manage their workload and stress levels – all forms of simulation allow students and interns to learn from error in a safe environment.
I spoke to a junior doctor who completed her internship 2 weeks ago and asked her to recall the initial few weeks of internship.
What were the biggest challenges for the first few weeks?
“Knowing and understanding your role in the team was particularly difficult. As medical students we are not immersed in the team – we sort of hang around the fringes and have very little dealings with nurses and allied health professionals (AHPs). It was not until I had a few weeks under my belt that I realised that the extended team (AHPs and nurses) were an invaluable source of information and support. I found the team based training in intern boot camp particularly helpful in imroving my teamworking skills and in working with the nurse. I just wish we had done some more of it in medical school.
Knowing your boundaries and limitations was also very difficult. It sound ridiculous but because I found everything difficult and new, it was hard to know what I was actually supposed to be able to do.
Procedural skills were a real challenge – even basic ones like venepuncture and cannulation. We had spent some time on phlebotomy as medical students but not enough to really get comfortable. I found the task based training in the intern bootcamp very helpful – small groups and helpful feedback. Initially I found even connecting extension tubing and opening and closing clamps difficult as my hands were not used to the equipment but the task training allowed me to practice these skills over and over without hurting any patient. I found it very difficult to maintain a sterile field or aseptic technique as I kept touching off everything.
Learning on the job, with a patient’s health, or even their life in the balance was probably the most stressful aspect of my internship. In hindsight, I wish there had been more simulation and task training in medical school – I think it would have given me to confidence to practice procedures on the ward under supervision as a student. At the time I think I was terrified to ask to perform a procedure as I was so nervous.”
Tell me about your first night shift?
“It was great that we had 4 weeks of no night time duty so at least I felt confident that I knew the wards and the nurses and some procedures etc. However the hospital at night is a different place and the first time my bleep went off I nearly had a heart attack!
I found dealing with ill or potentially ill patients very scary – I was the first person called to see chest pain, pyrexia and dyspnoea and was therefore expected to commence manangement and escalate the call. The most difficult part of the process was making decisions – making decisions around the investigations required, the initial management required and even whether or not I should call someone.
In medical school we say what we “would do” …”I would do A, B, C…” – in the real situation this is not that straightforward – you have to actually do A, B, C. What concentration of oxygen? What if he has COPD? How much fluid and what type and where to prescribe it? What rate? (no idea). Oh he needs a cannula inserted now so that he can actually get the fluid….not great at cannulation. Yes he needs an ECG but is that ST elevation or high take off? Do I need to call the cardiology registrar? He may be cross with me?
Things that may have seemed straight forward suddenly become huge challenges.
Intern boot camp was a massive help in preparing for these kind of situations. We worked through all the common intern emergency calls – PE, sepsis, STEMI, non-STEMI, LRTI, haematemesis, anaphylaxis and I improved my situation awareness, I learned to speak out and follow protocols. I dreaded doing the simulations if I am honest and watching myself afterwards on the playback but I learned so much that I would have liked to have gone through it again if I could have. I felt better after the bootcamp and went home to read up on some protocols!!
I have to say, I’m a big advocate of more simulation and practical skills training. If we could do this type of training in medical school, maybe every few weeks it would really make a difference. I think it would go a long way to solving the problems around preparing interns for these critical and stressful situations.”
Do you have any advice for final year students on learning to apply their knowledge?
“Overall I think that internship is like an apprenticeship and you learn something new every day and you grow in confidence. I think after about 12 weeks I had settled in and felt more comfortable with venepuncture and cannulation and no longer broke out in a sweat when I got a bleep during the night.
As interns we are the first point of contact for the unwell patient and we have to do so much more in terms of managing the patient, requesting investigations, interpreting them to come to some sort of an initial diagnosis and knowing when to contact the registrar or SHO for help. All of this is a very dynamic process that does require knowledge but much more it requires calm, focus and an ability to gather information and make decisions whilst using all resources available to you – other interns, nursing staff, anyone who can help you.
So the best advice I can give, is to address your learning needs and learn to do procedures correctly and follow protocols as early as you can. Ask for help from everyone, be an active part of the team and learn from observing them and your seniors. Just because you’re no longer a student doesn’t mean it’s time to ease up on the work. Put time aside when you’re off duty to address your learning needs.
Don’t be afraid to tell someone if you are suffering stress – tell another intern and access supports like intern tutors and occupational health if you need. Occupational health is totally confidential and very helpful.
Finally, be sure to take all of your annual leave and don’t be afraid to relax and wind down whenever you get a chance. One more thing – Keep up your extracurricular activities especially sports and exercise.”
Dr BH in conversation with DB
Medical Exam Tutor is a virtual patient platform which we have developed to address significant gaps in the preparation of medical students for immersion in real world clinical practice and is currently integrated into both undergraduate and intern training programmes. It harnesses the power of technology enhanced learning to allow learners to work through patient cases, making management decisions at every stage of the patient journey..