Implications for Undergraduate Education
9.3 Key findings from the literature .1 Medical internship
Medical internship was introduced in South Africa in 1950 by the South African Medical and Dental Council and has been regulated and administered by the HPCSA from 1997. The purpose is to equip trainees with the knowledge and practical skills for them to become independent, competent and safe medical professionals having obligations to patients, health systems and communities (HPCSA, 2002). In the early years, internship training took place in specialised and sub-specialised departments and lasted one year. Initial lack of uniformity in the programmes led to some interns spending six months in medicine and six months in surgery without exposure to other domains, such as obstetrics and gynaecology or paediatrics (Meintjies, 2003). Since then the format has become more structured with prescribed rotations through different disciplines (Meintjies, 2003). Criteria are set in terms of a minimum time spent in each domain, rather than competency-based exit criteria.
The structure of rotations from a one year to a two-year programme was phased
in from 2005 in order to address skills deficiencies in unsupervised CSOs, as brought to light by the Confidential Enquiry into Maternal Deaths in South Africa (Moodley et al., 2014). However, despite accreditation and monitoring of health facilities, there is considerable variation in the quality and scope of internship supervision and practice at facilities due to situational challenges. The major issues raised repeatedly by junior doctors include excessive workloads, overtime work, stress and sleep deprivation, in addition to the predictable adjustments from university to the world of work (Essa, 2010; Sun et al., 2008). Sein and Tumbo (2012) identified the determinants of effective training in internship as good-quality supervisors, effective supervision, adequate opportunity for experiential learning, conducive environment, good support system (hospital management, hospital staff, academic opportunities), personal attributes and reasonable workload.
Internship for medical and psychology graduates is regarded as part of their training, as laid down in the following extract from the Health Act regulations 2009:
4.1 The curriculum of a student in medicine shall provide for (a) academic learning, (b) training and development of skills; and (c) development of a student’s professional attitudes and conduct.
4.2 On the successful completion of the curriculum referred to above, such student should have developed into a basic medical practitioner under supervision in an approved internship programme.
4.7 In order to develop a graduate who has all the above characteristics, a two- phased approach shall be followed, consisting of undergraduate education and training, followed by an internship training programme.
It is noteworthy that although internship is legally part of professional training in South Africa, it does not involve tertiary educational institutions. By contrast, in other countries, internship or its equivalent (known in the uk as Foundation years Fy1 and Fy2 and in Australia as Postgraduate years Pg1 and Pg2) is managed by postgraduate councils or deaneries and includes a strong academic component.
In countries where there is a greater involvement of tertiary educational institutions, this appears to benefit the learning and development of newly qualified doctors (Higgins and Cavendish, 2006; Pardhan and Saad, 2011; Sein and Tumbo, 2012). In a study conducted in Ireland, 84 interns considered an improved clinical experience throughout the undergraduate years to be at the heart of curriculum development but stressed that, to succeed, it would have to be accompanied by leadership within the healthcare system and efforts to improve the learning environment after qualification (Hannon, 2000).
Problems with internship in South Africa were highlighted by two studies in the 1980s.
A national survey of interns in 1982 and 1983 by Brink et al. (1986) drew a response rate of 85%, and found long working hours, lack of formal training and negative attitudes towards the medical profession. They showed a loss of enthusiasm for medicine over the course of the internship year, and recommended urgent changes including that universities should be involved in internship training, and a more formal, structured vocational training programme be implemented. Touyz et al. (1988) surveyed interns in Johannesburg hospitals in 1985 and 1986 and found similar levels of stress, workload and lack of sleep, with around 40% reporting a loss
of interest in medicine. They suggested that this is not unexpected from interns who are fatigued, anxious and excessively stressed, with inadequate in-service teaching in most departments. Their recommendation of support groups and a mentoring system, is still relevant, and could turn internship into a more reflective experience by making the professional and personal development aspects more explicit.
The key competencies required of a South African medical graduate have been studied extensively (See Chapter 6), and most studies report that final-year students felt well prepared for internship (Draper and Louw, 2012). Nkabinde et al. (2013) found that the two-year internship adequately prepares South African medical graduates for CS, and that has provided the basis for independent medical practice in district hospitals. However, certain critical skill gaps need attention, particularly in obstetrics and anaesthesia. Areas of weakness in ear, nose and throat, urology, ophthalmology and dermatology could be addressed by including these as a compulsory rotation in surgery, medicine or family medicine during internship.
Clinical competence is the focus of most medical education studies, which tend to ignore the lived experience of interns. Medical internship is most often viewed as an apprenticeship, in which the novice learns through immersion in a work environment, through close observation of and interaction with experienced clinicians. Bandura’s social learning theory (1971) would view this type of learning as based in relationships rather than in knowledge or content. Lave and Wenger (1991) developed the situated learning theory involving ’learning as participation’
situated within ’communities of practice’. Professional identity formation is a major process during this period, which has implications for professional development and career choice. The social and psychological transition from university life, the frontline responsibility for patient care, the long hours without sleep, the development of professional attributes, and the attitudinal and ethical challenges of clinical work, all test the adaptability of the intern to an extreme. Those who have been through it see it in retrospect as a formative experience, refining the graduates’ professional identity through mastery of practical knowledge and skills.
Although largely a matter of individual development, Lave and Wenger (1991) emphasise the collective nature of the processes in terms of the norms and limits imposed by the professional community, which the novice is expected to conform to, as well as challenge.
In South Africa there has been little or no explicit effort to incorporate the reforms proposed by the Lancet Commission into internship training, such as the promotion of inter-professional education, or the ‘new professionalism’ that envisages HCPs as ’change agents’ engaged in ’critical enquiry’. In the absence of involvement of education institutions, interns are generally regarded as a junior component of the medical labour force, rather than as learners, let alone innovators. Immediate service pressures, particularly in low-resource settings, take precedence over learning, innovation, and even the health of workers. The reforms proposed by the Lancet Commission have little chance of being implemented, as the hierarchical system into which interns are inducted perpetuates the dynamics of power and maintains the status quo. Light (1988) postulated that apart from workload pressures, the hierarchical power structures contribute to making internship a potentially damaging experience. He links this hierarchy to the arrogance observed in interactions of doctors with subordinates and patients.
9.3.2 Pharmacy internship
Internship for pharmacists follows immediately after completion of four years of full-time study leading to the awarding of a B Pharm degree. The period for pre- registration is a minimum of 12 months. The year is important as an opportunity for the intern to gain practical experience and knowledge in the practice setting including community and institutional pharmacies, and manufacturing pharmacies.
During this period, interns complete a continuing professional development (CPD) portfolio, tutors submit progress reports and the intern writes the pre-registration examination, offered three times a year. After successful completion, the intern may register as a pharmacist performing CS in a public-sector facility before he/
she can practice independently. The pre-registration programme is based on exit- level outcomes which describe the knowledge, skills and attitudes required of an entry-level pharmacist. During the year, the intern should gain the technical skills to augment their undergraduate study.
This competency-based approach developed by the SAPC is salutary, as it directly influences pharmacy undergraduate education (Summers et al., 2001), and sets a precedent for other professions. There have been no published reviews of internship for pharmacists, but the first large group of CS pharmacists was studied in 2001 (reid, 2002). In an exit questionnaire, the vast majority felt that they had made a difference during the year, and had developed professionally. Pharmacists placed in institutions where there had never been a pharmacist especially rural hospitals made a tangible difference. Examples included introducing new stock systems and budget control, better patient counselling, training of primary care nurses on drug use, and attending ward rounds. Most CS pharmacists felt valued as part of a team, and played a part in management of the pharmacy or unit. However, there were enormous variations in the quality of management.
9.3.3 Clinical and counselling psychology internship
Leach et al. (2003) examined the state of counselling psychology in South Africa through discussion of its racial history and present-day positions, and noted that counselling psychology is undergoing significant changes. Pillay and Johnston (2011) found that only a third of clinical psychology interns felt adequately prepared for their internship, and one-third planned to emigrate. Pillay and kramers (2003) reviewed the intern clinical psychology training programme for a 20-year period (1981 to 2000). They reported a significant increase in female interns and found that a quarter of former interns were working outside South Africa, the majority in Europe.
Counselling psychologists are often at the frontline of societal friction and trauma, as they deal with the ’downstream’ consequences of the socio-political determinants of health. when compulsory CS was instituted for clinical psychologists in 2003, Pillay and Harvey (2006) found that more than half the respondents were not proficient in the primary language spoken by their patients. Notwithstanding the difficulties, around 90% of the sample believed they made a difference in the communities they served. In line with other studies of newly qualified HCPs, kottler and Swatz
(2004) describe intern training as a rite of passage, similar to an initiation process.
For psychologists this involves moving from lay to professional status. watson and Fouche (2007) suggested that the counselling profession is struggling to establish a relevant identity that addresses the inherent problems created by South Africa’s history. More assertive social advocacy would enhance the status of the profession.
Counselling interns are potential change agents who are well placed to make a difference beyond providing clinical care. Empowering people with the tools to deal with challenging work, family or community situations before they develop mental illness, could prevent a significant amount of ill-health.