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Preparing interns for practice in the 21st century

Stephen R Leeder
Med J Aust 2007; 186 (7): S6. || doi: 10.5694/j.1326-5377.2007.tb00957.x
Published online: 2 April 2007

In Australia, the mismatch between university-based medical education and preparation for the practicalities of lifelong professional practice has traditionally been confronted during internship — the year (or two) between university and specialisation or general practice. Internship was when wild-horse medical graduates’ spirits were broken and discipline was imposed by tough hospital managers and senior clinicians. The educational model used might have come straight from the military — tight rosters, hours of holding onto surgical retractors in theatre or of organising operating lists, days of admitting patients and trudging miles to retrieve pathology and radiology department results in preparation for rounds with “Sir”, and nights and weekends on call or in “cas” all confirmed the hierarchical command structure that ran through senior residents, registrars, and superintendents to staff or visiting medical officers.1,2

Most problems involve some contribution from the individuals they affect. Obsessional traits, which are not uncommon among doctors,3-5 may be useful in a rigorous study regimen, but they can also result in unrealistic perfectionism, inflexibility and alienation, which are counterproductive in the workplace.

The experience of those of us who completed internship three or more decades ago remains recognisable, even though the formality of the apprenticeship (all-white uniforms with ties) has changed, the working hours are marginally more humane, and pay for interns has increased.6 However, the challenges of these years remain substantial. This is despite educational reforms introduced by state-based committees,7 formal placement programs that broaden the opportunities for interns to venture beyond large city hospitals,8-10 and abandonment of the practice of allocating the unwanted to smaller hospitals with horrific workloads and no supervision. Concerns about patient safety have placed supervision centre-stage, with a more open system for reporting errors required. Junior doctors, who do most of the work, are, not surprisingly, involved in many of the errors.11-14

Ten challenges confront us in ensuring that the 2 years immediately after medical graduation are used to best effect:

Expanding the home of intern education to remote general and community practice

Modern IT and communication systems have enabled interns to receive training in remote general and community practice and still receive good quality mentoring and supervision. The expansion of education of medical students to rural and remote Australia has been remarkably successful. Students speak positively about the clinical substance of learning in these settings and the personal attention paid to them by clinical staff. Links between intern training and general practice have already been established in many places.

With the increased numbers of medical schools and the need for more places for clinical training at all levels of medical education, an expanded home for intern education that is quality assured and appropriately supported that extends beyond our big cities is being discussed.

Expanding medical education into private hospitals may also be necessary as the number of medical students increases in response to medical workforce policy changes. However, a decade of talk has seen little progress in the extension of specialist training into the private sector, and there are few specialist trainees working full-time in not-for-profit hospitals and almost none in for-profit hospitals. Recent discussion has focused on having advanced trainees in private hospitals, but that experience would be less valuable for interns. Private hospitals need major changes in governance before they can offer good intern experience.

Bridging university and specialty training

It is surprising that there are differences among universities, intern training programs and specialty colleges, given that many of the people who work in these programs are the same people. There is an encouraging and growing interest among the colleges (stimulated by the requirement that their training programs be accredited by the AMC, and by the dogged efforts of a few individuals) in developing educational programs, and not simply accreditation barriers, for their future fellows. Universities are commencing or reactivating postgraduate courses in medicine in various special areas. There are encouraging signs. Monash University has commenced a course in communication that spans undergraduate, intern and specialty training years. This will be an interesting experiment to watch, and it may set useful precedents for greater continuity of education in other fields (Neil Spike, Head, Department of General Practice, Monash University, personal communication).

The Confederation of Postgraduate Medical Education Councils has done well to come up with the Australian Curriculum Framework for Junior Doctors,18 which will have far greater meaning when a truly robust, effective, feasible and valid assessment system is in place. This is one among several promising prognostic indicators that intern education and support are taking a turn for the better. For that, many people who have laboured to achieve progress over many years should be praised for their tenacity and wisdom.

  • Stephen R Leeder

  • University of Sydney, Sydney, NSW.


Correspondence: steve@med.usyd.edu.au

Acknowledgements: 

I thank Associate Professor Merrilyn Walton and Professor Richard Ruffin for their conversation on this topic over months, and for their comments on this article; and Amanda Dominello for her help in its preparation.

Competing interests:

None identified.

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