Training the intern: The value of a pre-intern year in preparing students for practice

Abstract

Aims: To evaluate the clinical and professional development that occurs during a New Zealand trainee intern year in preparation for the first house officer role.

Methods: A quantitative questionnaire was distributed to all trainee interns (year 6) and year 5 medical students in New Zealand at the end of the 2007 academic year. This survey assessed self-reported competency and performance across clinical, professional and role development domains.

Results: Response rate was 65% (457/702). Compared to year 5 students, trainee interns reported significantly greater competence and performance levels across all three domains. The greatest improvement occurred in the independent performance of procedural skills (trainee interns: 77%, year 5: 35%, p < 0.001) and clinical tasks (trainee interns: 94%, year 5: 56%, p < 0.001) and in the level of clinical responsibility taken (p < 0.001). At the end of the trainee intern year, 92% of students felt prepared to be a junior doctor, versus only 53% at the end of their 5th year (p < 0.0001).

Conclusions: The trainee intern year is important in preparing graduates for the intern role. The year affords increased responsibility and practical experience, whilst retaining an educational focus, facilitating the move from competence towards performance. Preparedness for practice was substantially higher following the New Zealand trainee intern year than has been reported with other pre-intern placements.

Introduction

The transition from medical student to intern is a significant and challenging time in a doctor's training (Lempp et al. 2004). It can be stressful for the young doctor and there can be varying expectations from employers and supervisors on their capabilities (Goldacre et al. 2003; Wall et al. 2006; Cave et al. 2007; Leeder 2007). It is important to align undergraduate with early postgraduate training to smooth this transition (General Medical Council 1993; Commonwealth Department of Health and Ageing 2003; Medical Council of New Zealand 2003; Dunedin School of Medicine 2007; Faculty of Medical and Health Sciences 2007; Royal Australasian College of Physicians 2007; Wellington School of Medicine 2007; Workforce Taskforce 2007).

Table

Practice points

The transition from medical student to junior doctor is challenging. The design of the final year in a medical programme may ease this transition. In New Zealand, significant experiential learning occurred during the trainee intern year that facilitated a move amongst students from competence towards performance. These results suggest that the trainee intern year prepares students well for the intern role.

Many medical schools have tried to ease the transition to internship by offering short periods of shadowing an intern (Jones et al. 2006) or ‘pre-internship’ placements (Evans et al. 2004; Lempp et al. 2004), usually of 2–4 weeks duration (Jones et al. 2006). In contrast, New Zealand has had a transitional year within its undergraduate medical curriculum. The concept of a ‘trainee intern’ or pre-intern year in the final year of undergraduate training was introduced in 1972, when the main barrier examinations were shifted from year 6 to the year 5 of undergraduate training (Allen & Colls 1994). The advent of a clinical apprenticeship was introduced to address the conflicts of education and service provision placed upon final year students (Anonymous 1972), and to deliver high levels of practical clinical experience and responsibility (Corboy & Herbison 1993). It was to act as a transitional year between medical student and intern, with trainee interns assuming responsibility for up to one third of the patient load (M. R. G. s. H. W. A. Committee 2006). Although a small stipend is paid to these students, the New Zealand trainee intern year remains under the jurisdiction of the medical school and has therefore retained an educational focus. This ensures that a trainee interns’ learning is not compromised by service obligations, but rather occurs in the context of increasing service.

There is increasing interest in the value of pre-intern experiences, and anecdotally, the New Zealand model seems to work well, yet there has been surprisingly little documentation about the value of a full year's pre-internship. This study aimed to explore this.

In this study, we compared medical students at the end of year 5 with those at the end of their trainee intern year in 2007, in order to evaluate the learning that occurs during the New Zealand trainee intern year.

Methods

Study population

New Zealand has two medical Faculties (University of Auckland and University of Otago) producing approximately 300 medical graduates per year. Both schools offer similar 6-year undergraduate programmes. The first 3 years are predominantly a mix of taught medical science and clinical principles, and the years 4 and 5 are focused on attachments through a variety of clinical attachments supplemented by lectures, tutorials and practical sessions. The main barrier exams are taken at the end of year 5 and following successful completion, students become trainee interns attached to clinical teams – namely general medicine, general surgery, obstetrics and gynaecology, paediatrics, psychiatry and general practice. In contrast with years 4 and 5, the trainee interns are fully embedded within a clinical team and are encouraged to be responsible for the supervised care of up to one third of the patients on their team. They are provided with a tax-free educational grant of $NZ26,756 per annum. Assessment during the trainee intern year comprises mostly a mixture of observed consultations in real life settings and supervisor's reports.

In 2007, all year 5 and trainee intern (year 6) medical students in New Zealand were invited to participate in this questionnaire survey. Surveys were distributed on the final academic day of the year by a third party at the University of Auckland and by anonymous student mailbox drop at the University of Otago.

Ethics approval

Ethics approval for the study was obtained from the University of Auckland Human Participant's Ethics Committee (UAHPEC) and from the University of Otago Ethics Committee.

Survey design

The anonymous questionnaire contained 39 items. Items were divided into four key domains; clinical skills, professional skills, role development and opinions and perceptions (Table 1).

Table 1.  Summary of questionnaire

Domain	Questions
Clinical skills	1. Levels of self-reported competence in the diagnosis and management of six common clinical presentations
	2. Levels of self-reported competence in the interpretations of common investigations in clinical settings
	3. Performance of procedural skills
	4. Performance of clinical tasks
Professional skills	1. Communication
	2. Professional skill acquisition
	3. Professional limitations
	4. Clinical ethics
	5. Cultural competence
	6. Clinical decision making
	7. Self-management
Role development	1. Role in the clinical team
	2. Acting safely and independently in clinical settings
	3. Approach to learning
	4. Confidence and preparedness for the first house officer year
Opinions and perceptions	1. Importance of the trainee intern year in preparing for first house officer position
	2. Importance of the trainee intern year in preparing for a long-term career in medicine

Questions for the survey were drawn from the skills identified in the Universities’ 5th year and trainee intern year student guidebooks, the Medical Council of New Zealand's Indicative List of Skills for Interns (postgraduate year 1 doctors) (2003) and the Royal Australasian College of Physician's Professional Qualities Curriculum (2007).

The survey was piloted and validated through a focus group of four medical students from the University of Otago and three medical students from the University of Auckland. These respondents were asked to comment on content, clarity, consistency, appearance and the potential for bias in the questionnaire. Potential ambiguities identified were corrected prior to the distribution of the survey.

Participants were asked to rate their experience and perceived skill level using 4-point Likert scales of competency and performance as outlined in Table 2.

Table 2.  Description of competence and performance levels used in survey

Diagnostic and management – Skill levels
Level 1: Proficient	I am able to identify main problems and differential diagnoses, propose and initiate a management plan in consultation with the team. I do this in clinical settings.
Level 2: Competent	I am able to integrate and synthesize key patient problems, main differential diagnoses and propose a basic management plan. I am able to implement elements of these under supervision.
Level 3: Advanced beginner	I am able to perform elements of history taking and/or examination techniques in controlled settings.
	For each problem, I am able to propose a short differential diagnosis.
Level 4: Novice	I am able to perform elements of history taking and/or examination techniques in controlled setting.
	I am not yet able to form a differential diagnosis for the clinical presentation.
Interpreting investigations – Skill levels
Level 1: Proficient	I am able to systematically describe the investigation, interpret findings and suggest an initial management plan in the context of the clinical presentation.
Level 2: Competent	I am able to systematically describe the investigation and interpret the findings in the context of the clinical presentation.
Level 3: Advanced beginner	I am able to describe the investigation in the clinical setting.
Level 4: Novice	I have seen the investigation in the clinical setting but am unable to describe or interpret it at this stage.

Competency for a graduating doctor was defined as reaching level 2 or above. That is, being able to integrate and synthesize patient problems, main differential diagnoses, interpret investigation results in the context of the clinical presentation, propose a basic management plan and implement elements of these under supervision.

Data analysis

Statistical analyses were performed using SPSS 15.0 software and GraphPad Prism 4.0. Chi squared tests were used to compare the percentage of students in the 2 year groups reaching the minimum threshold level of competency expected of graduating doctors as defined above. Mann-Whitney U-tests were used to compare differences in median scores on the Likert scales. The p-values <0.05 were defined as significant.

Multivariate analyses were undertaken to investigate whether university, clinical school, year level, gender and age were associated with the levels of reported competence and performance taken over all presentations or skills.

Results

Responses

The response rate was 65% (457/702) overall and 73% (275/379) and 59% (189/323) for year 5 and trainee intern students, respectively. The average age of respondents was 23.9 years (year 5) and 25.1 years (trainee interns). Males comprised 40% and 41% of year 5 and trainee intern respondents, respectively.

Clinical skills – diagnosis and management

Trainee interns were more likely to report high competency levels (Levels 1 and 2) in the diagnosis and management of the six surveyed common medical and surgical presentations (Table 3). 79% of trainee interns reported operating at the expected standard of graduating doctors for all six skills, versus only 66% of year 5 students (p < 0.05). In particular, 29% of trainee interns reported operating at competence level 1, compared to only 14% in year 5. Year level was the only independent factor associated with an increased level of competence on multivariate analysis (p < 0.0001, Wilks’ λ = 0.83).

Table 3.  Reported competency levels in the diagnosis and management of common clinical presentations and the interpretation of investigations by 5th year students and by trainee interns

Presentation	Year 5 (%)	Trainee intern (%)	p-value
Diagnosis and management
Chest pain	87	94	0.072
Acute abdominal pain	81	87	0.224
Unwitnessed fall	60	75	0.017
Shock/hypotension	55	72	0.009
Rectal bleeding	80	81	0.246
Electrolyte disturbance	37	64	<0.001
Interpreting investigations
Chest X-ray	83	90	0.107
ECG	79	89	0.041
Arterial blood gas	75	82	0.151

Clinical skills – interpreting investigations

There was no significant difference in reported competency levels between year 5 students and trainee interns, except for in the interpretation of ECGs; 79% versus 89% (p < 0.05).

Clinical skills – procedural skills

In all eight procedural skills, a higher percentage of trainee interns were performing these independently, compared to year 5 students (p-values range from 0.019 to <0.0001) (Table 4).

Table 4.  Independent performance of procedural skills and clinical tasks by 5th and 6th year students

Skill/task	Have performed – year 5 (%)	Have performed – trainee intern (%)	p-value
Procedural skills
CPR	11.7	90.9	<0.0001
IV Cannulation	84.4	97.3	0.019
Venous blood sampling	85	95.8	0.009
Arterial blood gas	23	84.7	<0.0001
Suturing	24	66.1	<0.0001
Cervical smear	24.7	53.2	0.01
Digital rectal exam	16.8	66.7	<0.0001
Male catheter	12.8	63.8	<0.0001
Clinical tasks
Ordered lab/radiology investigation	86.5	100	0.018
Prescribed medication	53.9	97.4	<0.0001
Charted fluids	37.8	95.8	<0.0001
Consented patient	25.9	76.2	<0.0001
Written a discharge	74.9	99.5	<0.0001

In multivariate analysis, the only independent predictor of procedural skill performance was year level (p < 0.0001, Wilks’ λ = 0.54).

Clinical skills – clinical tasks

Performance of all five routine clinical tasks (Table 4) without direct supervision was reported significantly more often by trainee interns than Year 5 students (p ranges from 0.02 to <0.0001). By the end of the trainee intern year, greater than 95% of trainee interns had performed five of the six clinical tasks surveyed. Performance rates for year 5 students by comparison was far more variable between tasks.

Professional skills

There was a significant difference in the percentage of trainee interns reaching the minimum expected level of a graduating doctor for the skill questions on communication with both the clinical team and allied health professionals and applying diagnostic reasoning in situations of uncertainty, compared to year 5 students. This was accompanied by a trend towards a significant difference in the ability to articulate limitations and in cultural competence amongst trainee interns. (Table 5).

Table 5.  Professional skills – year 5 and trainee intern students reporting reaching expected minimum level for graduating doctor

Professional skill domain	Year 5 (%)	Trainee intern (%)	p-value
Communication with clinical team	58	86	<0.001
Articulating own limitations	78	89	0.05
Applying diagnostic reasoning in situations of uncertainty	49	68	0.01
Communication with allied health professionals	40	55	<0.001
Cultural competence	40	55	0.05
Clinical ethics	29	32	0.76
Balancing priorities	47	57	0.20

Year level was the only independent factor associated with an increased level of competence on multivariate analysis (p = 0.02, Wilks’ λ = 0.95).

Role development

Likert scales were used to evaluate the role on the clinical team (0 = observer: 100 = actively involved). There was a significant shift towards active involvement between the end of year 5 and the end of the trainee intern year (46 (SD = 22) to 67 (SD = 19), p < 0.0001).

Similarly, a significantly greater proportion of trainee intern students reported being asked to act independently in clinical settings most days or everyday compared with their year 5 counterparts (49% versus 17%, p = <0.0001).

A shift in learning focus was also observed between the 2-year levels: 65% of year 5 students reported an approach to learning primarily focused on the assessment of their academic and clinical abilities. In contrast, the majority of trainee interns, 64%, reported focusing their learning primarily towards learning to be an intern (p = 0.001).

Role development – preparedness for intern year

92% of trainee interns versus 53% of year 5 students felt at least adequately prepared for their intern year (p < 0.0001).

Both year 5 students (95%) and trainee interns (92%) believed that the trainee intern year was important in preparing them for their intern role.

Discussion

The results of this study demonstrate a significant increase in students’ reported levels of competence and performance during the New Zealand trainee intern year. Marked development occurs across clinical, professional and role development domains. These differences persisted after controlling for age, gender and university. Development is accompanied by a shift from basic competence towards performance, important for the shift into professional practice.

The importance of a pre-intern attachment in preparing medical graduates for their first postgraduate year has recently been demonstrated (Evans et al. 2004; Lempp et al. 2004; Jones et al. 2006; Watmough et al. 2006). This is the first study to do so in the context of a year long pre-internship.

A marked increase in the performance of procedural skills and clinical tasks occurred during the trainee intern year.

Familiarity with these ‘bread and butter’ aspects of the intern role reduces the anxiety associated with the transition, and improve confidence (Lempp et al. 2004; Jones et al. 2006).

Taking on increasing clinical responsibility is an important aspect of the New Zealand trainee intern year. Trainee interns reported acting independently in clinical settings (without direct supervision in appropriate situations) on a regular basis. In contrast to year 5 students, they described their role on the clinical team as being more actively involved in patient care and team activities. Active involvement in the workplace and engagement with the clinical team has been shown to be important in the effective development of clinical practice (Sheehan et al. 2005).

Moving beyond university-based competence into workplace performance is important in developing effective clinical practice at an intern level (Sheehan et al. 2005). This may be because assessment up until the end of year 5 has traditionally tested students knowledge ‘competence’, rather than the application or ‘performance’ of that knowledge. In contrast, trainee interns focused on learning how to be an intern. This realignment of focus may facilitate a move by students towards experiential learning. In addition we hypothesize that the changing nature of assessment may drive this realignment of focus. In other centres, in which pre-intern periods have been introduced without a similar change to workplace-orientated assessment, a focus dominated by final examinations and progression has been reported. This appears to hinder the effectiveness of such a period in providing a bridge to assuming professional responsibility (Lempp et al. 2004).

That the majority of trainee interns (92%) in our study reported feeling adequately prepared to take on the intern role affirms the importance of a pre-intern year in the transition to working life. These findings contrast with other studies which have reported lower proportions of students feeling prepared for the intern role (UK; 58%, 2002, Australia; 64%, 2006) (Goldacre et al. 2003; Dent et al. 2006; Wall et al. 2006; Cave et al. 2007). These results support the notion that the design of a medical course can influence the preparedness of medical students for clinical practice (General Medical Council 1993). These comparisons should be interpreted by acknowledging they compare the end of a 6-year course with the end of 5-year courses. Nevertheless, they are still comparisons of final years in each course.

Early medical education should be broad, preparing students for a lifetime of clinical practice. Nevertheless the undergraduate curriculum should align with the requirements of the early postgraduate years (General Medical Council 1993; Commonwealth Department of Health and Ageing 2003; Medical Council of New Zealand 2003; Cave et al. 2007; Dunedin School of Medicine 2007; Faculty of Medical and Health Sciences 2007; Royal Australasian College of Physicians 2007; Wellington School of Medicine 2007; Workforce Taskforce 2007). Concerns about the low levels of preparedness for the intern role reported by UK graduates in 2002 (Goldacre et al. 2003; Jones et al. 2006; Watmough et al. 2006) resulted in the introduction of shadowing and pre-intern periods during the final year of medical school (Lempp et al. 2004; Jones et al. 2006; Watmough et al. 2006). Tomorrow's Doctor's (UK) recommends that students have ‘opportunities to shadow the PRHO post that they take up when they graduate’ (General Medical Council 1993). Early data from these interventions suggest that a short pre-intern placement provides opportunity for focused clinical apprenticeship not obtained in previous curricula (Lempp et al. 2004; Jones et al. 2006) and that this can improve feelings of preparedness amongst students (Jones et al. 2006). A year long apprenticeship has been part of the New Zealand medical curriculum for over 30 years. The high rates of preparedness to practice, reported in this study, suggests that such a model is valid and valuable. The length of the trainee intern apprenticeship may contribute to its success as trainee interns are seen as useful (and therefore valuable) additions to a clinical team, in contrast to less experienced year 4 and year 5 students.

We should emphasize that this article relies on self reports of competence, rather than direct measures of that competence. A further limitation in the analysis is that multiple testing was undertaken over the skills and presentations surveyed. However, the results within domains are consistent and the differences persist in the multivariate analyses even after controlling for age, sex and university.

Finally, this study asked trainee interns to assess their preparedness for practice before they had commenced work as an intern. This was in line with the timing of international surveys assessing preparedness for practice. However, whether trainee interns’ perception of their preparedness for clinical practice differed from their actual experience as an intern is an area for future investigation.

This study confirms the importance of a pre-intern year in preparing medical students for practice as an intern. The trainee intern year represents an integral part of this transition process in New Zealand. Learning occurs in the context of increasing clinical experience and apprenticeship. This facilitates a move from basic competence towards clinical performance, increases skill acquisition and encourages development of the professional role. The very high levels of preparedness to practice reported by New Zealand graduates compared to their international counterparts suggests that a pre-intern year can help prepare students for the intern role.

Acknowledgements

We are grateful to the medical students who completed the questionnaire. We would like to acknowledge Joy Rudland, Director of Educational Support and Development, Faculty of Medicine, University of Otago, for her input into survey design. This study was supported by the New Zealand Medical Students’ Association. We are grateful to the Medical Council of New Zealand for providing financial support through a summer studentship award to Anna Dare to complete this study.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Additional information

Notes on contributors

Anna Dare

ANNA DARE is a final year medical student at the University of Auckland and Immediate Past President of the NZ Medical Students’ Association.

Nicholas Fancourt

NICHOLAS FANCOURT is a PGY2 House officer at Auckland District Health Board and the Immediate Past President of the NZ Medical Students’ Association.

Elizabeth Robinson

ELIZABETH ROBINSON is a biostatistician at the School of Population Health, Faculty of Medical and Health Sciences, University of Auckland.

Tim Wilkinson

TIM WILKINSON is the Associate Dean (Medical education) at the University of Otago, Christchurch.

Warwick Bagg

WARWICK BAGG is the Associate Dean (Medical Programme) and Associate Professor in Medicine, Faculty of Medical and Health Sciences, University of Auckland.