The existing cumbersome and sometimes inefficient system of training, internships and community service needs to be revamped, streamlined and improved, a group of local healthcare professionals have urged.
Writing in the SA Medical Journal, the authors said junior doctors, who contribute significantly to the health workforce where medical practitioners manage a quadruple burden of disease, must complete two years of internship training and one of community service to work in state facilities after graduation to register as independent practitioners.
However, they suggest that more research should be done to evaluate the internship programme.
The 2030 Human Resources for Health Strategy report states that there were 43 503 doctors in South Africa in 2016, while the Health Professions Council of South Africa (HPCSA) had 43 901 medical practitioners registered in April 2020, with not all actively practising in the medical workforce.
The HPCSA said there were 4 458 interns in posts in April 2020.
If we extrapolate from the data in these two reports, medical interns comprise ~10% of all practising doctors here, making the adequate placement and training of medical interns, and the optimisation of their function, a critical component of ensuring health service delivery to patients countrywide.
Improve the system
There is little published research in the literature, and most of what’s there is relatively dated and does not evaluate the programme in its current form. Research should also consider the recent positive step of the addition of a six‑month family medicine rotation into the programme, and whether this makes interns feel more comfortable and competent for their community service year.
Government, interns, internship curators, community service medical officers and members of leadership committees should work collaboratively with interns to ensure clarity surrounding work expectations and roles interns should play within the health system. This must consider intern competencies and health system needs.
The transition from medical school to internship and the transition from internship to community service must be carefully evaluated to ensure practising doctors are both competent and confident in delivering care, especially care that involves procedural skills, clinical and biological knowledge, and experience.
This should be facilitated by the provincial Departments of Health, the individual hospitals/hospital complexes and the faculties of health science throughout the country where relevant.
Placements
Importantly, interns should be selected and informed of their allocation with a minimum of six months’ notice, so that they can plan their lives accordingly.
The current situation, where allocations are released between mid‑November and mid‑December for work beginning on 1 January the following year, is completely unacceptable and erodes the trust and fortitude of SA graduates, and should be urgently addressed.
The increasing number of medical graduates resulting from increased admissions to medical schools in SA and the return of foreign‑trained SA doctors needs to be properly accounted for when planning for remunerated internship and community service posts.
The NDoH and National Treasury must prioritise the placement of newly graduated doctors, acknowledging them as an important part of the health workforce, contributing significantly to the functioning of the health system across the country.
The transition from student to independent health practitioner is an essential part of the professional growth of health workers. When this transition is managed correctly, it lays the foundation for the rest of the practitioner’s career and can be hugely enriching.
When poorly managed, it contributes to cynicism, moral injury, disaffection and burnout.
More transparency about the governance and administration of the internship period is also necessary.
Specifically, there should be clarity surrounding the roles of the NDoH and the provincial Departments of Health, and access, for relevant stakeholders, to data on the number of available posts, the number of incoming interns, the number of unplaced interns, the number of doctors who reject their posts (and the reasons for this), and the percentage of interns who complete their two‑year period after starting the programme.
This recommendation is equally applicable to the community service year, where there are similar problems around placement and administration.
Internship critical
The medical internship period is vital to develop a skilled, competent health workforce in SA. Interns make up at least 10% of the practising doctors in SA, and our health system places a high workload and heavy responsibilities on them.
The aim of the internship programme is to create functional, independent and enthusiastic practitioners committed to a career in the health sciences, but there appears to be a mismatch between the intentions of the NDoH and the realities experienced by interns and community service doctors.
While there is limited research surrounding our internship programme, the existing literature suggests a need to improve the level of support for interns, particularly in the surgical disciplines.
Independent practitioners must be able to manage surgical, obstetric and anaesthesia cases confidently and competently, to the benefit of the communities they serve.
Among the few articles is a national survey conducted by Bola et al, which states there was a “significant failure in providing supervision of interns performing interventional procedures for the first time”. It is important to note that this study was conducted in 2013 and is therefore slightly outdated, but considering there is little else to draw from in the literature and that there has not been a large‑scale change in the programme since then, we feel that this article is worth analysing.
Those authors found that 33.0% of interns had performed a procedure for the first time without supervision, and 25.6% had experienced an adverse event while having no senior help available.
They hypothesised that this situation promotes a cycle of “confident incompetence”, which had been similarly described by Marteau et al in another context. It was found that experience without feedback or supervision increases confidence but not skill. Most (77.8%) of the interns surveyed by Bola et al said that this compromised patient safety, and 4.4% said that it compromised patient safety every single day.
The findings suggest that the level of supervision during internship in SA may not be satisfactory, creating a situation in which a large proportion of the healthcare workforce is not well equipped or well supported.
This state of affairs is concerning, especially when we consider the clinical responsibility placed on the internship cohort around the country.
New research is needed to guide interventions that will ensure that our internship programme meets its desired goals.
Training, with supervision and practice, significantly improves clinical competence and confidence of practitioners, something any internship programme should consider. Research shows that surgical skills workshops for trainees increase confidence and competence of medical students, regardless of pre‑training confidence, and that, after training, increased confidence is associated with increased competence.
The Departments of Health should prioritise researching, designing and implementing an internship and community service period that emphasises the clinical skills, reasoning and quality of an independent practitioner.
This must consider input from interns and student representatives as well as from health academics, leaders and civil society advocates, to gain broad perspectives on how to create an internship period that not only provides skills, training and support to our newly qualified doctors, but consciously harnesses their tremendous potential within our health system.
R Boden, MB ChB; M I Majiet, MB ChB; I Balde, MB ChB; T Naledi, MB ChB, FCPHM (SA); E Panieri, FCS (SA), MMed (Surg); L Cairncross, FCS (SA), MMed (Surg); S Maswime, MMed (Obstet Gynaecol), PhD.
See more from MedicalBrief archives:
Junior doctors still unplaced for community service
Review of SA’s 15 years of compulsory community service for doctors
SA Health system boosted 4,000 interns and community service practitioners
Mpumalanga interns told to find and pay for their own digs
Substantial number of community service doctors still unemployed — SAMA
SA medical interns finally allocated in-service training places