The heart beat goes up to 200, the blood pressure goes up to 180/100 mm hg, pupils are dilated, tremors (+) in bilateral upper limbs………
These are not the case notes of a patient but of a final year MBBS student when his results have just been declared. Well for all practical purposes, one is a doctor now. Oh yes, a lifelong dream of oneself, parents, family and society has been fulfilled. For all practical purposes, just 12 months stand in between getting a registration number and a official prefix to one’s name.
But wait, 12 months???? 12 is a year. A year is long enough for things to change. So what does a medical student do for 12 months after he passes his final exam ? For the uninitiated, the answer is INTERNSHIP.
Now the definition of internship varies from hospital to hospital and sometimes even from a department to department in the same hospital. 1) In some places, an Intern is a mythical creature who exists on the record books, signs attendance register and then makes way to the hallowed sacred library to mug for post graduate entrance. 2) In a vast majority of places, an Intern is a multipurpose health professional: works up few cases, collects blood samples and traces reports of all patients, runs around to fix scans, echos, EEGs, makes uses of convincing and oratory skills to arrange blood, and anything and everything that a postgraduate or senior resident would want him/her to do. 3) However in a few places, an intern is part of a treating team, takes part in the case discussion on rounds, presents cases, is made to test his clinical competence or the lack of it that he has acquired over four and a half years of medical education. 4) And in still fewer places, an intern is the one who calls all the shots and takes all the decisions especially when on call.
So does internship actually become a life changing experience? Does the system make an intern a competent doctor who would be able to give primary care?
Speaking from the viewpoint of one who has just completed internship in a system that is based on definition 2 and 3 above, the answer lies somewhere in the middle path rather than the extremes and it would also depend on the individual as much as it depends on the system.
It’s a time when one gets to know more about their likes and dislikes, strengths and weaknesses. But most of all, internship can be an opportunity that either strengthens or completely nullifies misconceptions and prejudices.
Yours truly disliked surgery. In fact before setting foot in the department, fear of clumsiness, fear of what if something goes wrong was being played out in the mind. But 6 weeks in the department…… hold your breath….. Nah, I still wouldn’t want to be a surgeon but it did remove a lot of prejudice and misconceptions that I had. A realization that not all surgeons are gifted or born. Quite a few get where they are from practice was a comforting notion. Putting the first suture got me into quite a bit of tangle more than the suture!!! But there were post graduates/senior residents joking about how their first time was worse or funnier gave comfort. The good old adage “Practice makes one perfect” was epitomized with practice sessions on unlucky banana peels, leftover suture materials. Slowly the joy of scrubbing up, getting to cut, putting the final sutures and even assisting a transplant began to sink in with admiration for the subject that I really had not given much thought.
Every intern will have a story to tell on how internship changed perception of a subject. A male intern P deciding to choose OBG after 8 weeks of posting there will be the coup de triumph for the system called internship and yes, it did happen in my batch too. Or take the case of Intern J. – entered internship with the notion that he is going to move into management and move away from clinical sciences, but came out of each department wanting to do that subject in post graduation. One will never know whether it was the subject, the glam quotient or the challenge that kept changing his mind but yes internship can turn topsy turvy any pre conceived notion.
But what about the dark side if it can be called so. The fear and angst one feels when a subject they love the most is something that they cannot handle or get put off. One might have been passionate about medicine and would have been fantasizing himself as the Indian Version of HOUSE MD but 6 weeks of medicine posting and the dream is kaput!! The hectic schedule, the tiring duties, sometimes the monotony, being too theoretical might make an intern introspect and question his beliefs on a subject and whether he would like to pursue it in the future. Or take the case of someone who might be a born surgeon, excellent hands and skills but has an experience of being part of a surgical team which has outstanding results but at the same time few surgeries where the outcome for patient has not worked out well. Now the intern cannot sleep, is constantly thinking of why it went wrong, dreads going to follow up reports of those in the surgical ICU and decides to do a complete flip and apply for medicine.
Yes, internship can change an opinion of a subject drastically and more often than not I would presume, our decision for applying for a particular subject would be based on experiences in internship with patients, post graduates, and a huge role by the senior doctors in the department who can either make or break the opinion of a subject on the impressionable mind of an intern.
This brings to me a few suggestions on how internship can be modified and tweaked a bit to EMPOWER interns in choosing the right subject. Many sunrise specialities are something which interns in our country are not exposed to. Especially since the concept of shadowing does not exist, internship should be used to provide such opportunities.
1. Cut down the long postings such as medicine, surgery, to 4 weeks. Rigorous 4 weeks but enough time for interns to get a hold on the subject and explore it. This would also ensure more dedication from the side of interns who would not want to let go off learning/practical opportunities knowing that they have only 4 weeks.
2. Could also consider cutting down a few short postings if a institiute does not have a variety of presentation of diseases or if the patient load is not high.
3. Use the time obtained from this to post them in departments which are available at the postgraduate level, integrated degree or even some of the superspeciality departments as electives. Increase the number of electives a intern can choose based on the time obtained so that one can do dermatology, radiology, or even forensic medicine rather than having to choose one of the three.
4. Some of the subjects that come to my mind which require exposure at internship level are radiotherapy and geriatrics. Or with integrated degree such as neurology and neuro surgery available, posting in these departments might help a student reach a decision better. Or when one is in medicine, one can have postings in geriatrics, Medical Oncology, or if in surgery in Surgical onco, CTVS, Urology. I wouldn’t recommend postings in cardiology, nephrology because a medicine posting should be good enough to give an idea at this stage.
5. Policy change might be tough at the national level or a state level considering quite a few medical colleges. This must start off at the institutional level with teaching institutes which have the facilities to go ahead implementing it and creating a model for the others. Of course one way about getting over the issue of medical colleges which might not have all these facilities would be to start a “package” which can have rotation in these departments immediately post internship in other teaching institiutes or even corporate hospitals who would benefit from the extra manpower and at the same time an intern or just post intern would benefit from exposure to these departments without much financial burden.
Of course many of these suggestions are raw and come with their flaws but an idea worth exploring is worth a million than just being dumped. If we, the ones who are the core of the system and have been part of the system do not speak out constructively, we only have ourselves to blame for the stagnation and monotony.
As stated before, 12 months is a long time. Clinical competency, communication – is there enough being done to make us a “PROFESSIONAL” are all issues that we intend to touch upon to EMPOWER the occupants at the bottom of the hierarchy : INTERNS. But wise men say that Fortune lies at the bottom of the pyramid.
Until next time……………………