Medical Internship Training Programme in a Medical College – Voice of Internees: Mixed Model research

Context : The interns after completion of rotatory training programmes are often reported to be non-competent and lacking in clinical skills to work independently in the community. Internship training in India is facing serious challenges such as faulty/virtually no curriculum for medical interns, disinterested learners and lethargic attitudes in programme implementation. Aims : To collect and analyse the perceptions/opinions and attitude of learners (Medical Interns) on teaching, learning and evaluation of the current Medical Internship Training Programme. Methods and Material : Qualitative data were collected by focus group discussions while the quantitative data were collected by a self-rated perception scale. Content and domain analysis was done for qualitative data and descriptive statistics was used for quantitative data. Results : Respondents reported no formal teaching and poor learning of skills. Interns were not required to deal with medico legal cases and emergencies during the training period. Work based evaluation was not done routinely and there was a lack of supervision and involvement of senior faculty in training. Communication with patients was very minimal due to hectic working pattern with no time for pre-PG preparation. The working environment was unsafe and interns were not confident to work independently as community physicians. Conclusions : Interns perceive the training program as very poorly implemented and producing semi-skilled doctors with less confidence in clinical and non-clinical skills and competencies.


Introduction
The Medical Council of India (MCI) describes internship as "a phase of training wherein a graduate is expected to conduct actual practice of medical and health care and acquire clinical and nonclinical skills under supervision so that he/she may become capable of functioning independently" (MCI, 1997).
Competency based learning includes designing and implementing a medical education curriculum that focuses on the desired and observable ability to perform in real life situations. In order to effectively fulfil the above roles the medical student would have obtained following set of competencies at the time of graduation from the M.B.B.S. programme: 1. Clinician, who understands and provides preventive, promotive, curative, palliative and holistic care with compassion.
2. Leader and member of the health care team and system with capabilities to collect, analyze and synthesize health data.
3. Communicator with patients, families, colleagues and community.
4. Lifelong learner committed to continuous improvement of skills and knowledge.
5. Professional, who is committed to excellence, is ethical, responsive and accountable to patients, community, and profession.  Chaturvedi & Agrawal (2001) and Lal (1999) In the past many studies have been conducted to evaluate various stakeholders, including interns. We could find very few studies dealing with the perceptions and attitudes of learners, (interns). Hence this study was planned to identify and evaluate the perception and attitudes of learners, for better implementation of Medical Internship Training Programme across the country.

Objectives
To collect and analyse the perceptions/ opinions and attitude of learners (Medical Interns) on teaching, learning and evaluation of the current Medical Internship Training Programme.

Subjects and Methods
The study was conducted at a care Medical College and teaching hospital in India with medical interns as study participants. The variables used were perceptions/opinions and attitudes regarding teaching (class room, hands-on, demonstration and PG preparation), learning (discussions, rounds, managerial and soft skills) and evaluation (knowledge, skills and attitudes), monitoring and supervision, communication skills, safety at work, motivation to work as a community physician, confidence to work independently, pre-PG exam preparation and suggestions for modification of the syllabus/ evaluation /period etc. Data were collected using both qualitative and quantitative methods.
Qualitative data were obtained by ten focus group discussions (FGD) conducted following standard FGD guidelines. Each FGD had 10-12 members and average time taken was 60-75 minutes. The responses were noted on FGD formats. The verbatim responses were changed to English for wider understanding by the readers. Data was then analysed using content and domain analysis.
Quantitative data were collected using a pre tested and validated self-administered questionnaire rated with Likert scales. The responses on perception and attitude of Medical Interns, were obtained on 5 point Likert scale (SA=Strongly Agree -score=5, A=Agree -score=4, N=Neutral -score=3, D=Disagree -score=2 and SA=Strongly Disagree -score=1). Average score was calculated for each item using the formula: Total no. of responses X score assigned / total respondents. An average score of more than >3 was considered as significant / effective. This data was analysed using the descriptive statistics. allocate the responsibility to his resident to teach some basic skills as given in the log book and then evaluate it from interns whether the resident taught them or not  Assessment of training should be completed by staff at each posting by concerned department and discussed in college council meetings  distribution of time in such a manner so that there is some time for self-study for PG preparation  8 hour duty (three shift) for interns to be implemented

Quantitative
Average score of all the items as given in table 1, were >3 except for the item "internship training helped learner to effectively deal with medical emergencies and ethical issues". The research project given during the internship training and rural postings was greatly appreciated by interns.  , 1997). This period of training which includes a sudden change of responsibility and accountability, is supposed to be under supervision and mentoring. This study showed the perceptions, feelings and attitude towards conduct of the Internship Training program.
The Interns reported no formal teaching/ training time table at departmental level; nobody was assigned the duty for responsible supervision, they were not allowed to do the clinical work, and required to do non-clinical assignments and casual evaluation. Interns were not confident in communication or emergency management skills and reported inability to work independently during and after internship. They opined that if interns were posted 8 hours in rotation, then PG preparation time will be adequate. Similar findings were also reported by Bansal (2004), Bhavsar (2010), Giri and Parhar (2012), Shreshta and Mishra (2008).
Other authors such as Simon (1992), Lal (1999) and Chaturvedi and Aggarwal, (2001)  responses. Interns were well satisfied with rural training as also quoted by intern in the FGD. It was only after completion of rural internship that they felt confident in interacting with and treating the patient.
In the FGDs, interns were mostly interested in hospital posting scenarios and would discuss of rural posting only on probing. Positive impact of this rural posting might be depicted in the attitude of interns resulting in some mismatch in qualitative and quantitative analysis.

Conclusions and suggestions
The Internship training program was very poorly implemented and producing semi-skilled doctors with less confidence in clinical and nonclinical skills and competencies.