Intern Case Study Report: Interns and Supervisors

Department of Education, Science and Training Australian Medical Education Study

Intern Case Study Report

Mary Lawson, Margaret Bearman and Alison Jones

August 2007

Table of contents: Intern Case Study Interviews

1. INTRODUCTION .................................................................................................................................... 2

2. METHODOLOGY................................................................................................................................... 3

2.1 GENERAL APPROACH............................................................................................................................ 3 2.2 INSTRUMENTATION............................................................................................................................... 3 2.3 INTERVIEWERS...................................................................................................................................... 3 2.4 SAMPLING AND ENROLMENT OF PARTICIPANTS.................................................................................... 3

2.4.1 Interns .......................................................................................................................................... 4 2.4.2 Supervisors................................................................................................................................... 4

2.5 AUDIO-RECORDING OF INTERVIEWS ..................................................................................................... 4 2.6 ANALYTICAL STRATEGY ...................................................................................................................... 4

3. RESULTS.................................................................................................................................................. 5

3.1 DEMOGRAPHICS.................................................................................................................................... 5 3.1.1 Interns .......................................................................................................................................... 5 3.1.2 Intern Supervisors........................................................................................................................ 5

3.2 INTERN RESULTS .................................................................................................................................. 6 3.2.1 Pre-Student .................................................................................................................................. 6 3.2.2 The Graduate ............................................................................................................................... 6 3.2.3 Medical School Education ........................................................................................................... 6 3.2.4 Transition..................................................................................................................................... 8 3.2.5 The Intern Role within a Community of Practice......................................................................... 9 3.2.6 Supervision, Support and Guidance........................................................................................... 10 3.2.7 Intern Development.................................................................................................................... 11 3.2.8 The Environment........................................................................................................................ 12 3.2.9 Specialty Training...................................................................................................................... 12

3.3 INTERN SUPERVISOR RESULTS............................................................................................................ 12 3.3.1 Supervisors on Undergraduate Training ................................................................................... 12 3.3.2 Supervisors on the Intern Role................................................................................................... 15 3.3.3 Supervisors on the Teaching of Junior Doctors......................................................................... 16 3.3.4 Supervisors on Preparation for Specialty Training ................................................................... 20

4. DISCUSSION.......................................................................................................................................... 20

4.1 LIMITATIONS OF THIS STUDY.............................................................................................................. 20 4.2 GENERAL DISCUSSION: “WHAT MAKES FOR SUCCESS IN MEDICAL EDUCATION?” COMBINED

PERSPECTIVES FROM BOTH COHORTS ...................................................................................................... 21

5. INTERN CASE STUDIES: SUMMARY OF STUDY ........................................................................ 22

6. REFERENCE ......................................................................................................................................... 23

APPENDIX 1: INTERN INTERVIEW PRO-FORMA .......................................................................... 24

APPENDIX 2: INTERN SUPERVISOR INTERVIEW PRO-FORMA................................................ 29

APPENDIX 3: A MODEL OF INTERN EXPERIENCE ........................................................................33

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1. Introduction The first year of medical practice is a critical one. It is frequently reported as being highly stressful. The year marks the transition from student to professional status. As medical students graduate and enter internship, they experience first hand how well their medical school education has prepared them for their first year of practice. Preparedness for the intern year has been a focus of attention as a key outcome of medical school education. However this focus has also been criticised as being too narrow. It has attracted criticism from those who view the practice of medicine as a continuum. In their view, preparedness for specialty training needs to be included as an important outcome of medical school education. This qualitative study is designed to investigate the experience and expectations of the graduate / intern and their supervisors during this important year. The key research questions, as outlined by the Department of Education, Science and Training (DEST), are:

1. How well prepared are medical graduates for their role as interns?

2. What are the interns’ own perceptions of their role, their performance and their preparedness for internship, and how does this change, if at all, over their intern year?

3. What are the intern supervisors’ perceptions of the intern role, performance and preparedness for internship, and how does this change, if at all, over the intern year?

4. What do interns feel their employers expect of them (in terms of duties and competencies) during their internship year?

5. What is the level of fit between interns’ day to day work and the required competencies as outlined by the employers?

6. What areas of their medical education did interns find particularly useful to the needs of their intern placement, and what areas could be improved?

These questions lend themselves to exploration via an in-depth interview methodology. This method complements other components of the DEST Australian Medical Education Study. For example, interns participated in surveys, focus groups and interviews as part of other fieldwork conducted in the Australian Medical Education Study but only in these intern case studies were they given the opportunity to report in-depth about the nature of the skills, knowledge and professional attributes required of them in the workplace. They were also encouraged to think about their level of preparedness for the next stage of training.

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2. Methodology

2.1 General Approach Semi-structured in-depth interviews were considered to be the ideal method for capturing the type of qualitative data required. Participants were drawn from three Australian states (New South Wales, Victoria and Western Australia). A target group of 10 interns and 2 intern supervisors per state were sought.

2.2 Instrumentation Interview pro-forma were designed for each group (interns and their supervisors). The intern interview pro-forma was structured and designed to match the key research questions outlined above. It collected general demographic information and tracked the changing expectations and experiences of interns from before medical education to completion of the intern year. The intern supervisor pro-forma was derived from the intern pro-forma. Again, it was structured in design and focussed mainly on the preparedness of graduates for internship. Both pro-forma were reviewed by several members of the project team, an external consultant as well as the DEST Medical Education Study Secretariat. Please refer to Appendix 1 for the final intern interview instrument and Appendix 2 for the final intern supervisor instrument.

2.3 Interviewers

Three interviewers were used in this study. One was an experienced senior researcher, the other two were research assistants, trained in the use of both pro-forma. Training took the form of role-play sessions with an experienced actor playing the role of intern or supervisor.

2.4 Sampling and Enrolment of Participants

Participants were enrolled through invitation from key contacts in major metropolitan hospitals. Contact with the interns was usually arranged via Medical Education Officers or their equivalent. Poster advertisements were distributed to intern groups, and potential subjects were asked to contact a member of the research team to volunteer their participation. Recruitment continued until the required number of interviews was completed.

One intern interviewee from NSW did not complete a substantial portion of the interview due to work commitments and was not considered to have participated. This interview was replaced with a further intern interview in NSW.

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2.4.1 Interns

Participants were selected for interview if they had completed PGY1 in 2006. There were two volunteers who responded to the local call for participation who completed PGY1 in 2005. As this was determined at interview, they were admitted to the study on an opportunistic basis. . Participants were sampled by state. Ten were drawn from NSW, ten from Victoria and ten from Western Australia.

2.4.2 Supervisors

Participants were selected for interview if they directly supervised interns. They were sampled by state. Two were drawn from NSW, three from Victoria and two from Western Australia. An additional supervisor was recruited in Victoria as one of the participants only indirectly supervised interns. However, the level of experience of this supervisor was considered high and the interview was included in the analysis.

2.5 Audio-recording of Interviews

Interviews were either conducted by telephone or face-to-face and recorded using digital audio recorders. All digital audio files were transcribed by specialist transcription companies.

2.6 Analytical Strategy

Three intern and three supervisor transcripts were read by two experienced qualitative researchers. They then created a coding framework to commence coding. The supervisor transcripts were considered too diverse to create a meaningful model; their data has been amalgamated into a qualitative report based on the broad themes of the coding framework. The two researchers then coded twelve transcripts between them; two of these transcripts being coded by both researchers. As the emerging data was strongly convergent, a model and associated theory was developed. The remaining transcripts were then read for counter instances; and the model and theory adjusted as necessary.

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3. Results

3.1 Demographics

3.1.1 Interns The ten NSW participants had an average age of 27 years. Three participants identified their ethnicity as Anglo-Australian or equivalent; seven identified themselves as being from a range of Asian ethnicities, including Chinese, Indian and Korean. Five had graduated from the University of Sydney; five had graduated from the University of NSW. There were eight males and two females. Six participants were intending to specialise in surgery; one in radiology; one as a physician; and two had not yet decided. The ten Western Australian participants had an average age of 26 years. Six participants identified as Anglo-Australian or equivalent; two as Asian; and one as Jewish. Nine graduated from the University of WA; one from Flinders University. Two graduated in 2004. There were seven males and three females. Six participants had not yet determined a choice of specialty; two were intending to become physicians; and two were intending to become surgeons. The ten Victorian participants had an average age of 26 years. Three participant identified as Anglo-Australian or equivalent; five identified themselves as being from a range of Asian ethnicities, including Chinese, Indian and Malaysian; one as Jewish. The genders of six participants were not recorded; the others were two males and two females. Six participants graduated from Monash University; two from the University of Melbourne; one from Adelaide; and one participant’s medical school was unknown. Six participants had not yet determined a choice of specialty or did not indicate their choice of specialty; the others were intending to specialise: in obstetrics and gynaecology; in surgery; in anaesthetics; and as a physician.

3.1.2 Intern Supervisors There were seven intern supervisor participants in total with two from Western Australia, two from New South Wales and three from Victoria. These seven supervisors were drawn from a variety of discipline groups. There were two consultant geriatricians, two Directors of Emergency Departments, one surgeon, one general physician and one neurologist. Supervisors were asked to provide their age range. The spread of ages was: one aged 35 – 40 years, four aged 41 – 50 years and two aged 51 – 60 years. Two participants described their ethnic origin as being White South African, three as Caucasian Australians, one as Indian and one as Asian Australian. Two women and five men participated in the supervisor interviews.

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3.2 Intern Results

A model of intern experience was derived from the data. This model demonstrates the transitions to medical school and into internship and the various elements of the community of practice which shape the intern role (refer to Appendix 3). The following theory provides further insight into medical school graduates’ development through internship.

3.2.1 Pre-Student At the beginning of their education, medical students had a range of expectations – some naïve, some realistic – of what medical school would entail. Generally though, they expected medical study to be rewarding and interesting. These expectations were instilled by a number of sources, including medical practitioners within the family, the portrayal of the profession on television and experiences of being a patient. However, medical school changed many students’ ideas of what medical practice involved.

3.2.2 The Graduate Medical school education generally prepared students well for internship. They graduated with realistic expectations of the intern role. Commonly, they had expectations of: large amounts of paperwork or clerical work; working in a challenging environment; consolidating skills; working in teams; patient management; and of deploying their basic clinical skills. Most expected to be working in an environment that would support their needs.

3.2.3 Medical School Education The most significant preparation for internship took place during clinical experience in the later years of medical school.

“I think the most valuable experiences I had would have been the in-hospital experiences not the in-lecture experiences because in lectures [you gain] an expectation of what the medical world is and what medical practice is but it’s not the same as actually being in a hospital and seeing sick people … The ‘hands on’ stuff is the better stuff.”

Intern L, WA The type of clinical experience appeared to be more important in preparing interns for practice than the length of time spent in the clinical environment per se. The critical factors identified included a structured pre-internship and whether or not they were assessed. Pre-internship placements were noted as being particularly useful:

“I felt quite prepared mainly by doing a pre-internship, I think. If I didn’t have the pre-internship I think …I would have had the wrong idea of what it would have been like.” Intern J, NSW

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“From the pre-intern year, I think speaking to all the other interns they pretty much tell you that your job is not as exciting as what you hoped it to be. And you’re pretty much the secretary of the department …” Intern K, WA

Medical school education generally provided the interns with the basic clinical skills and knowledge to begin clinical practice. Although some did not feel confident in the beginning, some of this was related to the emotions of transition to the workplace and their self-confidence.

“I felt less prepared than I actually was.” Intern M, WA

Once they had become interns however, their notions of preparedness changed. Some now believed they were unprepared for specific areas of practice. These were fairly wide-ranging and examples provided included difficult communication with families; communicating in other difficult situations such as breaking bad news; prioritisation of clinical problems; and team work issues such as inter-professional and intra-professional communication, negotiating the hierarchy or managing ‘politics’ in the workplace. Some also felt that they had been provided with concrete training in areas such as teamwork and communication skills. These two aspects may not be mutually exclusive: lack of preparation may not have been due to deficiencies in medical school education:

“[Medical school education] was lacking in ways that it cannot really repair.. It can’t teach you how to deal with how frustrating it is to cope with an enormous mound of paperwork … it can’t teach on how to deal with difficult registrars; it can teach you about the ins and outs of some of the various sub-specialties, you might be working in …. It’s a learning curve and [you] just have to bite the bullet.”

Intern I, WA

“On my first weekend’s cover, I had to tell a girl five years younger than me with two little kids that she was going to die within a not very long period, which it turns out was a mistake, thank Christ … Her family were absolutely devastated, her husband shouted at me for about fifteen minutes then apologised and burst into tears and I thought … go back to the yelling, I liked it a lot better. It’s very difficult …” Intern F, Victoria

Whilst the interns interviewed had graduated from various medical schools with different curricula they were, as a group, generally positive. Some queried the relevance of basic medical sciences or disliked rote learning; others wished for more clinical exposure; others reflected upon problem-based learning in generally positive terms. For the most part, they were satisfied with their preparation for clinical practice as an intern and the teaching methods that they had experienced to prepare them. An exception to this was those who had felt that their courses did not contain enough clinical experience.

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Generally, medical school education was considered to have also prepared interns for the years beyond internship.

“All of the interns could do a lot more than they are actually given. But your medical education is more than enough to do what is required for an intern year.” Intern G, WA

Participants’ own motivations toward study whilst at medical school appeared (either implicitly or explicitly) to contribute significantly to their level of preparedness for practice.

3.2.4 Transition The transition from graduate to intern can be a ‘steep learning curve’ for those involved. It represents a period when the individual has to assume responsibility for patient care. They are required to be accountable for their actions in a way they have not experienced as students. Whilst their focus as medical students may have been predominantly theoretical they are required as interns to address the authentic practice of medicine. This can be depicted as a shift from asking ‘what is going on with this patient?’ as students to ‘what do I do for / with this patient?’ as interns.

‘There’s a big difference between your actual clinical knowledge and then your application of it…. So you can actually find [something] out as a med student but then when you’ve actually gotta act on it … it’s a big difference…” Intern H, WA

Some pre-intern programmes provided more opportunity for the application of theory to practice. There was also a general sense that familiarity with an environment contributed to feelings of being better prepared:

‘I was fortunate enough to be going to the hospital for my internship that I was also a student at. So I was shadowing an intern for eight weeks and doing ward work … as an intern would but with things being countersigned like orders and medications and that sort of thing. So from that experience I think I was fully aware of what was required and was confident with the different clerical systems that were used at the hospital…that is one of the hardest things…”

Intern B, NSW Emotions such as anxiety, fear and enthusiasm are prevalent; they may drive some to feeling less prepared than they actually are. There was an overall impression of anxiety regarding the impact of not recognising serious illness; graduates were aiming “to do no harm”. The group was generally pragmatic about transition and, on the whole, saw the challenges of transition as inevitable. Some believe those areas that they felt ill prepared for (see section on medical school education) were aspects of working that can only be learnt ‘on the job’. For example:

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“… the politics bit is something you’ll never be prepared for… Until you’re truly working in it, you don’t really feel it… Because when you’re a medical student, you’re protected from all of that because everybody just rolls their eyes back and just go: ‘oh fine, she’s a medical student.’ But now that you’re an intern, you are one of the doctors ….” Intern C, Victoria

3.2.5 The Intern Role within a Community of Practice The new interns moved into a ‘community of practice’ [1] relatively smoothly. This term recognises that an intern is part of a much wider system of interlocking roles, where personalities, employment responsibilities, learning, enculturation and socialisation are interlinked. In general, within this community comes a unifying shared responsibility for patient care.

“You rely on people so much that you have to become part of the team, there’s no real choice about it… You need the registrars’ help and discussions. And a lot of that’s innate in the system where you have dieticians and speech [therapists] and physiotherapists. And everyone [is] having input into the patients … you just become part of it.” Intern H, WA

Within this, the interns generally perceived their main role as being clinical administration, including monitoring patients, admissions and discharge, ordering tests and ensuring that certain elements of patient management were well coordinated.

“[Duties were] organising tests, doing a bit of ward work, making sure those test were organised so things didn’t delay the patient’s management or [the] patient’s discharge. I guess to sum it up, [it] would be to make things run smooth … on the ward while they took care of the big decisions.” Intern A, NSW

This was implicitly a highly supervised role. Interns perceived themselves to be at the ‘bottom of the food chain’ within a clinical hierarchy. On some rotations, supervisors had slightly different expectations. For example, emergency rotations were commonly described as requiring more from the intern in terms of diagnosis but with more available support. ‘Cover shifts’ provided a distinctive change in role; these shifts were much less well supervised and entailed a lot more responsibility. One aspect of the intern role was an appreciation of their limits and within this was the requirement to be able to ask for help appropriately. As one participant commented:

“…Once you’ve worked out when’s the appropriate time to seek assistance then working in a clinical team is not a problem … There’s a two way street of being able to carry out instructions and orders and things from the people above you but then also knowing when to seek help when you’re out of your depth in a certain situation … I think [that’s] how [the] team structure works And once you get that sort of balance, things seemed to go alright.” Intern B, NSW

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Qualifying graduates had the expectation that they would be working within a supportive environment. In general interns described themselves as working within a culture of support. For example, as one intern commented:

“… Most of my registrars were extremely supportive, so whenever I had a really difficult patient they’d come along and handle the entire situation and they would actually really protect the intern a lot.” Intern C, Victoria

Interns generally felt the expectations put upon them were reasonable; and that they needed to perform their tasks ‘well’ and efficiently. There was a sense that expectations shifted during the year, so less was expected in the first few months of practice. Another fundamental aspect of the intern role was that it was designed to provide professional development through experience:

“Each [difficult] situation makes you better at dealing with the next difficult situation… To a certain extent you are [prepared by medical school] but it’s not until you’re actually faced with [challenges] and you do something and you think: ‘oh I could have done this better’. Intern K, WA

Two elements appeared critical to this development: ‘cover shifts’ and supervisors. In a sense these two elements were interlinked. On ‘cover shifts’, levels of responsibility were higher because, while supervision was always available if required, it was much less readily accessible as it usually entailed waking a registrar. However, as one participant noted:

“… the more responsibility you get given, the more you learn” Intern E, Victoria

Some participants explicitly commented that an intern required a willingness and self-motivation to learn in order to perform well in the system.

3.2.6 Supervision, Support and Guidance The community of practice provided, broadly, adequate guidance to the interns. However, this guidance was frequently opportunistic rather than formalised. For example, there was often no clear sense of the clinical supervisor role:

“Who [are] the clinical supervisors? I’m not sure who they are.” Intern D, Victoria

As junior doctors, the interns were supervised and supported by registrars, consultants, directors of clinical training, nursing staff and, to a lesser extent, other junior doctors. This support meant that difficult decisions or tasks were not undertaken alone; it enabled both high quality work and appropriate professional development. There was variability between environments and this possibly reflected discipline differences. In some environments registrars were more important and in others consultants were dominant. In some settings there was considered to be almost no support. However, on the whole, a culture of support existed. Likewise for the most part, interns found good role-models in their seniors.

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When adequate support was not given, for reasons of personality, incompetence, administrative difficulties or institutional dysfunction, the interns had difficulty in fulfilling their roles. In short, they were only prepared for practicing with support.

“A lot of medicine kind of depends on who you have as your seniors. And if you have good seniors then you’ll become a good doctor” Intern L, WA

As part of this formal support – which provided on-the-job assistance – there was another role for the senior members of the community of practice. This was a teaching role, where advice, feedback or guidance was given through more advanced practice. There was a sense that interns felt reliant on their seniors’ goodwill to provide this ‘extra’ teaching.

3.2.7 Intern Development Much of what has been described thus far in the community of practice provided ‘informal’ learning. This was either ‘practical’ through experience or guided by seniors:

“You do pick up a lot in your intern year that you don’t realise, and it was good to get a bit of a pretty broad spectrum [experience] because there were a lot of specialties, not just general [medicine] and surgery.” Intern G, WA

It is important to note that rotating through different environments may play a large role in both the development and satisfaction of interns. Particular environments provided specific opportunities for developing different skill sets. Likewise, as mentioned above, the challenges of cover shifts were viewed as a very important part of professional development. Formal educational methods, such as a once weekly lecture or tutorial, also played a role in intern development. Access to formal learning was a sizeable barrier, often due to workload. Individual institutional circumstances gave interns better access to these teaching methods. Some suggested that the informal and formal methods worked well together; many emphasised the value of the informal or on-the-job learning:

“The informal learning is generally one on one so there’s more facility to ask questions, it is directed at your level because your registrar or consultant has a feeling for where you’re at and they … know the principles involved for your level of understanding. They can tell you where to go from there if you wish to know more. They can take up the issue a bit later on if needs be … and very often they’re more clinically pertinent … points. Pearls of wisdom rather than just didactic nonsense that you can get from text books anyway.” Intern I, WA

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3.2.8 The Environment The institutional environment – including the clinical administrative systems, administrative expectations, staffing levels, staff morale and the logistics of rosters – clearly affected the experience of the intern. Hospital administrations often expected them to work long hours with heavy workloads. This particular component was highly dependent upon the specific environment of a department and/or a hospital. Lack of staff and incompetent administrative systems contributed to heavy intern workloads. Problems, if they occurred, appeared to be amplified in smaller and rural hospitals. Within a particular institution, the culture could vary considerably from department to department or discipline to discipline.

3.2.9 Specialty Training The intern year was seen as a step upon a career path. Participants described themselves as preparing for specialty training through experience; and needing sufficient experience before wanting to narrow their focus. They did not particularly relate specialty training to medical school education.

3.3 Intern Supervisor Results Data gathered from the educational supervisors fell into two categories. These were preparedness for internship and the internship itself. Under the category of preparedness for internship, supervisors drew on their expectations of what they thought undergraduate medical education should have provided as well as the characteristics of graduates developed beyond medical school.

3.3.1 Supervisors on Undergraduate Training Generalised impressions Supervisors made generalised comments regarding the capabilities of their interns which included both negative and positive aspects:

‘I would have to say that they are far less capable and more dependent and unable.’ Supervisor A, Victoria

‘My impression is that the knowledge has got worse ….. my impression is their communication skills have improved.’

Supervisor B, Victoria

This supervisor continued to comment specifically on the clinical knowledge and skills of interns:

‘Clinical knowledge was poor but on reflection I think probably their clinical skills are a bit better.’


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Specific gaps in knowledge, skills and attitudes Interviewees detailed the knowledge, skills and attitudes they felt that interns should have acquired at medical school. Although there was no clear consensus in terms of gaps in undergraduate education and training, some supervisors identified where they thought there were some deficiencies in preparation for the intern role:

‘…. because the patients admitted to hospital are generally sicker, I’m not convinced that young doctors of today have been adequately trained to identify the elderly sick patient who requires immediate attention and requires specific therapies.’

Supervisor C, Victoria

‘I’m confident they have a basic understanding of the pathology of people’s diseases but I am certainly not confident that they can detect when someone’s condition is deteriorating.’

Supervisor E, NSW

‘…. I think that with the excessive availability of high tech imaging equipment, CT scans, chest x-rays, MRI scans etc., our clinical techniques are sometimes not developed because there is an imaging route which can sometimes answer the question which could have been answered through a clinical examination.’

Supervisor C, Victoria To obtain the degree of proficiency in these areas is regarded by supervisors as requiring extensive clinical experience. Supervisors referred to some specific gaps that encompassed the skills and knowledge domains:

‘In my view they should have a better knowledge of oncology – it seems to be a subject which is not emphasised enough at the minute’


‘They are not well prepared in IV insertion, they are not well prepared in the prescribing of intravenous fluid therapy, and probably the most significant thing that they are not well prepared in is prescribing.’

Supervisor E, NSW

Specific areas where interns are well prepared Some respondents drew on areas where they felt graduates were well prepared:

‘they’re taught very well in the Australian system about evidence-based medicine and research… the sort of resources that are available..’

Supervisor D, NSW

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This particular supervisor also highlighted excellent practice in terms of patient-centred medicine:

‘they’re much more sensitive… more responsible towards the patient as an individual in terms of respecting their privacy, thinking of the impact of the illness upon them and certainly in terms of breaking bad news and the follow up.’

Supervisor D, NSW Work readiness and professional attributes Supervisors discussed some of the necessary professional attributes for being an intern. This was particularly within the context of being prepared for the world of work:

‘They [interns] get a shock when they realise that doctors are not highly regarded … they don’t appreciate that nursing staff for instance don’t get things ready for them or clean things up for them. They are not well prepared that they are at the bottom of the pecking order.’

Supervisor E, NSW

These comments draw on the perception that graduates need to be ready for ‘working’ and the need for medical school to prepare them for what that entails. This also reflected some of the comments about the graduates as individuals, rather than their medical education and how they adapt to the role of intern:

‘I mean the major barriers are, firstly the barriers that they put in place themselves, by their lack of initiative or interest…’

Supervisor F, WA ‘If they’re motivated, eager to learn, positive people then they will make good interns’ Supervisor B, Victoria

Responsibility emerged as a theme in comments relating to undergraduate education:

‘… they are not being taught to take responsibility…’ Supervisor A, Victoria

Other comments related to the need to be more emotionally resilient and to balancing workloads, some noting how other roles such as part-time work as a medical student or being a graduate on entering medicine can help preparation. Several interviewees noted that graduates vary and so it was difficult to generalise in terms of their preparedness. Some noted that the graduate may just not be suited for the job.

‘The individual variation is great, I think life experiences are great because of cultural differences etc…. so to make a blanket comment would be very hard.’


Teaching strategies Interviewees also reflected on the teaching methods used at undergraduate level. Some made suggestions for approaches that they felt would prepare graduates better for the role of intern, including the use of a ‘pre-internship’ rotation or ‘shadowing period’.

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‘I think when they are exposed to a pre-intern term when they are sort of supervised by another intern or another resident …. they actually tend to be better when they start.’

Supervisor E, NSW

‘The ones that come through the graduate medical programme …. When they’re in third year and they come and work on the wards for two months … that prepares them well. They have really as medical students got very involved in ward work…’

Supervisor D, NSW

3.3.2 Supervisors on the Intern Role Supervisors were quite specific in what they expected an intern to be able to do. There was a general focus on patient management and interns knowing their limitations:

‘they should be able to recognise a sick patient and get help appropriately….. they should be able to take a proper history and examination’


‘… to perform a sound, competent, clinical examination. Recognise what investigations are required for specific patients and that they have the ability to initiate therapy…. and importantly that they have the capacity to recognise when they themselves need help and ….. that they need more senior advice.’

Supervisor C, Victoria There were some comments relating to professionalism and attitudes:

‘attitude is extremely important in the sense of commitment to the patient, sense of commitment to the profession.’


‘I don’t think they are getting enough time to debrief and feel supported. I think they feel they are working too hard. I don’t think they are.’

Supervisor A, Victoria There was a general feeling that interns need to deal with taking responsibility – this was occasionally described as part of the theme regarding transition from student to junior doctor.

‘their attitude will be one of assuming responsibility, maturing through responsibility.’ Supervisor A, Victoria

Some attributed concerns about taking responsibility to the context in which the intern works:

‘They’ve got this thing of shifts – constantly handing over and I don’t think they are being taught to take full responsibility for what is there.’

Supervisor A, Victoria Supervisors drew on the skills interns would have to develop, with support:

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‘we need to put a little bit more time into for instance [into] pharmacology and prescribing and probably managing the common things they see in hospitals. Just going over the common things …. giving them better supervision.’

Supervisor E, NSW There was a view of the intern role developing over the year with an appropriate shift in expectations of them. This incorporated the role of the institution in supporting that development: ‘I think their practical knowledge should improve as the year goes by and their ability to interact and also make decisions that are appropriate to their level - should also improve during the year.’

Supervisor G, WA

‘we probably expect too much of interns at the beginning of the year….. that transition is often a difficulty.’

Supervisor F, WA

‘The organisation’s expectation is partially clinical care provision …I think my expectations are slightly different …. I think it’s both an educational and a working [role]. These junior doctors have been trained but need a lot more experience and supervision to get to that next level of competence and improving their capacity to practice autonomously.’

Supervisor F, WA There was some tension between the perception that interns needed to be around for a good length of time to learn the skills and take responsibility, but that they should not be over-burdened. This again linked to the graduates’ own perceptions of the intern role. It was also noted that other forms of support could be provided to ease this transition period for the interns, such as a counselling service to help them deal with the death of a patient. In general, interviewees did not underestimate the significance of their role as supervisors. The intern year was seen as a significant time for career development:

‘It’s a time when the intern actually has to apply what they have learnt over the last six years. … it is a defining year and depending on what happens in your internship year you might decide what happens for the rest of your life. It is an important year and a lot of it depends on the peer group and also the support that you get from the specialists.’

Supervisor G, WA

3.3.3 Supervisors on the Teaching of Junior Doctors In respect of graduates’ development during the intern year, supervisors reflected on their own experience; on how they themselves had acquired their skills to teach, what methods they used, as well as some of the challenges and benefits of the supervisory role.

The supervisor’s development as a teacher of junior doctors Many supervisors noted that they had received no formal training for their teaching role although some had attended short courses and had started teaching when they were at registrar level. Some reflected on how they had been taught and how their perceptions of the effectiveness of those methods had impacted on their own approaches to teaching. These

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experiences had shaped their own teaching in terms of both trying to emulate their positive experiences and also reject some of the negative ones.

‘There was an enormous amount of undergraduate time spent standing at the bedside having cases demonstrated. I would reflect on how boring that was in that often there was far too much talk and so … I would try and have the medical students or residents doing something rather than standing there.’

Supervisor D, NSW Few had received any feedback on their teaching skills, although one interviewee who had done some courses provided by the university considered that the experience had helped to formalise their ‘trial and error’ approach. Teaching strategies Supervisors expanded upon a range of methods that were used to help develop the interns’ competence, to include formal teaching as well as mentoring and supervision. They also identified the importance of the role of other staff in helping interns learn.

‘Probably eighty per cent of what they learn is as they are doing the job and a lot of it they learn from their registrar.’


‘… a sympathetic registrar who takes the time to tell them why each thing is being requested of them and what it means in a clinical setting…. If they are given a role that is not just running around chasing up results they get much more out of the term.’

Supervisor D, NSW The importance of good role modelling by the supervisors and their colleagues was also extensively noted:

‘I want to make sure that I give them a more positive role model so they want to do what I do, the way I do it…’

Supervisor F, WA Experiential learning on the job played a big part in interviewees’ perceptions:

‘I see it as an apprenticeship and a role model experience.’ Supervisor A, Victoria

‘…. The more time they spend in hospital, the more likely they are to be better, the more they read, the more likely they are to be better and the more they role model themselves the more they are likely to develop.’


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One interviewee noted the difference between undergraduate teaching and dealing with interns, with a shift in emphasis towards patient management:

‘I would teach them at the bedside in specific cases. We would do signs and classic symptoms, but we would certainly concentrate on, say compared with the medical student teaching, very much on what investigations are needed, what’s the follow up that’s needed and what’s the treatment that’s needed, so they would get very case based teaching…’

Supervisor C, Victoria Supervisors stressed the link between supervision and learning. It was recognised that this method of instruction may not be as transparent (and therefore valued) as more formal teaching sessions:

‘They bitterly complain that we don’t give them enough formal teaching because they don’t feel that they are learning anything unless they are sitting there and listening to you give a talk with a PowerPoint…. But the constant gentle, side by side guidance seems to be more effective… It needs to be complementary. So the tutorials are good for providing a framework but in terms of allowing them to develop their clinical reasoning and their experience in detecting illness and handling people, they are better off side by side coached even when they don’t notice.’

Supervisor E, NSW Formal teaching sessions were also seen to have their place, particularly where interns were likely to be exposed to the uncertainty of medical practice:

‘Ward rounds and grand rounds are fantastic ideas, because they get to learn from more than one teacher at the same time and there’s often a debate and interactions between teachers … which teaches a tremendous amount of understanding that there’s actually more than one opinion of the same condition.’

Supervisor F, WA Increased exposure to consultants and to acutely sick patients was also suggested as a more effective method for developing interns’ skills and abilities. Informal learning, rather than formal lectures, was seen as a valuable part of the process. One supervisor emphasised the importance of a structured approach to the attachments during the intern year, with an orientation, good supervision, mid-term assessment and end of term assessments being promoted as best-practice. The value of being able to identify any difficulties mid-term and to follow this up was noted.

‘They would get their same allocation of patients that a resident does and if we notice that they are struggling terribly then they get extra supervision.’

Supervisor E, NSW

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Supervision and role modelling were also related to future development and career paths. One interviewee noted:

‘…for a tutor or a teacher to actually encourage their junior staff to be interested in their own knowledge and advancement of their knowledge …. To see that next level…. Giving them some guidance on how to do that and I suppose even in time showing them future career directions and how they can achieve that.’

Supervisor F, WA

‘I suppose towards the end of the year you are talking more about what they want to do and where they should be heading.’

Supervisor G, WA Barriers and enablers of effective supervision There were several barriers or challenges in being an effective supervisor or teacher of interns. The issue of time pressures was raised, with perceptions of supervisors already being ‘over-extended’.

‘Closer supervision and more dedicated teaching time with less workload pressure would certainly be advantageous [to improve the learning experience of interns].’

Supervisor E, NSW One commented that time limitations also got in the way of allowing consultants to attend sessions on learning how to teach. One supervisor noted that better administrative support for their clinical role would free up time for teaching. Another was concerned about remuneration:

‘I think it would be fair to say that teaching is not remunerated possibly as well as it should be in the Victorian hospital system. With further medical funds you’ll find that their time was more carefully used [for teaching].’

Supervisor C, Victoria One supervisor noted how they were getting support for their teaching role. This support came from the hospital administration and the postgraduate medical council. A suggestion to improve the supervision of interns was to have a senior registrar position with specific responsibility for looking after the interns. Additional comments There were some comments from supervisors that related more to the environment in which they worked, but outside of any specific impact on their own capacity for teaching. These included references to restrictions on junior doctors’ hours, exposure to patients, less experienced doctors doing the teaching, experience of working with International Medical Graduates and new approaches to medical education.

3.3.4 Supervisors on Preparation for Specialty Training Preparation for specialty training did not emerge as a significant theme from the supervisors interviewed. Interviewees tended to concentrate on their role in supervising interns. One noted that preparedness for specialty training would really depend on the specialty that they were considering entering – commenting that there has always been ‘quite a big leap’ to the next level of medical training.

‘The actual theoretical knowledge needs a substantial jump from medical school to specialty entry….. They need to understand the input of all the different specialties on their patient generally before they go off into their own sub-specialty so that they know when to worry and who to call.’

Supervisor E, NSW It seemed that supervisors considered that preparation for specialty training came from the intern year and beyond, rather than from medical school education. One supervisor noted that specialty exposure at student level was ‘superficial’ and did not allow for an informed choice of specialty career path.

4. Discussion

4.1 Limitations of this Study The intern case study was originally conceptualised to collect data from interns at the start, middle and completion of their intern year. This would have enabled a degree of tracking to occur. As this was not possible within the practicalities of the study framework, it is not possible to know confidently to what extent the interns’ expectations and perceptions changed as they progressed. Interviews were undertaken towards the end or on completion of internship. It is possible that memory either augmented or lessened experiences. It was considered necessary to sample interns practicing in a number of States across Australia. Due to practical constraints, only ten interns in each of three States were interviewed. As the interns were interviewed towards the end or on completion of internship, they had experienced a wide range of clinical placements. It remains unclear in a study of this nature to what extent their experiences can be generalised to intern experiences across Australia. It is also impossible to attribute a particular experience to a particular clinical attachment. For the intern participants, a relatively high proportion of male interns were interviewed. This occurred in all states. Interns were recruited as they volunteered and there are no obvious reasons to explain a systematic bias in the recruitment processes adopted. However, it needs to be noted that there may be sex difference in both perceptions and experience of either medical school or internship that need to be taken into consideration. With the intern supervisor interviews, the interview process was not able to pinpoint examples that could be related to specific interns and their knowledge, skills and attitudes. This provided

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the potential for supervisors to rely on their own perceptions or biases. It was also noted that the supervisors were drawn from a range of disciplines. It would be difficult to expect a thorough exploration of perspectives on particular issues within a sample of the size used. In addition, the interns interviewed experienced a wide range of clinical placements that covered diverse disciplines and clinical settings. These differences were seen as influential in the intern experience but the range of supervisors included in the sample did not reflect this diversity comprehensively.

4.2 General Discussion: “What makes for Success in Medical Education?” Combined Perspectives from Both Cohorts It is notable that the majority of interviews were, principally, of a realistic and positive nature. Interns generally had reasonable perspectives when they commenced their medical school education. On graduation they were generally satisfied with their knowledge, skills and attitudes and felt fairly well prepared to commence the intern role. They also had largely realistic views of what the intern role would involve. Taking responsibility for patient care was a dominant theme. Both supervisors and interns identified and elaborated upon the tension that exists between being ready to take responsibility and needing to have the degree of experience to be ready.

If you are expected to take a lot more responsibility you generally do and if you do you do a better job Intern F, Victoria

Clinical experience was highly valued both at medical school and intern level. The shift in emphasis from theory to practice was generally embraced by interns on transition to the workplace. The issue of accountability was also common to both groups interviewed. For example, interns identified this as being a key factor in the transition from medical school when their focus was required to shift to being actively involved in, and responsible for, patient care. Some of the negative components of the job were viewed pragmatically as being an inevitable aspect of a challenging role. This is somewhat unexpected given the nature of some of the experiences reported by the interns. This is illustrated effectively by the early experience reported by intern F in section 3.2.3. This particular intern was unsupervised while telling a young patient that she was considered to be terminally ill. The intern in this instance felt that medical school could never provide adequate preparation for this experience. The intern did not ask for support in performing this task as “it was something that I felt I could deal with”. However, it is surprising both that the intern was left unsupervised in this instance and that there was a high level of acceptance by the intern in dealing with the situation.

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The fact that the majority of the interns interviewed were male needs to be carefully considered in relation to this finding in terms of potentially different levels and styles of coping between the sexes. Regarding potential deficiencies in the preparedness of interns for practice, there were notable similarities and differences between the interns and their supervisors. In terms of similarities, both cohorts focussed on preparedness for the actual role of the intern with neither highlighting major areas of deficiency for specialty training.

‘It doesn’t matter if they can’t answer a surgeon’s question in theatre if they kill the patient with an unsafe prescription before they get there”

Supervisor E, NSW

Both groups commented on the need for individuals to take personal responsibility for their learning and provided the perspective that ‘what you put in’ to the internship role related closely to ‘what you got out’. There were two notable differences between the cohorts in terms of perceived preparedness or gaps in preparation and values placed on different types of learning. Firstly, interns identified a range of non-technical skills (including complex communication skills) as being somewhat deficient in their experience. The supervisors focussed more on the need to be able to identify the sick or rapidly deteriorating patient and to act promptly and appropriately. Similarly the supervisors appeared to be more focussed on teaching methods at medical school whereas the interns themselves seemed generally satisfied with this aspect. Whilst both groups valued clinical experience highly, it did appear that supervisors placed higher emphasis on the potential of learning from bedside and informal teaching. It is possible that interns perceived this as less significant in terms of actually contributing to their learning in the internship year. This may be related to the transition from a university to a workplace learning environment. Role-modelling, together with level of supervision, were commonly recognised for their significance in shaping the intern experience.

5. Intern Case Studies: Summary of Study A set of structured interviews was conducted with interns and intern supervisors across three States in Australia. The interviews were designed to enable an in-depth picture of the intern year to be developed. They focussed, in particular, on the interns’ feeling of preparedness for their role, how that changed over the year and the impacts of the community of practice in which they operated. Thirty seven interviews were conducted and analysed in total, comprising 30 intern and 7 supervisor interviews. A model was developed to summarize the main themes raised by the interns, who were strongly convergent in their perspectives. Supervisor perspectives were more diverse, and are summarised under topic headings. There were some differences in perspective between the two groups, for example in terms of recognised deficiencies in preparation for practice. The tension that exists between the need to take responsibility to become competent and only becoming competent by taking that

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responsibility was elaborated on by both groups. There was a general level of satisfaction with the knowledge, skills and attitudes taught at medical school and the methods used to impart them. Level of supervision emerged as a key factor for successful completion of internship.

6. Reference [1] Wenger E. Communities of practice: learning, meaning, and identity Cambridge, U.K.: Cambridge University Press, 1998.

Appendix 1: Intern Interview Pro-forma

Experiences of Medical Interns in Australia

1. General 1.1 Participant ID#: _______________ 1.2 Interviewer: _______________ 1.3 Date: __ __ / __ __ / __ __ 1.4 Participants Gender: Male Female 1.5 Participants Age: __ __ years 1.6 Which ethnic group do you most strongly identify with: _________ 1.7 Site _______________ 1.8 State VIC WA NSW 1.9 Have you decided on a specialty training programme and if so which one? 1.10 Rotations completed in intern year Rotation Length Type (GP/Rural/Hospital) 1 2 3 4 1.11 Name and year of medical school at which you qualified: _________________ Our aim in conducting this interview is to enable you to describe your experiences of being an intern this year and to explore how well your medical studies prepared you for your internship. We will ask some questions to guide you, but feel free also to talk about the things that you think are most important to you in describing your preparation for internship and your experiences as an intern.

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2. Early Experiences with Medical Education I’m going to begin by asking a few questions about your early experiences in studying medicine. 2.1 Thinking back, what was it that attracted you to studying medicine? Probe

Why did you want to be a doctor? What motivated you to choose to study medicine? What did you expect medicine to be like?

2.2 How did you find the first few years of studying medicine? Probe

Did your expectations meet the realities of studying medicine? What did you like about your early medical school education? Was there anything you didn’t like or found challenging or difficult? Can you think of any examples of what you liked or perhaps found challenging? How well supported did you feel throughout this time?

(i.e. peers/teachers/supervisors/university) 3. Preparedness for Being an Intern We are now going to discuss how prepared you felt when you started your intern year. Again, I will ask a few questions, but feel free to expand or elaborate where you would like to. First, thinking back to when you were about to start your intern year: 3.1 What did you think would be expected of you as an intern? Probe

What did you think your role would involve? What do you think influenced what you thought would be expected of you? How did you feel about the year ahead? Were you in any way concerned about what you might face on a daily basis or your ability to cope? Why? Were you excited about the year ahead? Why? How did your medical studies inform your expectations of your intern year?

3.2 Did you have any expectations of yourself? Probe

What were these? What sorts of things influenced your expectations of yourself?

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3.3 How prepared did you feel to start your intern year? Probe

Did you feel you were adequately prepared? Why / why not? Were you confident of your clinical knowledge? Please describe How did you feel about your clinical skills? Please describe Did you think you were emotionally prepared? Please describe How about your ability to work in a clinical team? Do you think you were prepared for dealing with difficult situations?

Were you confident that you would be well supported? 3.4 Are there any aspects of being an intern that you feel could not be prepared for by medical school? Probe

What was this / were these? Why don’t you think medical school could prepare you for this area / these areas? Is there anything else that could or did prepare you for this area / these areas?

4. The Intern Year Now a few questions about your experiences d year. 4.1 Can you reflect or tell me about the experiences you have had over your intern year. Probe

What did you enjoy? What was difficult or challenging? How do you feel about your working conditions? Were you satisfied with your learning environment? Why / why not? How well do you think your medical education prepared you for your intern year? Why?

4.2 You spoke about what you thought would be expected of you during the year. What actually did your clinical supervisors expect of you? Probe

Ask about levels of expectations about duties and / or competencies Who expected the most of you? Were the expectations fair? Why / why not? In reality do you think your clinical knowledge was adequate? Why / why not? What about your clinical skills? Why / why not? How did you feel you coped emotionally with the demands of the year? How did you feel about the level of responsibility you were delegated? Was there ever a mismatch between what you expected and what your clinical supervisors expected? To what extent do you think your medical education helped you meet the expectations of your clinical supervisors?

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4.3 Did you feel well supported during the year? Why or why not? Probe

Who supported you? Could there have been anything else done to support you? Did you think there were good role models or mentors for you? Was there adequate guidance for you when you had to make difficult decisions? Did you ever feel mistreated? Why and by whom? If you feel you experienced poor role models, how did you deal with this?

4.4 How well did you think you performed throughout the intern year? Probe

Describe how you grew and developed throughout the year. Did your level of preparedness for the intern role change throughout the year? In what way? Were there any times which you found particularly challenging? How well do you think your medical education contributed to your performance throughout the year? Why?

4.5 Can you tell me about your learning experiences throughout the intern year? Probe

Can you describe what was positive? Did anything significantly influence your clinical education? What could have been improved? To what extent do you think that your medical education provided a good foundation for your learning experiences as an intern? How ready do you feel for specialty training?

4.6 In your opinion, what are the key things which contribute to the learning experiences of an intern? Probe

Perhaps, other interns, grand rounds, ward rounds, bedside teaching,, interaction with clinicians, interactions with other members of the health professional team, seminars or small group discussions, self-directed learning, reading, on the job experience etc. So do you think more formal or informal learning was a key factor?

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5. Suggestions for Change and Improvement 5.1 Overall, how satisfied are you with your intern year? Why? 5.2 What do you think could have been done differently to change or improve your learning experience? 5.3 Could anything have been done differently to change or improve your overall experience last year 5.4 Is there anything which could have been done differently during your medical education to change or improve your preparedness for your intern year and future specialty training? 6. Other We’ve reached the end of our interview. Is there anything else you would like to tell us about your experiences this year?

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Appendix 2: Intern Supervisor Interview Pro-forma

Clinical Supervisor’s Perceptions of Interns in Australia

1. General 1.1 Participant ID#: _______________ 1.2 Interviewer: _______________ 1.3 Date: __ __ / __ __ / __ __ 1.4 Participants Gender: Male Female 1.5 Participants Age Range: Under 30 years 31-40 years 41-50 years 51-60 years 61 years or over 1.12 Which ethnic group do you most strongly identify with: _________ 1.13 Site: ____________________ 1.14 State: VIC WA NSW 1.15 Name and year of medical school at which you qualified: _______________ 1.16 Type of current clinical location: ____________________ 1.17 Number of interns currently supervising: _____ Our aim in conducting this interview is to enable you to describe your experiences of teaching the intern year and to explore how well prepared medical graduates are for their role as interns. I’ll ask some questions to guide you, but feel free also to talk about the things that you think are most important to you in describing your perception of the intern role, performance and preparedness for internship and how this changes over the intern year. I’ll start by asking you to provide a picture of your own personal teaching experiences and responsibilities.

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2. Teaching Experience of Supervisors 2.1 Looking back, how did you – formally or informally – learn to teach? Probe

Can you list any teacher training that you have completed, for example any courses at your college?

When did you start to teach and under what circumstances? If any, how did formal teaching education assist? What do you take from your own experiences as a student?

2.2 What are your current clinical and teaching roles? Probe

What are your main responsibilities with respect to interns? What role do you play with respect to intern assessment? What are your other teaching responsibilities, including medical students?

2.3 How do you find your role as a supervisor and teacher of interns? Probe

What do you like about this role? Is there anything you don’t like or find challenging or difficult? Can you give examples of the above? How well supported do you feel as a teacher (i.e. by peers/hospital admin/PG medical

councils)? 3. View of Preparedness for the Intern Role Now I’m going to begin by asking you a few questions about your view of the intern role and what medical students require to enter practice. Again, I will ask a few questions, but feel free to expand or elaborate where you would like to. First, thinking back to interns at the start of their year: 3.1 What do you expect of interns? Probe

What do you think the intern role should encompass? What do you expect from graduating medical students in terms of knowledge, skills or attitudes? Why are these knowledge, skills and attitudes necessary for the intern role? What does the intern role involve? What knowledge, skills or attitudes did you expect them to develop as interns? Why do you have these expectations? How you think that your expectations of the intern role might have changed since you began teaching?

3.2 Is what you expect from interns aligned with what the organisation expects? Probe

For example in terms of the extent to which you follow local guidelines / frameworks to guide intern teaching / experience. Please describe

3.3 How well are graduating medical students being prepared to start internship? Probe

Do you feel that they are being adequately prepared by medical schools? Why / why not? Are you confident of their clinical knowledge? Please describe How do you feel about their clinical skills? Please describe How well are they being prepared to work in a clinical team? Did you think they are emotionally prepared for the role? (e.g. breaking bad news to patients, making errors etc) Do you think they are prepared for dealing with difficult situations? How do you think the preparedness of medical students has changed since you began teaching?

4. The Year 2006 as a Supervisor Now a few questions about your experiences last year. We are after some specific information of your interns so I’m going to ask about you about your interns as a group last year. 4.1 Can you reflect or tell me about the experiences you have had last year as a teacher of interns? Probe

What have you enjoyed about teaching or supervising interns this year? What was difficult or challenging? How do you feel about your teaching/supervising conditions? Were you satisfied with the teaching environment? Why / why not? Were you in a position to provide adequate guidance for your interns when they had to make difficult decisions?

4.2 What are your perceptions of your interns last year? Probe What did your interns find particularly challenging about their role? What did your interns find easy? Did your interns meet all of your expectations?

When they did not, what did you do? Are your interns prepared for specialty training?

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4.3 How well did you think the interns performed throughout last year? Probe

How did they manage the transition from medical school to internship? How did the interns’ medical school education contribute to their performance during the year? How did the junior doctor training programme contribute to their performance during the year? What other factors aided their progression? What factors impeded their progression? How did last years interns compare with previous years’ experiences?

4.4 What do you think interns require from their education? Probe

What are the most effective forms of intern education? (If necessary, prompt with: Other interns, grand rounds, ward rounds, bedside teaching, interaction with clinicians / other members of the health professional team, seminars or small group discussions, self-directed learning, reading, on the job experience etc) Who are the interns’ main role models or mentors? What is the role of informal learning in intern education?

4.5 What do you think the interns required from you as supervisor? Probe

What would aid your capacity to teach interns? What interfered with your capacity to teach last year? Do you think that you met their expectations? Do interns require additional support and if so what is the nature of support that could be provided?

5. Suggestions for Change and Improvement 5.1 Overall, how satisfied are you with the intern year itself? Why? 5.2 What do you think could be done differently to change or improve the learning experience of interns? 5.3 Is there anything which could be done differently to change or improve the overall experience of the internship year? 5.4 Is there anything which could have been done differently during the medical education degree to change or improve students’ preparedness for the intern year and future specialty training? 6. Other We’ve reached the end of our interview. Is there anything else you would like to tell us about your perceptions of the intern year.

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INTERN ROLE

Development

Pre-student

Medical school student

The graduate

Environment

Transition

Accountability; now feeling/being involved in patient care. ‘Inevitable’, ‘challenging’, an often emotional time (fear/anxiety/enthusiasm).

Working

Range of expectations and rationales for commencing study.

Generally satisfied with knowledge skills, attitudes and methods

Clinical experience in later years critical. Certain pre-internship experience

particularly useful.

Generally realistic expectations e.g. paperwork ‘dogsbody’.

“Teachers”

Institutional culture

Departmental culture

Teaching methods

COMMUNITY OF PRACTICE Patient care

Shared responsibility

Variation of role /support Generally culture of support

Without support cannot fulfil role

Ward work

Cover shifts

Workload

Seniors Peers Nurses Allied health

Support

Formal & informal

Responsibility

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Appendix 3: A M

odel of Intern Experience

Intern Case Study Report: Interns and Supervisors

Documents

Transcript of Intern Case Study Report: Interns and Supervisors