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EVERY year teaching hospitals around Australia have to deal with some medical interns who cannot manage the clinical environment.
Often it was clear before these graduates entered the hospital system that they couldn’t manage.
Some have overwhelming anxiety or other mental illness. Some have academic skills but do not have good problem-solving skills — or simple commonsense.
Some have passed exams but have not invested enough time in hands-on clinical training to be “work-ready” when they start employment as a clinical doctor.
Whether the problem with these interns is impairment or lack of aptitude, the result is a group of people with a medical degree who are unable to effectively practise medicine.
The only answer seems to be to hold them in the hospital system in highly supervised positions for prolonged periods.
This not only presents a burden to the clinical service where they are employed, but sometimes can delay the recognition that — in reality — not every medical student is suited to clinical medicine.
This problem raises some important questions.
Does an MB BS make you a graduate with a medical degree, or a doctor?
If a medical degree qualifies you to enter an internship, what responsibility does the university where that student graduated have to certify fitness to practise?
Should it be possible to obtain a medical degree if you don’t have the skills or aptitude to practise?
The vast majority of new graduates enter medical practice as hospital interns with a degree of trepidation, but without undue mishap.
As medical education becomes more hands-on and as hospital orientation procedures improve, the transition from student to practitioner is becoming smoother.
But these changes don’t resolve the problem of students who are not meant to be doctors in practice.
It’s time universities started to seriously consider answers to these questions for the sake of the profession, the medical students who can’t cope and the community as a whole.
Dr Ieraci is a specialist emergency physician with 25 years’ experience in the public hospital system. Her particular interests include policy development and health system design, and she has held roles in medical regulation and management. She also runs the health system consultancy SI-napse.
Posted 25 October 2010
I agree that a medical degree is just that, a degree and no more. I take the position that interns graduate being competent only to make a decision to prescribe paracetamol, and their real training begins from there.
I’ve found most of them are keen as mustard, regardless of how competent they really are, and will take every opportunity to learn. However, in 2010, they’re still treated as “dog’s bodies” and made to do tasks completely unrelated to medicine. They’re inhibited by ancient work practices that inhibit on-the-job learning. I’ve seen them paged literally every 3 minutes for non-urgent reasons – this results in what work psychologists call “work fragmentation”.
With the known high lifetime incidence of mental disease (about 20%) in the community, this is bound to be reflected in medical students and doctors, if not magnified by the stressfulness of our profession (we all know of colleagues who have taken their lives). Yet, there is talk of kicking people out. I would support this for colleagues who turn out to be sociopaths. The rest need mentoring, support, and more training, and if necessary, should be diverted to more suitable career paths. For a caring profession, we have a very poor record for the way we handle colleagues who are having problems.
I agree that not everyone who gets into medical school is cut out to be a doctor. Nevertheless, the way the government funds domestic students means there is little to no incentive for universities to fail students and even less so to kick them out completely.
I look at my classmates and even some interns/residents and have grave concerns about their ability to practise safely. Unfortunately, no one seems willing to kick them out and only the really bad ones have to repeat a year, with some very mediocre ones still making it through.
I suppose it is the same with every profession: for instance, not everyone with a LLB will make a good lawyer. It’s just that the stakes can be higher with medicine!
No, the universities are passing on students who are clearly unfit to practise medicine, possibly for fear of litigation. I once heard that a university attempted to fail a final year student who exhibited inappropriate professional behaviours. The university was sued by the student, who won, based on the fact that what is appropriate “personal and professional development” was not explicitly spelled out for students. I also studied and worked with a junior doctor who took 7 years to complete the 4-year graduate medical program. As an intern he was grossly incompetent due to a complete lack of empathy and disregard for safe patient care. He managed to get through a number of disciplinary reviews before (thankfully) quitting a few months from the end of his internship year. Had he not quit he would have gained full registration. This is not because of the hospital and clinical supervisors, who kept logs of his behaviour and regularly lodged complaints, but (I believe) because of the university which passed him despite a litany of behavioural/disciplinary issues during the entire 7 years he spent attaining his degree.
Maybe Dr Ieraci is right – but I don’t think she is thinking of it from the interns’ point of view – I was one of those interns who did well each term assessment – but personal suffering in the form of anxiety disorders (including OCD) combined with a dose of bullying from a couple of registrars made me feel unsupported in the hospital system to the extent that I left and now work in public health rather than clinical medicine. Who knows what I could have achieved in clinical with appropriate mentoring and support from senior hospital staff…so maybe it is training system itself and trial by fire approach that is failing…
This not a new problem and I confronted it as a DCT in the late 90s. We had such an intern and I kept meticulous and comprehensive contemporaneous notes throughout the year. There was no challange when we refused to recommend his registration but I was prepared. Too many people in similar cirumstances appear to brush the problem under the carpet or hope it will go away.
I teach my students that earning the MB, BS is the same as getting one’s driver’s licence, after which one teaches the person how to drive a car. The licence is just that, the licence to kill. The MB, BS is the same, the licence to kill. Until that point, we teach you to pass exams. Once you have the legal qualifications, THEN we teach you how to be a doctor.
Agree – the Emperor has no clothes and Sue has again been the person to say so. Worryingly, I have heard stories of interns who were judged not yet fit to practice at the end of their 12 months, but when they confronted the hospital with lawyers and threats of legal action the hospital folded and passed them.
Dr Dinehart’s suggestion is frankly alarming. Medical administrators may be charged with managing or counselling junior medical staff, they really need better than average interpersonal skills, and the fact that so many perform poorly is no reason for shunting yet more poor performers into administration.
You can’t have it both ways unfortunately! The relatively recent focus on patient safety comes at the cost of producing interns that hit the ground running. Medical educators are increasingly not letting students perform minor surgery or manage any real care of a patient due to fear of litigation, time, etc. I think it is also our responsibility as hospital doctors to encourage more hands-on work from students. Universities don’t provide this part of education, hospital doctors do. And maybe next time you feel that a student is not up to the mark, don’t just tick the pass column of the student’s clinical assessment. We have the power to ensure good doctors are produced.
The granting of MBBS following proficiency at passing the examination is a permit only. The newly graduated doctor as a junior resident/intern may have some academic knowledge, but practical skills are probably lacking and that is why experience is a great teacher and all newly graduated doctors should then commence an apprenticeship for a minimum of 2 years with an experienced consultant or graduate of at least 3 years.
It was always regarded as a major risk for patients who required emergency treatment in hospital casualties in the first couple of months of the year when ‘set upon’ by the newly graduated doctors!!
Valid point, Sue. But a university degree, in this case MBBS, is just that. It is a stepping stone to an MD, PhD or DSc and to postgraduate diplomas.
It is also what is required for registration as a medical practitioner. Two possibly separate career pathways.
The problem to which you draw attention is one for the Medical Boards to consider. Should the new registration law take your concerns into account? If so, how? Medical student selection has had a chequered career – would ‘clinician selection’ do any better? I share your concerns, but don’t know the answer.
Peter Arnold, former Deputy President, NSW Medical Board
When a student doctor shows signs of being unfit for patient care, they should be directed to specialties where there is minimal patient care or risk. By the time the schools determine that a student is really not suitable for medical practice they have invested many years and dollars to get as far as they have come. There must be somewhere they can be placed where their acquired skills can be utilised without jeopardising patient safety. Administration comes to mind!
Perhaps it is the duty of hospitals, consultants (and specialist emergency physicians) to ensure that interns make the transition appropriately. It certainly seems that almost all of them make it through as competent doctors after 1 year – and at most 2 – so why is this suddenly worthy of attention? Additionally, if an intern has an anxiety issue, is it not their employer’s duty of care to ensure appropriate support and referral?
Does an MBBS make you a doctor? Evidently not when it comes to employer-employee relations.
Sue Ieraci’s comments are always full of common-sense. This is no exception. Interns are always rostered to the Emergency Department during their first year, and exposed to direct patient contact. It is now usual for them to have a reasonable level of supervision and teaching (Thank Goodness!) – but the inadequate may still be menaces to their patients, colleagues and hospital. She is 100% correct: what are we going to do about it? ‘Common Sense’ is not very common!