Doctors’ intern system is failing SA, warn medical deans
They want internships reduced to one year because raising it to two 'has not changed any of the health parameters'
Medical deans are suggesting that a doctor’s internship be reduced from two years to one because the community service and internship programme is “not meeting the country’s needs”.
Dean of the Wits medical school and former head of the SA Committee of Medical Deans, Professor Martin Veller, told Times Select: “The reason for considering the change is that it is the deans’ view that the internship and community process is not meeting the country’s needs.”
An increase in the number of interns had not improved health. “The lengthening of training has not changed any of the health parameters in this country.”
But the SA Medicial Association (Sama) believes the real reason behind the proposal is that the department of health (DOH) does not have enough money to pay all the interns’ salaries – an accusation the department has declined to comment on and which the medical deans have denied.
Sama president Dr Angelique Coetzer said the DOH was very keen on cutting internships because of a “bottleneck” caused by Cuban trained students.
An extra 700 Cuban-trained doctors will need internships in 2020. A further 700 Cuban-trained doctors will need internships in 2021, on top of the 1,200 locally trained students, she said.
“The health department is pushing this one-year internship. They don’t have the money [for posts].
“But they must be open and transparent and sort out their resources,” said Coetzer, adding that she believed the proposal would create inadequately trained doctors.
Veller said: “The motivation for our suggestion is based purely on training issues and has nothing to do with the issues related to cost. Indeed, it is our view that as this is a statutory requirement that the state must find the resources to pay for it.”
To become a doctor, students study for six years before completing a two-year internship at a government hospital. They then complete one year of community service, sometimes in rural areas.
The reasons given for the government increasing internship from one year to two years in 2005 was to improve medical students’ education by increasing their exposure to different disciplines, including obstetrics, surgery and internal medicine, in hospitals.
But this hasn’t improved doctors’ education or service delivery, according to the deans, who feel that, owing to a lack of supervision, the internship is not teaching students what they need to know.
Currently, interns are supervised by doctors in hospitals who sign off their log books using what Veller termed a “tick box” approach. For example, during a four-month obstetrics and gynaecology rotation, an intern needs to witness 40 Caesarean sections and have this signed off.
“As the universities are currently not responsible for this, little is done to ensure that the appropriate academic quality assurance processes are applied,” said Veller.
The deans want interns' training supervised by academics.
Nine years ago, the SA Medical Journal reported that interns were not properly supervised. “[Health Professions Council of SA] evaluations of internship posts have repeatedly shown that supervision is often lacking, and that even where supervision is present in the teaching hospitals, the internship experience is far from satisfactory,” it said.
Veller said it wasn’t only in rural far-flung hospitals that interns and community service doctors were treating patients without adequate support.
“Academic oversight in hospitals within metropolitan areas are often where the least training and supervision takes place.”
One doctor told Times Select his friend had been alone when he treated his first ectopic pregnancy (when a baby grows outside the uterus). In these cases junior doctors often used textbooks.
In what could be more controversial, deans also want to change the focus of the internship from academic medicine to primary care (improving service at clinics).
Primary care is diagnosing diseases and dealing with patients a GP would see rather than working with diagnosed patients who require specialist care, Veller explained.
One doctor, who was critical of this, said such a focus would lead to new doctors having too few skills and being able to diagnose appendicitis but not being able to remove an appendix.
Coetzer said the two-year internship cannot be shortened because doctors need practical skills they learn from working in different departments, unless the curriculum is changed. “You need to train in the practice of obstetrics and gynaecology. You have to do surgery. You need to do these things [deliver babies and do operations] during community service.”