How to make the most of your pre-internship term
Many final year medical students will currently be embarking a PRINT term or course. These are some of my thoughts on what you as a PRINT student should be trying to get out of the term and mirrors what I say in a presentation to medical students in my role as the Chair of the PRINT term at the University of Sydney.
Literature suggests that an increased number of errors occur at the beginning of each clinical year. This has been described as the July effect (Northern hemisphere), the January effect (Southern Hemisphere) or more evocatively by some as the “killing season”(1,2)
The Difficult Transition
The transition from medical school to internship has been described by graduates as stressful and one they do not feel prepared for. Medical schools also have acknowledged that medical students transitioning to doctors often lack skills for working safely in the clinical environment.
The literature suggests that adverse events involving interns may not occur because of a lack of knowledge but rather an inability to appropriately apply the knowledge in their work context; increased responsibility and workload, multiple relationships with patient and other health workers and competing clinical demands.
This has lead to the development of a variety of experiential transitional programs to final year medical students. The Pre-Internship or Preparation of Internship (PRINT) terms involve an observership or clerkship in a hospital. This is often supported by tutorials and simulation training.
The PRINT term explicitly aims to scaffold the students prior clinical learning by focusing on the capabilities required of internship and by exposing them to the responsibilities of the assessment and management of the patients within the complex hospital system.
Change in role
The Pre-intern has been described as a transition role between that of a medical student and an intern. I prefer the terminology of pre-intern rather than PRINT student as it helps to move you from the role of a student to one of an intern. The term provides an opportunity for the pre-intern to accept more responsibility. It is important that you take on the some of the roles of an intern; clerking admissions, completing discharge summaries, chasing results, communicating with medical ,nursing, allied health staff and your patients. Lave and Wegner introduced the concept of Legitimate Peripheral Participation which describes how new members become members of the community initially by participating in simple and low-risk tasks but that are none the less productive and necessary and further the goals of the community (3). Through peripheral activities, novices become acquainted with the tasks, vocabulary and organising principles of the community. If you as an pre-intern fail to take on these opportunities, you will remain on the periphery
What skills to develop as a pre-intern?
A UK study found that final year students felt prepared for carrying out basic clinical skills such as history taking and communication, but less confident about practical procedures, working with acutely unwell patients, prescribing, managing their workload and being on call. (4)
In regards to practical procedures it is worth examining the level of proficiency expected of interns. For procedures such venepuncture, IV cannulation, blood gas sampling and blood cultures there is an expectation that you can perform these day one as an intern unsupervised. There may be patients that are more difficult and you will need and will be expected to ask for help with these basic procedures. There is also some understanding that procedures such as IDC and NGT insertion may have only been completed on simulation models in medical school and residents or registrars will supervise you the first couple of times. If you are not comfortable and skilled in the performance of these procedures, now is the time to learn. Not on your first after hours shift.
Try and work an after-hours shift during the PRINT term as they are often the most daunting for an intern. Ask to be first on call so that you receive some of the calls from the ward from nursing staff. This will help with the development of some of the skills to learn especially around the management of workload and prioritisation of calls. The origins of this website lie in the challenges that occur on the wards after hours when direct supervision is not always available. I hope that this website provides some guidance but it should replace asking a senior colleague for assistance.
Practicising prescribing is important part of PRINT terms and seeking out the advice of the ward pharmacist is a good start. Medication prescribing and transcribing is a high risk task for an intern. Medication errors are very common and can be associated with significant morbidity.
But remember, you are not a doctor…yet. So you can’t actually prescribe any medications or fluids; complete death certificates; order tests without supervision or admit or discharge patients independently. In all your communications with patients, nursing and medical especially over the phone, clearly state that you are a pre-intern/medical student.