It is accepted and practised in Malawi that newly qualified doctors and paramedicals should undergo a period of supervised training before they can register on respective main registers. The internship for doctors is eighteen months made up of sixteen months attachment at an approved hospital and two months of district hospital management course. Paramedicals, i.e. Clinical Officers and Dental Therapists go through a one year rotation at an approved hospital. This document provides guidelines for newly qualified Medical Doctors, Clinical Officers and Dental Therapists by coming up with broad guidelines applicable to all health facilities and domains. It also includes appendices related to assessment and information bulletins.
Internship training should be a constructive, organized and progressive period of training. It therefore forms part of the responsibility of the Medical Council of Malawi (hereafter referred to as “the Council), in cooperation with educational institutions and Ministry of Health and Population, to ensure that newly qualified practitioners are adequately trained and sufficiently competent when applying to the Council for registration as medical practitioners. As such, it falls within the Council’s statutory obligation to act on behalf of the profession and in the interest of the public. Training will only take place at facilities approved by the Council, and as such, status shall be subject to regular inspections and adherence to the prescribed criteria and requirements. It shall be provided by trainers who are medical practitioners with adequate experience.
The following are the four basic requirements which shall be complied with:
4.1 Training shall only be recognized if the intern was registered in terms of the Medical Practitioners and Dentists Act, 1987 (Act No. 17 of 1987), for the full period of training and provided that training took place in one or more of the facilities which were approved by the Council for this purpose.
4.2 Training shall be for not less than twelve months for clinical officers and eighteen months for medical doctors including vacation on leave not exceeding one month and sick leave not exceeding one month, if required.
5.1 Facilities Relating To Clinical Domains an accredited facility shall provide adequate opportunities for the intern to obtain a wide range of clinical experience with regard to in-patients, out-patients and emergency services. There shall be sufficient facilities to ensure a proper diagnosis and correct treatment under satisfactory conditions.
5.2 Support Services
Support services such as radiological services, main laboratories (Haematology, Biochemistry, Microbiology and in the other Pathology disciplines), the pharmacy, the services of other health care professionals, a library and other specialized services should be available. Medical Officer and Clinical Officer Interns should be encouraged to do their own ECGs and routine side-room tests.
6.1 The responsibility of the intern firstly rests with the Medical Director as representative of the Ministry of Health and Population under which the facility operates. Thus, the Medical Director plays an important role in ensuring that the requirements of the Council are being met.
6.2 The Medical Director is aided by Heads of Department and other senior personnel who will supervise the training of interns on a daily basis to ensure that the aims and objectives of proper internship training are being met. Apart from their clinical obligation towards patients, it is essential that time be devoted to the training of interns.
7.1 This person, preferably an experienced member of the training institution, fulfils a very important role in the training of interns. This is particularly so in large hospitals where the complexity of the structure may not always work to the advantage of the intern who is the most junior member of the medical team.
7.2 The responsibilities of the Intern Coordinator include the following:
7.2.1 Ensuring that the training of interns takes place according to the prescribed guidelines.
7.2.2 Serving as an easy channel of communication between management and interns.
7.2.3 Acting as a spokesperson on behalf of interns.
7.2.4 Specifically assisting the Medical Director in the following:
(a) Organizing the orientation programme for new interns.
(b) Establishing a representative intern committee to meet monthly with the Intern Coordinator and keeping records of discussions.
(c) Ensuring that the different departments provide interns with written job descriptions, specifying duties, as well as the training that will be offered.
(d) Ensuring that on-going evaluations of interns per domain are recorded and the evaluation forms are returned to the Medical Council.
(e) Dealing with any personality problems, impairment or disciplinary issues pertaining to interns.
8.0 PRACTICAL DETAILS
8.1 Training Of Interns
8.1.1 During the internship, the intern should rotate through the major departments of the hospital namely, Medicine, Paediatrics, Obstetrics and Gynaecology, Surgery and OPD. Whenever possible they should stick to the Head of Department, joining him on ward rounds.
8.1.2 The intern should have the opportunity to gain a wide spectrum of experience in the management of medical and surgical emergencies and, where feasible, to perform those procedures himself or herself under supervision. Thus, attendance of ward rounds and service under constant supervision in casualty departments and in critical or high-care units, are of crucial importance in gaining insight into the management of seriously ill patients
8.1.3 In principle, the intern should assist with major surgical interventions and perform lesser procedures under supervision. He or she should also become familiar with certain common procedures, such as opening and closing of the abdomen, and appropriate parts of operations performed by senior doctors. Special emphasis should be placed on training in pre and post-operative evaluation and care.
8.1.4 Emphasis should be placed on the importance of daily or, where needed, more frequent evaluation and management of patients.
8.1.5 All supervisors should train interns to assess the spiritual and psychological needs of patients and to act accordingly. Furthermore, specific attention should be given to the care and counseling of the dying patient and the support of relatives. Supervisors should consistently assist interns with this function.
8.1.6 Referral of patients to other disciplines for consultation or for taking over the patient, should preferably not be left to interns, except in the event of an emergency where the Registrar or other senior practitioner is not available.
8.2 APPLIED THEORETICAL AND ACADEMIC TEACHING
8.2.1 The intern shall receive teaching during ward rounds and informal discussions which are directed at patient care. It is important that the intern be given opportunities to test and apply his or her knowledge and experience during ward rounds.
8.2.2 Weekly departmental or inter-departmental discussions should he held. It is important that specific problems, such as cardiac arrest, respiratory failure and their management should be discussed with a special view to intern training.Alternatively, interns may be asked to do case presentations.
8.2.3 Interns should be encouraged to express opinions and make proposals during ward rounds.
8.2.4 The intern should be taught by precept and example to care for the patient and his family with empathy and to realize that the patient is not simply another case.
8.2.5 Where hospitals conduct statistical, mortality and medical audit meetings, they should be arranged at suitable times to ensure compulsory attendance by interns.
8.2.6 Interns should be encouraged to take part in management meetings and perhaps even have some minor administrative responsibilities.
8.3 HISTORY-TAKING, SPECIAL INVESTIGATIONS AND RECORD KEEPING
8.3.1 The importance of proper recording of a comprehensive history, a full clinical examination and follow-up examinations should be emphasized. The supervisor must satisfy himself or herself that these records are of an acceptable standard.
8.3.2 Because doctors may sometimes find themselves in situations where minimal facilities are available, interns should be taught how to evaluate and treat patients on the basis of a thorough history and physical examination without the benefit of special examinations.
8.3.3 It follows that interns should be taught not to subject patients to needless special and X-ray investigations.
8.3.4 The importance of ethical practice and medico-legal risks must be brought home to interns.
8.4 COST AWARENESS
Cost is a major determinant of individual patient care and hospital budgets. It is, therefore, important to foster cost awareness, paying special attention to the following:
8.4.1 The cost and choice of pharmaceutical agents, as well as their safety. Regular consultations with and participation in relevant training, where applicable, by the hospital pharmacist(s), is therefore essential.
8.4.2 The desirability of requesting selected laboratory tests only, as well as the costs involved.
8.4.3 The importance and cost of relevant X-ray examinations. The dangers of radiation should be emphasized and guarded against.
8.4.4 Costs of other investigations and treatment modalities.
8.5 PATIENT ALLOCATION AND WORKLOAD
8.5.1 Unnecessary administrative duties and red tape are discouraged. Elimination of unnecessary procedures, the use of alternative personnel and modern technology, should be pursued.
8.5.2 Each department should, in conjunction with the Intern Coordinator, draw up a job description of interns, specifying duties, as well as the structured training programme which will be offered.
8.5.3 Departments should also decide how to prevent and deal with stress and unreasonable demands on the intern.
8.6 ACCOMMODATION AND FACILITIES
8.6.1 Satisfactory sleeping and recreational facilities for interns, especially when on duty, should exist in each accredited facility. Sleeping accommodation should be such that he intern may rest and sleep while awaiting the next patient or operation.
8.6.2 Meals and snacks should be available for persons on emergency duty, especially at night.
8.6.3 A room/area with recreational facilities and refreshments would enhance social interaction between interns. This would greatly improve job satisfaction and acceptance of the work environment.
9.0 INTERN RESPONSIBILITIES
Although interns, under supervision, are primarily responsible for patient care, they form an important part of the health team and should learn to work together with colleagues in the wider spectrum of medical and other health care services. The professional responsibilities of the intern should include the following important aspects:
9.1 Interns are required to keep carefully documented notes. Notes should be made immediately (on the spot date and time) after assessing each patient. They are responsible for following-up all investigations ordered, and to ensure that all results are available and chartered in the bed letter. They should cooperate with medical, nursing and the relevant other health care professionals, e.g. physiotherapy, social work, occupational therapy – especially in relation to their personal cases. Cases summaries must be completed on patient discharge. A concise summary should be given to the patient on discharge to be available at follow-up clinics.
9.2 The intern should play an active role in Out-Patient Departments, particularly in regard to the follow-up of their own patients. A balance should be struck between exposure to hospitalized and ambulatory patients.
9.3 The intern’s care of the patient should be holistic. As the primary medical care giver, the intern is the optimal person to deal with emotional, spiritual and family problems that are often present in addition to the physical illness. Confidentiality is imperative.
9.4 Interns must be aware of their limitations, both in knowledge and skills, and not hesitate to seek advice from senior colleagues. Such referral is not a sign of weakness, but of maturity and is to the benefit of the patient
9.5 Continuity of care is vital in a hospital situation. Appropriate hand-over of patients is essential.
9.6 Interns should avail themselves of formal teaching, as well as of the use of a library or reference books. Reading around patient problems will foster the habit of on-going medical education.
Note The responsibility of registration with the Council as an intern in terms of Medical Practitioners and Dentists Act, 1987, rests with the individual. However, it should be noted that no person may undergo internship training in Malawi without having been so registered.
10.0 EVALUATION AND REGISTRATION
10.1 Interns should have regular assessments during their training. They should be praised when deserved, and criticized and corrected when necessary.
10.2 At the end of each rotation, an evaluation should be completed, using the prescribed form for evaluation of intern rotation and experience. This form has two components:A section to be completed by the intern, and one by the trainer. The latter should do so in conjunction with his or her colleagues. The assessment must be discussed with and signed by the intern. The form must also be signed by the Head of Department and forwarded to the Intern Coordinator. This will facilitate the early recognition and correction of problems. A confidential counseling service, separate from the appraisal system, should be available.
10.3 At the end of the year, the Intern Coordinator, together with the Heads of Department, will certify whether an intern has satisfactorily completed his or her training by using the necessary Intern Duty Certificate, thus enabling the Council to register him or her as a medical practitioner to perform community service.
10.4 Interns are reminded that it is illegal for them to work in any form of practice outside approved health facilities.
10.5 Interns and medical practitioners are advised that the employment of interns in any clinical practice outside approved facilities is illegal and could lead to disciplinary action on the part of the Council against any intern who might engage in such practices, as well as against any medical practitioner who might be found to employ an intern as a locum or in any other fashion outside approved facilities.
11.0 RESOLUTION OF CONFLICT.
It does happen that conflicts arise as to the training and employment of interns. This may be due to the physical unsuitability of the facility, the terms of service, the trainers or the intern(s).
11.1 Most minor issues usually can be resolved through negotiation between the various parties. In this regard, the Intern Coordinator plays a crucial role.
11.2 Should serious problems regarding professional conduct arise, the Council will deal with such matters. This will consist of an investigation of the issues by means of a round-table discussion. The purpose of such inquiry is to verify alleged facts and to resolve the problems in a constructive manner. However, it should also be noted that the “ethical rules” and the professional conduct procedures of the Council, equally apply to interns as to medical practitioners.
11.3 Apart from the above, it needs to be remembered that interns are in the employ of the hospital concerned. Disciplinary matters in terms of those provisions should be dealt with in accordance with the Labour Act. A copy of any warning letter addressed to an intern should, however, be sent to the Council for its notification.
12.0 PROCEDURE FOR DEALING WITH IMPAIRED INTERNS
The expression impaired means a mental or physical condition, or the abuse of or dependence on chemical substances which affect the competence, attitude, judgment or performance of an intern.
12.1 It needs to be emphasized that management of stress in the study and practicing of medicine and dentistry requires social attention at all levels, but especially in students, interns and young practitioners. Factors creating stress need to be identified urgently and addressed, where possible.
12.2 In view of the above, the importance of early identification of impairment in students must be stressed once again, as well as the important role and responsibility of Medical and Dental Deans in this respect.
12.3 Please note that in terms of Council’s ethical rules, a registered person has a responsibility to report impaired colleagues to the Council. Please also note the specific reference made to students and interns.
1.1 General Remarks
1.1.1 This part provides more specific guidelines on the objectives and criteria for each department through which the intern may rotate. It is meant to be a guide and aid for both the trainers and trainees, recognizing that patient profiles and health services may differ widely in different hospitals and clinics.
1.1.2 The overriding goal of the internship programme is to expose the trainee to a wide range of patients and common conditions to further develop his or her clinical skills. Intern training is a step towards professional development, and should not be seen as the completion of training as a medical practitioner.
1.2 EMPHASIS OF TRAINING
1.2.1 Emphasis of training should be on the core values and skills of:
1.2.2 The importance of keeping case records and completing official documents cannot be stressed enough, both for the patient care and for medico-legal purposes.
1.3 ROTATION THROUGH THE DEPARTMENTS
The purpose of interns rotating through the departments is to ensure adequate exposure to and training in that domain. It allows trainers to import to trainees the knowledge, skills and attitudes of that particular aspect of medical practice. Continuity of training is essential, and blocks should not be broken up. It is recognized that night duties may entail cross over, but during the day the intern should remain in his or her department
1.4.1 Because of the importance of supervision and adequate training, the Council will expect for interns to be trained by practitioners with the following qualifications and experience, namely:
a full-time specialist; or
a full-time medical officer with a diploma in that department or
a full-time medical officer/in the case of clinical officers, a clinical officer with at least THREE years experience in that department.
1.4.2 Access to a trainer should be available 24 hours per day. Interns must be supported by at least one Medical Officer or Registrar on the hospital premises
1.5 JOB DESCRIPTIONS
Each hospital and department must specify what is expected of the intern in terms of:
casualty department cover
night and week-end duties
1.6 EDUCATIONAL OBJECTIVES
Each facility and department must specify what educational aids and opportunities are available to interns. These would include all or some of the following:
Standard management protocols for common conditions.
The standard Treatment Guidelines and Essential Drug List.
A checklist of conditions which interns are expected to encounter and/or learn about.
A checklist of skills to be acquired and procedures to be observed. (Such a list will depend on the diseases seen at the specific site, and the investigation and management will depend on the facilities available). Departmental meetings.
Presentations by Interns. Journal clubs.
Medical audit meetings.
1.7.1 The evaluation of both the training programme and the progress of the intern should be taken extremely seriously.
1.7.2 Evaluation should be ongoing.
1.7.3 There should be an intern assessment halfway through a rotation to institute any correctional steps that may be required.
1.7.4 A formal evaluation form should be completed by each individual intern at the end of each rotation.
Note: Interns who have failed to satisfactorily complete part or the whole of their training, may at the discretion of the Council, be required to undergo extra training