The Central Internship Committee (CIC) approved and adopted the Guidelines for the Internship Year for Hong Kong, and the recommendations and requirements contained therein will serve as guidelines to assess and evaluate the suitability of hospital units for the purpose of recognising intern posts.
- The Aims of General Clinical Training
- The Content of Training
- The Arrangements for Training
- Roles and Responsibilities of the Bodies Concerned with General Clinical Training
The Aims of General Clinical Training
- Medical Education is a continuous process – from graduation to retirement. The pre-registration year (internship) provides the new doctor with opportunities to develop a range of general professional skills and attitudes necessary for the practice of medicine. The core consists of supervised general clinical experience, with increasing responsibility for the care of patients. Time should be provided for education by means of hospital based programmes on topics relevant to this stage of the doctor’s training and also time allowed for private study.
- General clinical training should enable the pre-registration house-officers (Interns) to:
- understand the nature of problems presented to them as doctors, to develop knowledge and understanding of disease processes, and to make appropriate decisions;
- improve their skills of history taking, clinical examination and diagnosis, and learn to exercise them within the time constrains of practice;
- communicate effectively, both orally and in writing, with patients and relatives, with doctors and with others involved in helping patients in the hospital, in primary medical care and in the community;
- apply their knowledge of science and of logical method to clinical problems and be able to assess the reliability of evidence;
- investigate patients’ problems, and plan and carry out treatment, including the requirements for rehabilitation when appropriate;
- use laboratory and other diagnostic services effectively;
- adopt safe practice in relation to radiation protection and handling blood products, body fluids and tissues in the ward and laboratory with due regard for the safety of patients and others;
- be aware of and use opportunities for disease prevention and health promotion;
- develop and maintain appropriate clinical attitudes. These include respect for the dignity of the patient and concern for the relatives, an awareness of legal and ethical issues and of the importance of professional confidentiality;
- be aware of their own limitations and be ready to seek help;
- accustom themselves to the processes of audit and peer review;
- learn the importance of team-work and the principles of corporate responsibility; and
- continue their self-education.
The Content of the Training
- Posts must offer breadth and diversity of experience. In combination they must always include a core of general experience in medicine and surgery. Universities may recognise posts in medical, surgical and other specialties, provided that each post affords good general experience.
- Each consultant or principal under whose supervision an Intern may work should recognise that experience of the kind described above is required, since only this will provide an adequate foundation for subsequent specialist training. Care of patients with acute illnesses must form an essential component, but doctors should acquire some experience in the care of patients with chronic illness.
SKILLS WHICH MUST BE DEVELOPED DURING GENERAL CLINICAL TRAINING
- During general clinical training, the skills basic to the practice of medicine must be developed. Interns should be able to take a history, to carry out both physical and psychological examination, to recognise the indications for particular diagnostic and therapeutic tests, and to arrive at a diagnosis after consideration of all the available evidence. Interns should gain proficiency at simple manual procedures, including the administration of drugs, and good prescribing practice should be acquired. The nature of the experience obtained during general clinical training will vary from post to post, but during the twelve month period, training in the following areas is essential:
- Dealing with common medical emergencies: In particular Interns must develop skills in cardio-pulmonary resuscitation and in dealing with shocked patients.
- Communication: The skills required for history taking, and for explaining to patients of all backgrounds and ethnic origins the nature of their illnesses and the investigations and treatment that they will undergo, should be refined. Interns must appreciate that different approaches will be required when dealing with the particular problems and needs of infants, children, adolescents and young, middle aged and elderly adults. They should learn how to involve patients in decisions about themselves. They must also learn to communicate effectively with patients’ families and with medical and other colleagues involved in patient care.
- Knowledge of the importance of psychological and social factors: Interns should appreciate how patients’ illnesses, and the way with which they should be dealt are influenced by their background and level of understanding, their personalities and religious values. Two areas require special attention:
- Pain relief: For the first time Interns have responsibility for relieving pain. They should learn about the effects of pain and its relationship to personal distress, and about the pharmacological and psychological ways of bringing about effective relief.
- Care of the dying patient: Interns should learn from both specific teaching and the good clinical example of their consultants or general practice principals how to acquire a sensitive approach to dying patients and their families. They should also gain experience in breaking bad news, in discussing the patients’ anxieties and in recognising the stages of bereavement.
- Prevention of illness and promotion of health: Although Interns are principally concerned with people who are already ill, they should take advantage of opportunities to promote good health, for example, by enabling patients to recognise the consequences of abuse of tobacco, alcohol or drugs. They should concentrate their attention on those in the age groups most at risk.
- Effective use of resources: Interns must learn to use resources effectively, in terms of which drugs to prescribe, what investigations to request and the use to be made of their own and other’s time.
- Ethical aspects of medical practice: Interns cannot be expected to know everything about medical ethics. Discussion should concern issues that arise in their practice. Consideration should be given to matters such as how much a patient should be told, and emphasis should be placed upon the importance of maintaining confidentiality. Interns should appreciate the need to provide a proper explanation to patients when obtaining the necessary consent from them for the investigation or treatment proposed. All Interns need to be aware of how complex ethical issues have become.
- Professional conduct: All doctors should be aware of their individual responsibility for upholding the reputation of the medical profession and of the potential pitfalls of medical practice. Guidance is provided in the Hong Kong Medical Council’s red booklet “Warning Notice” which is issued by the Council to every provisionally registered doctor.
- Legal aspects: Interns should be aware of the statutory duties of medical practitioners, particularly in relation to its various kinds of notification and certification, and of the need to keep up to date with such matters. It is important that Interns understand the implications of the legal aspects with respect to medical records. Other legal matters, e.g., concerning organ transplantation or termination of pregnancy, should be discussed when they are relevant to particular patients. Interns should appreciate the risks of litigation including claims of negligence, which frequently stem from incomplete record keeping or failure to obtain valid consent.
- Teamwork: As well as working with the other doctors in their team, Interns should recognise the essential roles played by non-medical colleagues and the importance of securing mutual co-operation in the interests of patient care. Due attention should be paid to continuity of care and to the importance of adequate ‘hand-over’ procedures.
- Record keeping and information retrieval: Interns should learn how to keep good clinical records to transmit information appropriately and to operate information storage and retrieval systems effectively.
- Evaluation of the quality of care: Interns should participate in audit undertaken by the teams of which they are members.
- The advancement of medicine: Interns should be aware that the practice of medicine is constantly advancing and that many of these advances stem from careful observation alertness, and the routine recording of change. If research is being conducted in their unit they should be encouraged to take an interest and to contribute where this is appropriate.
The arrangements for training
- General clinical training may take place in hospitals and out-patient clinics (general practice). In approving hospitals and general practices for general clinical training, the Universities must have regard to the relevant provisions of the Medical Ordinance governing in Hong Kong.
- Both The University of Hong Kong (HKU) and the Chinese University of Hong Kong (CUHK) which grant a registrable primary medical qualification are responsible for recognising and approving Intern posts in hospitals.
APPROVAL OF HOSPITALS AND RECOGNITION OF POSTS WITHIN THEM
- In Hong Kong, the Central Internship Committee’s (CIC) determinations are as follows:
- all posts approved for general clinical training must afford general clinical experience;
- posts must only be in hospitals which have a suitable library, and which can provide access to adequate laboratory and radiological services;
- Interns must be supervised in each post by a named consultant (or principal in general practice) who is formally designated the educational supervisor, and who understands the duties of that role. Supervisors must be aware of the educational objectives of the internship year, and of the Committee’s recommendations;
- at all times of the day and night, a consultant or other members of staff in an appropriate specially senior to the Intern must be available at the hospital to provide cover and help. No other arrangement is acceptable. Interns must never be in the position where their only appropriate source of help is outside the hospital;
- the extent of the duties and the degree of clinical responsibility offered by every post should meet the requirements stipulated in these recommendations. Interns should have supervised responsibility for some acute admissions, and for the subsequent care of these patients. They should have such responsibility for an adequate number of in-patients on the unit and the Interns’ other clinical commitments; and
- time during contracted hours should be set aside for educational purposes: there should be at least 4 hours of protected time per week scheduled for Interns for specific teaching and education activities (including Practice Tips Workshops, grand rounds, departmental meetings, case presentations, journal clubs, clinical audit meetings, etc.)
It is a requirement that all posts must be resident.
- In the General Medical Council (GMC) Education Committee’s recommendations, the pre-registration year must include a minimum of four months experience in medicine and four months in surgery. However, in Hong Kong the Computer Matching Programme was implemented in 1987 which seems to be working well in the following combinations
- 6 months in a medical post recognised as providing good general experience and 6 months in a surgical post similarly recognised.
- However, if the minimum requirements for experience in medicine and surgery are met, e.g. 3 months each in general medicine and surgery, the remainder may be spent in posts in other clinical specialty which has been approved by the University and recognised as providing good general clinical training.
- The Universities should ensure that opportunities for part-time general clinical training are available on a personal basis to Interns whose health or disability preclude full-time training. In such cases, the equivalent of 12 months’ whole time training including sufficient night duty and on-call service, must be completed. Sufficiency should be determined by the quality of the experience, not solely by the number of hours worked.
SUPERVISION OF THE INTERN
- Each post provides a single educational experience. For this reason, the Intern should have a single supervisor. The supervisor has a major commitment to teaching and training the Intern, should help with both professional and personal development and should therefore be aware of the Intern’s individual needs. The supervisor should ensure that the Intern is not overwhelmed by clinical commitments, overburdened by responsibilities inappropriate to the experience acquired, or understanding an excessive on-call commitment. There should be no more than one in every three nights of on-call duty for each Intern throughout the 12 months of training.
- Duties of other medical staff working with the Intern: The teaching and guiding the Intern and for providing feedback on clinical progress may be extended to other doctors working in the same team and it is important that they give the supervisor early warning of any deficiencies that they note in the Intern’s performance.
- The supervisor has to give each Intern individual attention and should personally undertake, and should not delegate, certain tutorial functions;
- at the beginning of the post, discussion about the duties of the post, and it is advisable to provide the Intern with a written record of these;
- regularly monitoring and discussing the Intern’s progress with him/her. These discussions should be informal and Interns should be informed about their progress. They should also be invited to comment on the training and when problems are identified to discuss about them;
- checking with the assistance of others that the Intern’s performance is adequate with regard to the following skills: technical, administrative and organisational, and that any problems in respect of communication, medical ethics and etiquette have been overcome;
- facilitating and encouraging the Intern’s attendance at educational programmes; and
- ensuring that the Intern receives appropriate career guidance.
Responsible consultants have always undertaken these duties.
- If at any time the supervisor considers that the Intern’s performance is not reaching the required standard this should be discussed with him/her and brought to the attention of the Assistant Dean (Education), LKS Faculty of Medicine, HKU / Assistant Dean (Education), Faculty of Medicine, CUHK as early as possible to permit remedial measures to be instituted and to have the maximum chance of success. Should the Intern continue to perform unsatisfactorily, as evidenced by adverse comments by the supervisor in the Intern Assessment Report, that Intern could be required to repeat that portion of the internship either in the same unit or in another unit.
- Other Teaching
- Some formal education in the internship year is necessary. Although this will not form a substantial component of training it must not be allowed to go by default.
- Induction courses or sessions should be provided for Interns new to the hospital or practice. These should cover the hospital or practice procedures and routines, the accident and emergency services, resuscitation procedures, use of radiology and laboratory services, etc.
- Interns should be encouraged to attend pathology and radiology demonstrations, and cross-specialty meetings concerning topics of general interest, and any appropriate lectures or courses organised by clinical tutors. They should attend autopsies and biopsy presentations, especially where these concern their own patients, and be involved in case conferences.
- Interns should have the opportunity to suggest topics for inclusion in their educational programmes.
- Sufficiently advanced notice on educational programmes should be given to Interns and relevant Chiefs of Service in the hospital and to those in other hospitals should such programmes be jointly conducted by more than one hospital.
Roles and responsibilities of the bodies concerned with general clinical training
- The Universities must accept responsibility for assuring the educational standards of posts and for guiding and assisting graduates in selecting suitable combinations of posts. Some combinations of posts are not acceptable, e.g. a medical post in neurology followed by a post in neurosurgery. Substantial periods spent in closely related medical and/or surgical sub-specialties cannot provide the breadth and diversity of experience required for general clinical training.
- The control that The Universities should exercise covers the content for each recognised post in approved hospitals, including matters such as clinical duties, hours of work, night duty rotas and the personal study time allotted to the Intern. Interns should not be overburdened with tasks which have little or no educational value and for which medical training is not required. The Universities should not approve hospital units in which such tasks form an onerous part of the intern’s duties, as the educational value is very limited.
- The Universities should NOT recognise posts unless they conform to the above recommendations and should ensure that posts which they have recognised continue to fulfil the requirements specified. The Universities should ensure that any identified deficiencies in approved posts are overcome. The Universities must also be ready to close posts and negotiate the establishment of new posts when this is necessary to ensure adequate education and training standards.
- The Directors of Medical Education should maintain an up to date description of the clinical facilities (e.g., duties of post, spread of experience, number of beds [which should not exceed 30] and on-call rotas) and should establish a means of ensuring that significant changes to the job descriptions of posts do not occur without their prior agreement. The Directors of Medical Education should review approved posts regularly, preferably through visits. They should obtain comments from Interns on posts which they have held and this information should be taken into account in considering whether to continue to recognise a post, or to advise changes.
- Most of the above recommendations/guidelines were taken from the General Medical Council Recommendations on General Clinical Training – February 1992.
- Interns should complete the “Intern’s Assessment of Rotation” and “Logbook for Interns” through the website of their respective faculties at the end of each rotation.
NB: Feedback and comments from interns are essential for evaluating the effectiveness and adequacy of the quality of the internship rotations, in terms of educational value and training. Failure to complete and submit the survey questionnaires will delay the issue of an intern’s Certificate of Experience.