|ORIGINAL RESEARCH PAPER
|Year : 2012 | Volume
| Issue : 1 | Page : 16-23
Competence for Internship: Perceptions of Final-Year Medical Students
CE Draper, GJ Louw
Department of Human Biology, Faculty of Health Sciences, University of Cape Town, South Africa
|Date of Submission||23-Feb-2011|
|Date of Revision||20-Jan-2012|
|Date of Acceptance||21-Mar-2012|
|Date of Web Publication||30-Jul-2012|
C E Draper
Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town, 7925
Source of Support: National Research Foundation (South Africa) and the Faculty of Health Sciences, University of Cape Town, Conflict of Interest: None
Context: A 'new', problem-based medical curriculum was introduced at the University of Cape Town (UCT) in 2002. The objective of this study was to assess the perceptions of competence for internship and the factors influencing competence of final-year medical students. Methods: Eighteen focus groups were conducted (six per year) with UCT final-year medical students in 2007 (n =27), 2008 (n =27), and 2009 (n =30). Guide questions covered student's expectations of internship, perceptions of competence, priorities regarding competence, and factors influencing competence. Results: Participants felt generally positive about and competent to enter internship, and the transition into internship was characterized as having both personal and professional components. Participants identified interpersonal skills, theoretical grounding, and intellectual ability as strengths, and lack of basic science knowledge and certain procedural skills as weaknesses. Factors influencing competence included personal initiative, motivation, and clinical exposure. Curriculum strengths identified were teaching of interpersonal skills and development of students as lifelong learners. The main weaknesses identified were teaching and assessment of basic sciences, and problem-based learning (PBL). Overall, the participants felt generally positive about internship and the 'new' curriculum, and felt generally competent to enter internship. Their responses highlight the role of confidence in the development of competence. Conclusions: These findings highlight the complexities surrounding perceptions of students about competence and views about the content and methodology of the learning. Perceptions of students regarding competence are an important indicator of the attainment of intended curriculum outcomes, and provide valuable information for the improvement of curriculum.
Keywords: Medical curriculum, qualitative methods, students′ perceptions
|How to cite this article:|
Draper C E, Louw G J. Competence for Internship: Perceptions of Final-Year Medical Students. Educ Health 2012;25:16-23
| Introduction|| |
In South Africa, medical graduates are required to complete two years of internship in the public health sector at a secondary or tertiary level urban health facility. This is followed by a year of community service at an urban or rural health facility (including primary level). The transition of a medical student to an intern is a significant one that has received relatively little attention in the literature, despite being described as challenging and stressful. , The perceived lack of preparedness and competency of the graduate has been reported to contribute to anxiety surrounding this transition. , Preparedness and competency are very relevant topics in medical education, particularly after a time of international reform in the training of medical practitioners. A number of studies in a range of settings have required medical graduates to assess their preparedness for internship (or preregistration house officer year), ,,,,,,, with some of these emphasizing the impact of curriculum reform on various competency domains. ,,,
Although objective measurement may be the best means to assess the competence of medical students, there is merit in assessing their perceptions of competence and preparedness for internship. Self-perceived competence may indicate levels of self-efficacy, and these could contribute to the understanding of the behavior of students with respect to the competency domains being assessed. Low self-perceived competency in particular domains may signify areas for improvement within a curriculum. 
Factors influencing competence and perceptions of preparedness have also been considered, including both extrinsic factors such as educational environment and the presence of role models, and intrinsic factors such as motivation and preferred learning styles of students. ,,, Hutchinson maintains that the inter-relation of these factors contributes to the involvement of students, which ultimately determines their learning. 
At the University of Cape Town (UCT), medical students complete a six-year undergraduate degree before commencing their two-year internship. Interns work under medical supervision, and are based for the two years at either a secondary or tertiary facility (which could be an academic teaching hospital), usually in or near an urban area. This internship falls under the administration of the Health Professions Council of South Africa, and exposes interns to major clinical disciplines including medicine, surgery, pediatrics, obstetrics, orthopedics, orthopedic trauma, anesthetics, family medicine (at a community health centre), and psychiatry. Interns are employed by the South African National Department of Health for the duration of their internship.
A 'new' medical curriculum was introduced at UCT in 2002 which is largely problem based and is underpinned by the principles of the primary health-care approach.  It places a greater emphasis on biopsychosocial approach, intra- and interpersonal skills, experiential learning, and early clinical exposure.Two hundred students are accepted into the first year of the curriculum, the vast majority having just completed secondary school. Students come from a very wide range of educational backgrounds, due to South Africa's political history and past inequalities. They are taught in a variety of primary, secondary and tertiary level health facilities, both at centralized and decentralized locations in and around the city of Cape Town. For certain courses, the teaching platform is being extended into rural settings, many of which are communities of low socioeconomic status. Further details regarding the medical curriculum of UCT can be found in [Table 1].
This study aimed to assess perceptions of UCT's final-year medical students about their competence for internship and the factors influencing competence, focusing on the first three cohorts of students graduating from the new curriculum.
| Methods|| |
A qualitative approach was used to assess perceptions of students, and semistructured focus groups were believed to be the best method for this purpose, as well as for establishing the common perceptions among students.
A total of 18 semistructured focus groups were formed (six per year) with final-year medical students (2007: n =27; 2008: n =27; 2009: n =30; 45 female, 39 male). Between three and five students participated in each focus group, and the groups were similar in their diversity and reflected the diversity of the medical student population at UCT. The focus group sessions were integrated into the final-year family medicine rotation timetable, and students were asked to attend a focus group discussion as part of their rotation activities; participation was voluntary (82% of those approached, participated). Although the integration of the focus groups into the family medicine rotation timetable helped to maximize co-operation from the students, it did mean that each focus group was relatively small, since rotation groups typically consist of five to seven students. Nonattendance of certain students accounted for the final numbers of focus group participants (i.e., three to five students). Owing to the random assignment of students to rotation groups, it would be fair to say that the students who participated were representative of their whole final-year group.
The focus group sessions took place on campus, each lasting approximately an hour, and were facilitated by CD (CD was familiar to some of the students, as she was as a part-time lecturer and group facilitator in their first year of study, i.e., five years previous to the focus group sessions). All discussions were recorded via audio and transcribed verbatim by a third party. Guide questions were used to stimulate discussion around the following issues: expectations about internship, perceptions of competence, priorities regarding competence, and factors influencing competence including views on the curriculum. All students who took part gave written consent, which included a guarantee of anonymity, permission to record the focus group, and a statement regarding their voluntary participation and freedom to withdraw from the study without fear of repercussions. Ethical approval for this study was obtained from the Research Ethics Committee, Faculty of Health Sciences, University of Cape Town (REC REF 108/2006).
Elements of both inductive and deductive approaches to data analysis were employed.  Transcripts were coded for thematic content with the assistance of Atlas. ti Qualitative Data Analysis Software (Scientific Software Development GmbH, Berlin, Germany). The guided questions helped to provide a basic structure to the coding framework, drawing on a deductive approach to analysis, which involves hypothesis testing,  and in this case refers to the assessment of the data against the coding framework. The subcategories were derived from the data, using more inductive reasoning, which is more concerned with the generation of hypotheses or ideas from the data itself.  Since this study aimed to examine common perceptions of students from the 2007, 2008, and 2009 student cohorts, those perceptions that were evident amongst the majority of participants were, for the most part, included in the coding framework. However, views expressed by a minority of participants that served to elucidate other perceptions were also included.
| Results|| |
The main data categories and subcategories are outlined in [Table 2]. The coding framework was refined (while maintaining the main categories) after analyzing the 2007 data, and this refined framework was used to analyze the 2008 and 2009 transcripts. The findings from the 2007 focus groups were presented within a number of forums at the faculty level in 2008. This helped in confirming the validity of the coding framework by affirming the relevance of the categories and subcategories. Selected quotes from participants illustrate these categories in the sections that follow.
Expectations about internship
Participants across all years were generally positive about the transition to internship and believed they were ready to take the next step in their career. However, for the majority of participants, feelings about this transition were mixed:
…there's excitement about actually finishing our studies and being in the real world, the working world, earning a salary…there's also a lot of nervousness about whether we'll be good enough, will we be able to manage, will we be able to cope? Will we know enough, will we remember enough? Have we got enough practice in these procedures? (2008 student)
It was evident from responses of the participants in all groups that this transition is both professional and personal. Regarding professional transition, internship was viewed by most participants as an opportunity for further learning and development of competence and confidence, and to consolidate what they had learned. Along with these views was the expectation of support and supervision necessary for continued professional development.
I don't think it should be seen as a huge transition that marks the ends of studying and the beginning of working. It's kind of just a continuation of what we've been working towards all these years, and it's just going to carry on… (2007 student)
Dominant in the discussions relating to this professional transition was the expectation of increased responsibility in internship. Comments from some students suggested that this had to do with being able to make more of a difference in patient care, thus giving them a 'sense of purpose'. This was related to the understanding that they would be able to play a more important and involved role within a professional team, contribute to a greater sense of belonging to the team, and earn increased respect from colleagues.
The main concern among most participants regarding this professional transition was competence, and having to face situations where they would feel out of their depth. This included a lack of confidence in certain abilities, making the right decisions, or being given too much responsibility.
And then what happens when you are the only doctor in the hospital and you have to attend to those cases, especially emergency cases. That's what scares me - emergency cases where someone's life is at stake and you need to act as soon as possible. (2008 student)
With respect to the personal transition to internship, earning a salary was the main highlight for participants in all groups. Another common highlight was the prospect of not being a student any more. Internship was seen as a welcome break from academic life, and a chance to acquire new knowledge out of interest, and not because it will be assessed. Some participants believed that as interns, they would be able to have an increased focus on patients, and one participant described this as "working for real".
So you know, being an adult, having responsibilities and just living a normal life. For the past six years it's just been books and we haven't been normal; we've been closed away from the society because we are being trained, an initiation kind of thing we've been taken out of society. So I'm looking forward to be back. I miss it. (2007 student)
The most common concerns among participants relating to the personal transition to internship were the long hours and workload that they would experience, and the fatigue and burnout that may arise from the pressure, and the stress associated with these working conditions, which may impact on their competency.
Perceptions of competence
Participants across all groups expressed a sense of general competence to move into internship, and that UCT had done well to prepare them. However, many students voiced the need to move from feeling 'competent' to 'confident'.
The main strengths acknowledged by most participants were interpersonal skills and the ability to practice with a patient-centered, holistic approach. These skills extended to the ability of the participants to communicate effectively with colleagues, patients, and families of patients, and treat patients from a biopsychosocial perspective.
…this holistic practitioner, one that doesn't just deal with the clinical aspects of the patient but rather sees the patient within the disease…understanding that there are various other factors, environmental, social, psychosocial, behavioral as well, that influence and lead up to illness, and once you just focus on the illness itself you perpetuate the disease rather than treat it properly. (2008 student)
Another common strength mentioned by many participants was their theoretical grounding and intellectual ability, which enabled them to think critically, systematically, and laterally, and develop good problem-solving skills. Other strengths mentioned less frequently were their ability to adopt an approach to patient management, good diagnostic abilities, lifelong learning and self-directed learning skills, and good training in evidence-based medicine. Some students also believed their procedural skills were a strength, and maintained that these had improved among UCT students since the start of the 'new' curriculum.
Most participants believed that their main weakness as students was lack of basic science knowledge (mostly anatomy and physiology), which usually became most apparent in their surgery rotation. Inadequate procedural skills were identified by some participants as an area of weakness (despite some believing these were a strength), and the procedures mentioned most frequently were intercostal chest drains, starting intravenous lines, taking blood, and lumbar punctures. The 2007 group of participants were particularly concerned about practicing the skills in emergency settings. Although mentioned in 2008 and 2009, these concerns seem to have abated in later years. Other areas of weakness mentioned by some students were the language barrier (South Africa has 11 official languages), prescribing, and specific clinical disciplines such as ENT (ear, nose, and throat) and ophthalmology.
When asked about the most important area of competence, participants agreed that interns require a combination of competencies. The competency mentioned the most was openness to learning and a desire to learn. Also mentioned frequently were the importance of having confidence combined with humility, an awareness of one's limitations, and a willingness to ask for help. Attitudes that were recognized as important by some participants included flexibility, patience, passion, being realistic, having the right perspective, and remaining positive. Interpersonal skills that were identified as valuable were team work, communication, empathy, and a patient-centered approach.
I think the main thing is to be a safe doctor…someone who knows their limitations and is also that lifelong learner thing…where they don't know the answer now, but I'm going to find the answer… (2009 student)
Factors influencing competence
It was evident from the responses of participants that both personal and contextual factors influence competency, and that these factors do not function independently.
Personal initiative and motivation were the main factors mentioned across all groups. This factor encompassed making the most of the time and opportunities given, the need to actively seek and create opportunities for learning and practicing skills, and ensuring that time spent was productive. Some participants felt that extra work is required by students to be competent in certain areas, whereas others mentioned that a lack of confidence would make students less inclined to take opportunities to improve their competency.
…the amount you put in that's how much you're going to get out of it…when you look back you see that there were numerous opportunities that you could put more effort in and get a lot more out of it than you did. (2009 student)
The role of personality in competence was acknowledged by some participants, particularly with regard to interpersonal skills. Personal preferences were seen to play a role as students may invest more time and effort into clinical disciplines that they prefer. Burnout and fatigue were mentioned by some students with respect to competence, as these may affect motivation of students and willingness to take initiative. Not recognizing the importance of what you are being taught was also seen to negatively influence competence.
The majority of participants saw the amount of clinical exposure in their six years of teaching as the main contextual factor influencing competence. This exposure was seen to differ between disciplines, with extensive exposure in obstetrics and gynecology, but far less exposure in ENT, ophthalmology, and orthopedics. Some participants felt that exposure was opportunistic and 'luck of the draw', despite personal motivation, and that this could depend on the facility in which they were placed or the availability of someone to teach them.
A number of contextual factors mentioned by participants related to other staff. These included encouragement from senior colleagues, along with their approachability, willingness to teach and bring out the best in students, and their promotion and practice of the biopsychosocial approach. In contrast to this, a few participants commented on the 'hierarchy of medicine'-a system based on fear rather than encouragement.
…with the clinical teaching though, that it's all based on this sort of fear thing, they think if they make us scared of their wrath, if we don't know something, that way we'll learn, but I actually learn a lot better when I'm encouraged or when someone says 'Wow, you did that good. (2009 student)
Many participants spoke of the inclusion of students in the clinical team (especially in obstetrics and gynecology) and the way in which this develops confidence, as well as of the staff not being helpful or receptive to teaching students or being too busy to teach. Some participants mentioned the presence of role models, both for what they should and should not do.
The curriculum could be characterized as a contextual factor as it is external to the student, although it impacts on their perceptions and experiences. Regarding the curriculum, overall, the views of the participants were positive. According to majority of the participants, the main strengths of the curriculum were the teaching of interpersonal skills and the development of students as lifelong learners.
It's been often when we've been watching other doctors interact with patients - looking at them and saying I would never do that with a patient. And then you kind of realize that we've been trained to think of it and look at it in a different way. (2007 student)
One of the weaknesses mentioned most commonly was the teaching and assessment of the basic sciences. Some participants maintained that not enough time was spent on these, that time spent was not used constructively, and that there was limited teaching of topics of clinical relevance. Comments were made about being able to 'get away with' knowing very little in basic sciences for assessments. Another main weakness of the curriculum pointed out by many participants was problem-based learning (PBL). Although the participants were able to recognize its benefits, a number of them believed it placed too much responsibility on students for learning on their own at an age when they were not ready to take it on. They felt it lacked direction and needed more guidance from a facilitator with experience and a clinical background, and there was too much time wasted in the process.
Medical students can talk a lot of nonsense…people sometimes used to kind of like lecture the rest and then you didn't actually know if they were saying the right thing, and the facilitator didn't know either, and then afterwards you'd find out they were talking nonsense. (2007 student)
Another common weakness of the curriculum mentioned by participants was the imbalance in time spent on different disciplines, and apart from those disciplines mentioned earlier, participants believed more time could have been spent on dermatology, trauma, and languages. Many felt that too much time was spent on interpersonal skills.
| Discussion|| |
The findings presented indicate that overall, participants felt generally positive about internship and the 'new' curriculum, and felt generally competent to enter internship. Expectations of participants about internship, perceptions of competence, and factors influencing competence were similar across 2007-2009. A possible explanation for these similarities may be that a qualitative approach may be less sensitive to specific changes, but may detect more general views of students. These views may be in part reflective of the university's 'hidden curriculum',  and may take more than three years to shift substantially.
In terms of competency strengths and weaknesses, the findings of this study are similar to those of studies conducted in the United Kingdom, particularly with regard to communication, ,, patient interaction,  basic sciences, , and procedural skills.  Findings regarding strengths in communication and patient interaction are encouraging as they attest to UCT's focus on primary health care and biopsychosocial approach in the medical curriculum. Changes continue to be made to the medical curriculum of UCT in response to student and staff feedback. Examples of these changes include increased exposure of students to emergency medicine, a greater focus on the development of clinical reasoning in PBL using SOAP notes (SOAP: subjective, objective, assessment, plan), computer-based anatomy quizzes, and anatomy vivas. Areas of perceived weakness should continue to be monitored, and evaluated to detect changes in the perceptions of students. Regarding concerns of students about the basic sciences, it would also be useful to compare their academic performance with their perceptions of competence in this area to assess the alignment between perceived and actual competence.
Responses of participants highlight the relationship between confidence and competence, and it could be argued that confidence is an indicator of self-efficacy, which has already been linked to self-perceived competence.  Confidence is a personal factor influencing competence that can interact with some of the contextual factors mentioned by participants. A lack of confidence may influence the ability and/or willingness of a student to take up opportunities for clinical exposure or to maximize these opportunities for learning. Confidence may also be affected by feedback from and interactions with staff, their inclusion in the clinical team, and exposure to the 'hierarchy of medicine' mentioned previously. Considering the relationship between confidence and competence, it is vital that the staff (academic and/or clinical) involved in medical education is aware of the role they play in developing confidence and competence in students, not only by what they teach but by their attitudes and behavior as well. Communication of this to the staff should be done with the understanding that while a 'new' curriculum has been introduced, probably there are still staff members who favor a more traditional approach to medical education and are resistant to curriculum reform.
There were some inconsistencies in responses of the participants, and evidence of inconsistencies in perceptions could be considered an important finding of the study. For example, identified strengths of the curriculum were the teaching of interpersonal skills and the development of students as lifelong learners, yet time spent on interpersonal skills and PBL in the curriculum was criticized, although the value of these was not completely disregarded. A possible explanation for these inconsistencies is that participants may not be able to fully understand that the very things that they disliked in earlier years may have contributed to the development of strengths they are able to identify at the end of their academic career. This pattern has been observed in the attitudes of UCT students toward the primary health-care approach, where they were in support of the approach, but not necessarily positive about the way in which it was taught to them.  Another possible reason for these inconsistencies may be because the learning environment (curriculum) is just one of the contextual factors influencing perceptions of competence and confidence,  and that other contextual and personal factors may influence the development of these competencies, as has been found elsewhere. ,, Future research could provide additional insight into these other factors, and could also explore the impact of previous educational experiences of students on their perceptions of the learning methods they are exposed to in the medical curriculum. As mentioned previously, these educational experiences would differ greatly as a result of South Africa's political history and past inequalities.
Regarding the inconsistencies in views of students about PBL, their views of PBL as a learning model may be different from their views of the actual PBL process, although students did not articulate this difference in the focus groups. It may be that students have a greater dislike for the actual process (which includes three-hour sessions and extensive self-directed learning time), which may be what immediately comes to mind when discussing PBL in the context of the curriculum, but are more positive about the underlying philosophy of PBL that encourages lifelong learning. Further research would be necessary to clarify these views, and it would be important to clarify the exact context of PBL when it is discussed with students.
The strengths of this study include the three sets of in-depth data available on perceptions of competence of students, which provide insight into their experiences of the 'new' curriculum. Furthermore, by requesting participation from a preselected (and essentially random) group of students, the sampling strategy helped to reduce selection bias. This study could have been improved with increased input from other qualitative researchers on the qualitative data analysis to improve the validity and reliability of the findings. It could also be argued that the number of focus group participants could be increased, and that students from other rotations could have been included to assess the extent to which different clinical rotations could influence perceptions of competence of students. It is possible that the inconsistencies in the views of participants could be influenced by their caution in expressing negative views on certain topics or the pressure to agree with views expressed strongly by other members of the group.
| Conclusions|| |
Student perceptions of competence have previously not been explored in a South African setting. These perceptions are an important indicator of the attainment of intended curriculum outcomes and provide valuable information for curriculum improvement. An important finding from this study was that the participants from UCT were generally positive regarding their competence for internship. Furthermore, the findings of this study served to highlight the relationship between confidence and competence, as well as the complexities surrounding perceptions of competence of students and views about content and methodology of learning.
Although these findings are useful for the local context, and in particular provide insight into the perceptions of UCT students, they also have relevance for medical education programs in other international settings. All settings contain unique contextual factors which will interact with personal factors affecting perceptions of students about their competence. Views of students about their learning should be an important consideration as nontraditional medical curricula continue to evolve and develop.
Future research could focus on the changes in confidence/self-efficacy over time, and examine the extent to which these changes correlate with changes in perceptions as these students progress through internship. It would be valuable to compare perceptions of students with objective measures of their competence, as well as with the perceptions and observations of clinical supervisors. Additional research within the learning environment could clarify the extent to which these personal and contextual factors interact and influence student motivation, involvement, and learning, all of which can ultimately impact on competence.
| Acknowledgement|| |
The authors would like to thank the students who participated in the study and the Division of Family Medicine (School of Public Health and Family Medicine, UCT) for accommodating the research. Funding for this research was provided by the National Research Foundation (South Africa) and the Faculty of Health Sciences, University of Cape Town.
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[Table 1], [Table 2]
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