“They evaluate us based on the questions meant for registrar”: Exploration of Transitional Opportunities Experienced by Intern Doctors Open Access

Introduction: The transition between being an intern doctor before moving into the medical work force is a crucial phase in the life of an intern doctor. The transitional experience is a phase of learning, exploration, and adaptation for intern doctors. This study aimed to build insight into the opportunities experienced by intern doctors in Vanuatu during the internship transition. Methods: A qualitative study was carried out in two referral hospitals in Vanuatu, Vila Central Hospital and Northern Provincial Hospital. A convenient sample of 27 intern doctors participated through face-to-face semi-structured in-depth interviews. The participants comprised current intern doctors or those that had completed internship within the past 2 years and were currently working in the two referral hospitals in Vanuatu. To help direct in-depth interviews, a semi-structured open-ended questionnaire was employed. Thematic analysis was used to interpret the verbatim transcription of the interview material. Results: Six themes were described as opportunities, which are confidence gain in the work place, clinical competency, impact of supporting learning tools, impact of medical consultants, clinical learning environment, and developing interaction relationship. These opportunities have allowed the interns to become more efficient clinicians to make right decisions and when dealing with stressful and nonideal situations. Conclusions: The findings of this study indicate that the transitional opportunities experienced by medical intern doctors will enable them to improve their proficiency level, thus improving the clinical outcomes through recognizing the unique challenges and opportunities within Vanuatu’s health system. Globally, by comparisons these will add value understanding the broader context of internship programs and identifying potential solutions that are essential to adapt those learnings to the specific context of Vanuatu. Therefore, the six themes identified have prepared well the intern doctors during their 2-year internship program before becoming a fully qualified and experienced junior registered doctor.

Building a high-quality, secure health care system entails creating care procedures that protect patients from mistakes and unintentional harm [1]. Almost all doctors make mistakes, but they almost never disclose them to patients or families [2, 3]. In clinical practice, human errors are common but are generally underreported [4]. Across the world, 1 in 4 patients are likely harmed while receiving primary and ambulatory health care, particularly “low and middle-income countries.” Overall, 134 million adverse events occur each year in hospitals, leading to 2.6 million deaths annually due to unsafe care [5]. In the USA alone, an estimated 98,000 annual deaths could be attributed to avoidable medical errors, thus inspiring worldwide efforts to develop more effective patient safety programs [6].

A student’s journey from being a student to becoming a doctor is called the medical internship. It’s a time frame during which a medical student is expected to practice medicine, apply what they have learned in school, and develop the necessary clinical skills under close supervision in order to prepare them to provide safe and effective patient care on their own after they graduate from medical school [7]. Intern doctors are going through a challenging and formative time in their lives as they transition into new roles with associated obligations and expectations while also engaging in experiential learning [8]. Internationally, in Saudi Arabia internship is a 1-year period similar to the USA and medical graduates in Australia and New Zealand who trained under provisional registration before full registration is obtained [9]. However, the UK, the internship, known as the “foundation program,” runs for a 2-year period [10]. Being an intern after graduating from medical school comes with an increase in responsibility, which is difficult because it abruptly shifts from a relatively protected environment to being expected to function competently on a team that places a high value on efficiency. As a result, new medical graduates face difficulties like stress, distress, and burnout [11, 12].

Little is known about how Vanuatu’s medical internship program came to be and was guided, which results in an incorrect appraisal of the experiences and circumstances that contributed to the success of the intern doctors in Vanuatu [13]. Besides, the gaps in literature specific to Vanuatu show that there is limited research on internship programs focusing on the Vanuatu context; also there is lack of data on internship effectiveness and obviously understanding the impact of local context in terms of Vanuatu’s unique geographical, cultural, and socioeconomic context that is likely influencing the effectiveness of internship programs. Hence, the study is significant because it provides the first comprehensive look at internship programs in Vanuatu, filling a critical gap in knowledge in terms of improving the quality medical education through effective and relevant trainings, strengthening of the health work force, and informing policy decision-makers.

However recently, the Vanuatu Ministry of Health provided strong support for the newly revamped internship program, allowing intern doctors to grow in competence and confidence in a nurturing atmosphere [14]. However, with the new internship program intern doctors are expected to face challenges. Intern doctors in developing nations, such as Vanuatu, have additional difficulties, such as a lack of funding for the health sector, low wages, and discrepancies in access to health care [15]. Due to lack of previous study, this study aimed to determine and explore the transitional experiences of intern doctors as well as the opportunities they encountered during the internship period.

This descriptive qualitative study was conducted at Vila Central Hospital and Northern Provincial Hospital as these were the only two referral hospitals with better medical resources in Vanuatu with consultants and senior physicians who have guided the internship program including the in-charge nurses who have greatly assisted the interns. The internship training was done by the intern doctors between January 2018 and December 2020.

The participants either worked at the two hospitals as interns for longer than 6 months or had finished their internship within the previous 2 years and were now employed as registered doctors in one of the hospitals. In total, 38 interns were employed by the hospital. For the purpose of this investigation, 27 intern doctors served as a convenient sample [16].

A semi-structured interview open-ended questionnaire was used to collect data. It was derived from earlier studies and developed in accordance with the study’s research questions. Prior to the actual interview, the questionnaire was piloted. Demographic questions and ten main open-ended questionnaires were used in this study.

The health human resource manager was used to locate potential volunteers during the recruitment process. Trained research assistant addressed the participants and explained the study’s goals and the duration of the interviews verbally and on a participant information sheet. Each participant was required to sign a written consent form before the interview in order to participate. They choose to take part voluntarily. Face-to-face interviews were done in a quiet room by the trained research assistant. Thirty to 60 min was allotted for the interviews. Participants were interviewed in their preferred national Bislama language; otherwise, the English language was chosen for the interviews. All interviews were audio recorded so that the researcher could subsequently transcribe them and have a professional translator confirm their accuracy.

The primary researcher verbatim transcribed every interview once it had been audio recorded. After the transcriptions had been cleaned up, data analysis was done. In this study, the data analysis method of choice was thematic analysis [17]. The principal researcher went over each transcript line by line, looking for common phrases and terms, then allocating numbers to each word or idea. Data that had been coded and shared comparable traits were grouped together. These has been verified for any discrepancy with another independent researcher on randomly selected transcripts from the interview participants. After similar data were grouped, descriptive themes reflecting the participants’ described lived experiences were found [18].

Rigor is a means of establishing trust or confidence in a research study’s conclusions [19]. The Lincoln and Guba strategies of credibility, dependability, conformability, and transferability were used to examine how rigorous the study’s findings were [20]. However, in-depth interview questions were developed and derived from prior academic sources and studies as a data gathering method. Details and relevant background information were provided toward this study and its situation. Also, the shorting and editing feedback was from the academic expertise supervisors, providing an audit trial. The researcher confirmed neutrality and lack of bias.

The in-depth interviews used to acquire the data included a total of 27 participants. The 27 participants, who ranged in age from 27 to 36, were split into 70 percent males and 30 percent females. Twenty-two participants were still working as interns, and the remaining five had just finished their internships no longer than 2 years prior and were now employed in the referral hospitals of the two nations. There were only Melanesian Ni Vanuatu participants (Table 1).

The thematic analysis found six themes emerged from analyzing medical interns’ responses to the questions. In this section, participants were presented with a “P” and cardinal number like P1, P2.

Twenty-two participants revealed that their confidence level increased over time as they progressed through the internship program. Their confidence is built when dealing with nonideal and stressful situation, being confident in making right decisions and having to serve in rural areas also boasted their confidence.

Few [11] medical interns have described that their confidence level was boasted as they went through nonideal or stressful events during their internship. A participant, P8, (a 32-year-old male intern) stated that his confidence was boosted when he was on first on call.

Another participant, P21, (a 35-year-old male) describes his confidence through very stressful situation.

Six of the participants have stated that during their internship, decision-making was crucial and their level of confidence in making the right decision at the right time increases during their time of internship. P4 (a 32-year-old intern) described it as follows:

Five of the participants have acknowledged their rural block rotation as a rotational block that increases their level of confidence. P20 (a 34-year-old male) recalls that with the assistant from his registrar he felt confident and enjoyed his rural rotation.

A significant number of participants [21] felt that they were clinically competent through the internship program by allowing them to become an efficient worker, as well as increasing their skill development, and at the same time they were tasked as registrar. Eleven of the participants have reflected and described themselves as being efficient workers by continuous hands-on experience, doing continuous repeated procedures, and being able to work on their own has allowed them to be an efficient worker. A participant, P3, (a 29-year-old male) has reflected on how he worked on his own.

Some participants [8] have noted that their clinical competency has increased over time as they develop their clinical skills during their internship period. P12 (a 32-year-old male intern) recalls his time when doing certain clinical procedure.

Five participants have highlighted that during their internship they were tasked as registrar since there was no registrar but only interns and the consultants in their department. This have greatly enhanced their clinical competency skills. P16 (a 31-year-old male intern) said the following:

Despite the competency advantages, interestingly, another participant, P19, (a 32-year-old male intern) disapproved as quoted:

Majority of the participants [22] felt that in one way or the other, the internship program has greatly benefited them through the supporting tools that were provided for them in the course of their internship. Four major tools that were categorized and highlighted by the interns were the internship logbook, pre-internship trainee program, continuing medical education and learning resources.

Twenty-five participants were highly appreciative of the internship logbook that was given to them during the internship program. As it provides a set of direction and a goal to accomplish during their duration of internship, a participant, P12, (a 32-year-old male intern) has positively responded:

The response from the participant denotes as a comparison to the past internship program experience in Vanuatu whereby it is not well coordinated and guided in terms of no proper logbooks where given outlining medical procedures to be completed as a guideline to complete their internship. A number of participants [17] who were trained in Cuba and China medical schools were assigned to take up 6 months pre-internship training before assigned to the actual internship program. P9 (a 32-year-old male intern) described the pre-internship trainee program as supportive:

Though the participants were appreciative of the pre-internship trainee program, a few have mentioned that the program have ceased. P14 (a 33-year-old female intern) said the following:

All participants [23] have described that during their time of internship they have gone through some form of teaching known as Continuous Medical Education (CME) in their learning process during their internship program. P20 (a 34-year-old male intern) expressed the following:

Learning resources are in the form of learning tools, which are provided to assist the interns during their time of internship. Few [4] participants have acknowledged the learning tools provided in the form of laptops. P3 (a 30-year-old female intern) recalls as follows:

Conversely, a few participants have noted also that such support is only for a certain time. P5 (a 33-year-old male intern) noted the following:

Nine participants reported that their consultants encouraged them to choose the professional path and area of specialization they would like to follow in the future while they were doing their internship. The inspiration comes in the form of being a role model and positive attitudes from the consultants.

Four participants have recalled and highly spoken of their consultant as their role model, which influences their career pathway. P24 (a 31-year-old male intern) stated the following:

A few other participants [5] have also felt that the positive attitudes from their consultants influence them on their pathway to their career specialty. P21 (a 35-year-old female intern) recalls the following:

On the other hand, a significant number of participants [5] too have also noted the negative influences from their consultants that influence them not to pursue that certain specialty. P20 (a 34-year-old male intern) said the following:

All participants [23] have gone through and experienced a clinical learning environment during their internship. Their learning environment is experienced through the support from consultants and nurses, as well as from all interns supporting each other and the high clinical hands-on experiences.

All participants have acknowledged the effort and support put by the consultants and nurses during their internship program. However, a majority of the participants have highlighted that nurses were more of a much greater support than the consultants. P4 (a 32-year-old male intern) acknowledges to say the following:

Also, P19 (a 32-year-old male intern) added about the consultants:

Likewise, some participants [12] have acknowledged the support made by both the consultants and the nurses in a form of comparison. P17 (a 32-year-old male) stated the following:

Twenty-three participants have described during the internship that a significant learning support came from their fellow interns. P8 (a 32-year-old male intern) described as follows:

A vast majority of the participant have highlighted the opportunity to have hands-on experience during their internship period, which is something they never had the opportunity to do during their medical schooling years. P2 (a 28-year-old male intern) has gratefully responded when asked about the strength of the internship program in regard to its clinical learning environment.

However, P10 (a 30-year-old female intern) claimed the following:

A good number of the participants [12] have mentioned that during their internship it provides an opportunity for them to interact and build a working relationship with fellow health workers within the hospital. The participants have developed a good working relationship with other health care workers during their internship. P17 (a 30-year-old male intern) described as follows:

However, P2 (a 28-year-old female intern) mentioned that she felt that building relationship is a challenge and she is slowly developing it.

Teamwork has also helped the participant to learn better and build good lasting relationship together. P18 (a 32-year-old male intern) described that despite medical students learning from different medical schools in China, Cuba, and Fiji, they ensured to build a good working relationship.

According to study results, as interns advanced through their internship program, their confidence level grew over time. They acknowledged that their confidence is built when experiencing events such as having to do on calls on their own, having to do clinical hands-on procedures for the first time, and gaining confidence after continuous attempts. The capacity to gain confidence over time is necessary for providing high-quality patient care [24]. Studies state that interns and medical students felt responsible and privileged when working in the rural as it is a positive holistic experience [25, 26]. Other studies from the developed countries stated that the intern doctors’ confidence was greatly boosted through on calls, daily routine, educational activities, knowledge and skills, medical decision-making, patient and family relations, patient cases, professional interactions, and continual rotations [21, 22].

The interns have stated that their clinical competency has increased over time as they developed their clinical skills during their internship period doing certain clinical procedures. According to a study, clinical competency is a confluence of skills, knowledge, attitudes, and beliefs that are founded on reason, evidence from science, and critical thinking [27]. Despite encounters faced, some interns positively reflected that they appreciated what the internship program has offered them as they highlighted that they played the role as a medical registrar since there was no registrar in their department, which greatly enhanced their clinical competency skills. However, interestingly few interns felt that they were being evaluated and assessed as registrars while they are still an intern in terms of the assessment questions and expectations. Studies have also shown that the transition from competence to performance is facilitated by increased responsibility and practical experience while keeping an educational focus [23, 28]. Similar to this, professional activities like admitting a patient, ordering and interpreting investigations, performing basic procedural skills, prescribing and monitoring medications, and other professional practices capture essential competencies that trainees must master before engaging in them independently [29]. Studies depict that educational interventions to improve clinical competence of students starts at medical schools with having to develop communication skills [23, 30].

The study depicts that majority of the medical interns appreciate the internship program as it greatly benefited them through the supporting tools such as internship logbook, pre-internship trainee program, Continuous Medical Education (CME), and learning resources. According to a study, group coaching course interventions helped interns who were experiencing transitional difficulties adjusted to the medical culture, plan their careers, and maintain a healthy work-life balance [31]. Likewise, few privileged interns have acknowledged the learning tools provided in the form of laptops and stethoscopes provided to assist them during their time of internship. Several determinants to a successive internship program was successfully achieved from this current study. According to a study, academic possibilities, hospital personnel, medical intern doctor welfare, and management all have a substantial impact on the transitioning phase of the medical intern [32, 33].

The interns have noted that during their internship they were inspired by their consultants to have them decided on what career pathway in terms of specialty they would want to pursue in the future. Other interns felt that with the positive attitudes from their consultants it influences them on their pathway to their career specialty. Several studies have shown that personal development and interests, helping people, mentors’ support and encouragement, learning environment, and an acceptable work-life balance were the motivating factors for selecting a careers choice [34, 35]. The development of a career identity and a career direction requires internship experience [36].

Interns experienced a clinical learning environment during their internship. Their learning environment is experienced through the support from consultants and nurses, as well as from all interns supporting each other and the high clinical hands-on experiences. Numerous studies conducted globally demonstrate that a supportive mentoring environment fosters the development of the clinical learning environment, which not only shapes learning but also affects patient safety and the quality of care [37, 38]. Likewise, the favorable learning atmosphere, clinical learning opportunities, and lack of abuse also increase internship satisfaction [39, 40].

During the internship, medical interns expressed that it provides an opportunity for them to interact and build a working relationship with fellow health workers within the hospital. Likewise, teamwork was significantly noted in this study as the interns recognized that teamwork allows one to learn better and build good lasting relationship together. According to a study, interactions between interns, registrars, and consultants have a significant impact on how happy interns are at work and how much they learn [41].

During the time of interview, a good number of interns were posted to the other rural hospitals and health centers by which we also wanted to interview them as well. However, time constraints and the country’s geographic archipelago settings made it challenging to capture those additional medical interns out there performing their rural block rotation.

The study has shown that intern doctors gradually expressed themselves to be more competent and confident. The organization would benefit most from providing the intern doctors with a smooth transitional experience since greater competency would result in high-quality patient care, cost effectiveness, and most crucially improved patient outcomes. Also, the study findings have provided valuable insights that can guide improvements in medical education and internship structures not only in Vanuatu but in similar low-resource settings whereby policy makers and educators will not only strengthen the medical work force in the country but can address gaps such as the importance of mentorship, focusing on practical skills and competency-based training, leveraging technology and resources, and continuing to create a supporting learning environment where collaboration and knowledge sharing between institutions to improve internship programs in that meets the health demands in terms of quality and efficient health service to all.

We would like to thank all the study participants for participating in the interview and the two hospitals that allowed us to conduct this study.

Ethical approval for this study was obtained from Fiji National University (FNU), College of Health Research Ethics Committee (CHREC) with the ID#257.20, and the Vanuatu Ministry of Health (MoH) research and Ethics Committee. Written informed consent was obtained from the study participants before involving them in the study.

The authors have no conflicts of interest to declare.

The authors have not received any financial support.

M.S.: conception, methodology, data collection, analyzing, and writing – original draft. M.M.: conception, data analysis, supervising, and writing – review and editing.

Ethic registration ID#: 257.20.

The data that support the findings of this study are not publicly available due to ethical considerations but are available from the corresponding author upon reasonable request.