It's nothing like 'Grey's Anatomy'! 

You are about to say goodbye to university and are almost ready to be an intern. But before you are eligible for general registration in Australia and New Zealand, all medical school graduates must undertake a period of approved intern training. 

According to the Medical Board of Australia, every intern must complete the following:

  • A term of at least eight weeks that provides experience in emergency medical care
  • a term of at least 10 weeks that provides experience in medicine
  • a term of at least 10 weeks that provides experience in surgery, and
  • a range of other approved terms to make up 12 months (minimum of 47 weeks full-time equivalent service).

All terms must be accredited against approved accreditation standards by an authority approved by the Board. These authorities are commonly known as postgraduate medical councils.

Newly qualified doctors face several challenges in their first few years and can feel like they are not adequately informed of what to expect. Believe it or not, most of your days will be spent on paperwork and more paperwork requesting investigations as well as simple procedures like inserting cannulas and taking bloods.

But it can also be a very stressful environment for interns and junior doctors who are new to the system. Long hours and shift work can open up a Pandora’s box of problems and issues associated with anxiety and depression. 

2017 intern survey

2017 Intern survey - The Australian Medical Council and Medical Board of Australia undertook a survey of interns in September 2017, designed to assess how well medical school prepares students for their internship.

You are going to be a ‘real doctor’. 

Expectations of you will now rise and you will be required to take full ownership of your patients. You will now be responsible for your actions and the onus of sourcing information will now be yours. There are some key things that can get you moving as an intern and help you get as much as you invest. Attend ward rounds, unit meetings, grand rounds and theatre; review patients in the emergency department; be available for on-call shifts and be proactive.

  • Consider/develop a differential diagnosis
  • Consider/develop a management plan
  • Determine a disposition
  • Make sure things are followed through
  • Attention to detail is vital

Some of the responsibilities of an intern are:

  • Ward Rounds
  • Referrals
  • Drug charts
  • Fluid Orders
  • Discharge Summaries
  • Attending meetings with patients’ families
  • Liaising with nursing/allied health
  • Reviewing all investigations

Handling difficult patients

Quite often you will be faced with a difficult patient for example a patient who discharges themselves against medical advice and who is unhappy with care. Remember when dealing with these patients all efforts should be made to reduce their stresses by responding and acting quickly to concerns. Empathising evidenced by your actions and engaging them in discussion can alleviate some of the stress. Take the time to listen where appropriate, advise the patient of the hospital complaints procedure and execute proper reporting to prevent a future recurrence if applicable.

If the situation seems beyond your scope of control, make sure you seek assistance from a supervisor. If your personal safety is at risk, err on the side of caution before escalation.

Difficult colleagues

Sometimes, it’s not the patients who are the source of contention, it could be your peers or staff. The clash of varied personalities of nurses, registrars and consultants can lead to a stressful environment and flaws in your work. With questions raised about your competency, make sure you leave no room for error and determine if they are being difficult or there is an issue with your delivery. The patient’s needs are of your primary concern and you should always seek feedback. If the issue is not resolved, seek assistance either from a superior or MIPS.

Good relationships with medical colleagues, nurses and other health professionals strengthen the doctor-patient relationship and enhances patient care” 

  • Respect for medical colleagues and other health professionals
  • Delegation, referral and handover
  • Teamwork
  • Coordinating care with other doctors

Be an explorer

Your internship will move very quickly so make the most of it. It is the time to explore various fields, find something you like and develop the skills, form connections and build on your references. Extra activities will hold you in good stead such as Grand Rounds, journal clubs or performing audits.

Case study

A 25-year-old female patient notifies AHPRA alleging inappropriate conduct from an intern Her complaint states that the type of examination and reason for it was not explained, and it was inappropriate given her symptoms. There is no complaint of boundary transgression but claims she feels quite embarrassed and believes the intern should be disciplined and further trained so that no other female has to put through the same ordeal.

Given the nature of the complaint, the hospital did not assist the intern, but as the intern was a current MIPS member he obtained assistance by contacting MIPS’ 24-hour Clinico-Legal Support, the matter was accepted by AHPRA and an investigation commenced.

MIPS assisted the member by reviewing the medical records, obtaining a statement from the member and working together to provide an honest and open response to the complaint and the questions raised by AHPRA. AHPRA reviewed the response however determined that the intern’s conduct was unprofessional and provided a caution and instruction for him to undertake professional development on the issue of communication and informed consent. MIPS were also able to assist the member with the education required to meet AHPRA’s requirement.

How to avoid complaints

The easiest way to avoid complaints is to ensure your communication skills are of the highest calibre. Don’t raise false expectations with your patients. Get informed consent, provide warnings and be honest! Do not practice beyond your training, experience and skills. Always ask someone if there is any uncertainty. Remember the AHPRA Code of Conduct. Prompt notification to your employer and/or MIPS of any adverse or unexpected adverse outcomes, complaints, claims or investigations. Keep accurate and detailed medical records, demonstrate insight into the issues raised and work with the patient to mitigate an adverse outcome.

In the event of an AHPRA complaint

  • Do cooperate with AHPRA/Board personnel
  • Don’t adopt defensive or aggressive behaviour
  • Don’t blame others – especially the patient
  • Start with and end with credibility – be professional  
  • Consider “what is in the best interests of my patient?”
  • Exercise introspection, transparency, candour and honesty (ITCH)

Pay close attention to the following key elements in the AHPRA Code of Conduct

8.  Professional behaviour
    8.1  Ethical Behaviour that warrants trust and respect 
    8.2  Professional boundaries 
    8.3  Reporting obligations 
    8.4  Appropriate medical records
    8.5  Professional indemnity insurance requirement 
    8.6  Appropriate advertising of medical services
    8.7  Fair medico legal, insurance assessments

Wellbeing

Your wellbeing is paramount especially as you go through this new phase of your career. Make sure you treat your iinternship as a marathon; it’s not a sprint. Take care of yourself and look after others Ensure you get adequate exercise, you eat well, sleep and talk to your peers and superiors. It’s likely you are not the only one feeling this way.

To ensure your health:

  • Have a GP
  • Seek independent medical advice, be aware of risks of self-diagnosis and self-treatment
  • Conform to legislation about self-prescribing
  • Recognise the impact of your fatigue and the effect on patients
  • If you have a health condition/impairment that could affect your judgement, performance or your patients health:
    - Do not rely on your own assessment of the risk to patients
    - Consult your doctor & consider modifying your practice

Doctors need to be well themselves to be able to provide high-quality healthcare to their patients and the community, and to experience medicine as a rewarding and satisfying career. Research shows that doctors with good personal health practices are more likely to talk positively to their patients and pass on healthy behaviours.

Principles for being a resilient doctor by MIPS Director Leanne Rowe and past president of the Royal Australian College of General Practitioners, Michael Kidd in their book ‘First do no harm’:

  1. Make home a sanctuary
  2. Value strong relationships
  3. Have an annual preventative health assessment and a good relationship with your GP
  4. Control stress, not people
  5. Recognise conflict as an opportunity
  6. Manage bullying and violence assertively
  7. Make medical organisations work for you
  8. Create a legacy – how would you like to be remembered at the end of your medical career, practice ethically & honourably, act accordingly now 

Conclusion

As an intern/hospital employee, every State and Territory will cover you for your ‘medical indemnity’. Your AHPRA registration requires either an ‘indemnity arrangement’ or your own insurance. Your hospital/employer is ‘vicariously liable’ for you. They will ‘employer indemnify’ you and this is your ‘indemnity arrangement’ but ensure to get it in writing. However, any private practice must be independently insured.

MIPS provides a range of member benefits including assistance with clinico-legal issues that healthcare practitioners can experience throughout their careers. 

MIPS can assist you with the complaints made against you to your employer, AHPRA/Medical Board, Coronial Inquests where you require separate representation to your hospital , complaints to State complaint entities where you will require assistance and may require a lawyer, disputes or employment related issues with your hospital/employer, investigations by a State/Territory Drugs & Poisons Units and clinic-legal advice on issues such as informed consent, testamentary capacity, when to report to Coroner, release of medical records and family custody issues. Make sure you notify MIPS as soon as you become aware of any complaint made against you.

“I guess it’s because we all want to believe that what we do is very important, that people hang on to our very word, that they care what we think. The truth is, you should consider yourself lucky if you even occasionally get to make someone-anyone-feel a little better.” J.D [Scrubs]

Professional guidance

MIPS offers support and advice to all new intern members settling into their new roles within a hospital.  Hospitals are often complex and demanding places to work and interns may sometimes feel like they are being overwhelmed by what is required of them.  Talking to a MIPS clinico-legal adviser can help make that transition easier. 

The risk of a claim (being sued), complaint or investigation increases with professional responsibility. MIPS membership provides benefits including 24-hour Clinico-Legal support from experienced practitioners for example responses to complaints, reports or if you have a dispute with your employer.

References

Good medical practice: a code of conduct for doctors in Australia

Guidelines, resources and tools on intern training

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The materials provided are for educational purposes only. Whilst all reasonable care has been taken in preparing these materials, including the accuracy of the information supplied, MIPS does not accept any liability whatsoever arising out of the use or reliance of the information provided. Contact MIPS 24/7 Clinico-Legal Support 1800 061 113 or education@mips.com.au for specific advice.