|Ahead of print
|A cross sectional Study on the Impact of Coronavirus Disease-19 Pandemic on the Training of Interns in a Medical College Hospital, Andhra Pradesh, India
Roopa Suresh1, A C Sanjay Reddy1, Suresh Krishnamurthy1, R Anil2, Y J Visweswara Reddy1, P Janakiraman2, PJ Harsha3, H R Krishna Rao4, V S Subba Rao Ryali5
1 Department of General Medicine, PES Institute of Medical Sciences and Research, Kuppam, Andhra Pradesh, India
2 Department of Community Medicine, PES Institute of Medical Sciences and Research, Kuppam, Andhra Pradesh, India
3 Department of Pediatrics, PES Institute of Medical Sciences and Research, Kuppam, Andhra Pradesh, India
4 Department of Anatomy, PES Institute of Medical Sciences and Research, Kuppam, Andhra Pradesh, India
5 Department of Psychiatry, PES Institute of Medical Sciences and Research, Kuppam, Andhra Pradesh, India
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|Date of Submission||26-Apr-2022|
|Date of Decision||23-May-2022|
|Date of Acceptance||11-Jun-2022|
|Date of Web Publication||22-Jul-2022|
Background: A Medicine and Bachelor of Surgery (MBBS) graduate will gain the required skills and competencies under supervision during the internship training. Many factors influence the competency levels. Coronavirus disease-19 (COVID-19) pandemic could be one of those factors. Objectives: The objectives were to assess the competency levels among medical interns, postinternship, during the COVID pandemic and also to assess the association between the competency levels with their final year results. Subjects and Methods: A cross-sectional study was conducted among 113 interns using a self-assessment questionnaire. Self-perception about the competencies was graded into three categories as low, moderate, and high. The Chi-square test was used for analysing statistical association between self-perception and MBBS final year part II results. Results: The level of self-perception about the competencies among the interns was found to be high in-analysis, display and interpretation of information; hypothesis formulation and decision-making (45.1%) and interpersonal communication, management, organizing health care system and professionalism (42.5%), whereas it was low for obtaining information from the patients and their families (29.2%) and procedural skills (18.6%). About 75.2% and 76.1% of the interns had low self-perception for endo-tracheal intubation and lumbar puncture, respectively. High level of self-perception was noted for urethral catheterization (84.2%) and intramuscular drug administration (76.1%). It was found that none of the competencies were statistically associated with the grade based on marks obtained in final year part II. Conclusion: COVID pandemic has affected the interns training to a significant extent. There was no statistically significant association between final year grades and the competencies.
Keywords: Assessment, Corona virus disease -19, interns, medicine and bachelor of surgery, self–perception, training
|How to cite this URL:|
Suresh R, Reddy A C, Krishnamurthy S, Anil R, Reddy Y J, Janakiraman P, Harsha P J, Rao H R, Ryali V S. A cross sectional Study on the Impact of Coronavirus Disease-19 Pandemic on the Training of Interns in a Medical College Hospital, Andhra Pradesh, India. APIK J Int Med [Epub ahead of print] [cited 2022 Sep 25]. Available from: https://www.ajim.in/preprintarticle.asp?id=351750
| Introduction|| |
To provide independent and unsupervised primary care, internship is very much necessary in the Bachelor of Medicine and Bachelor of Surgery (MBBS) course. A medical graduate will gain the required skills and competencies under supervision during the phase of internship training. In the years 2020 and 2021, coronavirus disease (COVID-19) pandemic made the whole world go through a strenuous phase. In the fight against the pandemic, the requirement of junior doctors in India spiralled up. In this critical situation, the National Medical Council issued directions that the duties performed by interns in COVID -19 management will be treated as a part of their compulsory rotating internship.
There are many factors which influence the competency levels of the medical interns. Availability of resources, quality of supervision in training facilities, supervisors who are up-to-date and available, interactive bedside teaching, experiential learning, the environment and context of training, social factors and workload are some factors which determine the capability of the intern to handle patients independently in future.
Final MBBS Part-II examinations were conducted in February and March of 2020 as per Medical Council of India/National Medical Commission and Dr. Nandamuri Taraka Rama Rao University of Health Sciences (Dr. NTRUHS) guidelines in the state of Andhra Pradesh, India. The interns got into their training straightaway as per the instructions of Government of Andhra Pradesh in view of acute shortage of workforce in the form of frontline warriors. The first wave lasted till March 2021 and the interns had no choice but to devote themselves with the COVID-19 care strategy and guidelines prevailing in the country.
As the lockdown policy was effective during that period, there was drastic decline in the common/general patient load to the hospitals, decreased admissions, less number of surgeries, rotation of the specialists for COVID duties, increased workload, and an environment gripping with the fear of COVID infection which was inevitable. These factors affected the regular training activities of the interns considerably.
Therefore, it becomes important to know how a pandemic can influence the training of the future doctors of our country. Hence, our objectives were to assess the competency levels among medical interns of March 2020 batch, postinternship, during the COVID pandemic and also to assess the association between the competency levels with their final year results.
| Subjects and Methods|| |
It was a cross-sectional, hospital-based study among the interns who completed their compulsory rotating internship during the year 2020–2021 at our tertiary care hospital. The study period was from February 2021 to August 2021. All the interns were included in the study. The sample size was 113. All the interns who passed their final year examination in March 2020 were included in the study.
The study tools used in this study were a self-assessment questionnaire, and Dr NTRUHS final MBBS part II examination marks and results. The university final year examination marks and results were directly accessed from the Medical college office.
[Table 1] shows the specific skills used for assessing the competencies of the interns. Each skill was graded into three categories as low perception, moderate perception, and high perception. Each of these categories was given scores on 1, 2, and 3. Based on the total score achieved by the intern for that particular competency, it was categorized into low, moderate, or high perception.
On the last day of the internship, the self-assessment questionnaire was issued to the interns after explaining the aims and objectives of this study. An informed consent was obtained from them. The interns were asked to fill the questionnaire by themselves, to assess their competencies. It was correlated with their results obtained in final MBBS exam and tabulated for each competency of the questionnaire.
The data were entered into MS Excel 2007 version and analyzed using SPSS (version 20.0; SPSS Inc.,Chicago IL,USA). Descriptive statistics were used for the categorical data in the form of percentages. Inferential statistics (Chi-square test) were used for analyzing the statistical association. A probability value of <0.05 was considered statistically significant.
| Results|| |
A total of 113 interns participated in this study. Out of total 365 days of internship, 131 days (35.9%) were postings to regular departments, and the remaining 234 days (64.1%) were COVID postings.
The self-perception about the competency of obtaining information from the patients and their families was found to be moderate in about half (50.4%) of the interns. The competency of analysis, display and interpretation of information; hypothesis formulation and decision-making was self-perceived to be low (11.5%). About 48.7% of the interns had a moderate level of perception regarding demonstration of knowledge and skills regarding care for women. When competencies in relation to decision-making were assessed, 46.9% of them had a moderate self-perception. In relation to interpersonal communication, management, organizing health care system and professionalism, the interns' perception was low in 13.3%. The level of self-perception on procedural skills was low in a significant 18.6% of the interns [Table 2].
|Table 2: Levels of self perception regarding various competencies among the interns|
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Among the procedural skills, level of self-perception among the interns was low for gastric lavage (25.7%), examination of placenta (33.6%), vaginal examination (38.1%), endotracheal intubation (75.2%), and lumbar puncture (76.1%). High level of self-perception was noted for urethral catheterization (84.2%), intramuscular drug administration (76.1%), nasogastric tube insertion (67.3%), cardiopulmonary resuscitation (56.7%), and intravenous drug administration (54.9%) [Figure 1].
|Figure 1: Self perception among the interns in relation to procedural skills|
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After finishing the internship, the overall self-perception levels regarding the competencies among the interns were found to be low, moderate, and high in 15.9%, 48.7%, and 35.4%, respectively [Figure 2].
The final year results of the interns involved in this study were 37 first classes (32.8%) and 76 s classes (67.2%). Association between the final year MBBS results and competency self-perception is shown in [Table 3]. It was found that none of the competencies were statistically associated with the grade based on the marks obtained in Final year part II.
|Table 3: Association between final year MBBS results and self perception regarding competencies|
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| Discussion|| |
This study is the first of a kind/unique study in India. COVID-19 pandemic has impacted life in every form. As this pandemic was expanding and life-threatening, all the educational institutes were shut down on precautionary terms. As part of this, all the medical colleges in the country opted for virtual digital forms to impart teaching among the medical students. Whereas, the interns who recently passed final year MBBS exams as students and were supposed to start their compulsory rotatory internship program could not afford this luxury, as they had to be trained hands-on completely to get the confidence required to deal with real patients.
Due to the huge burden of COVID cases, workforce needed to deal with this crisis was unlimited at that point, as a result the interns were given this task of dealing with COVID patients. This was a very different start than compared to the regular training of interns of previous batches. This pandemic phase continued over a period of time which could affect the training of this particular batch of interns in terms of communication, decision-making, professionalism, performing procedures, etc.
Therefore, this study mainly focused on the influence of pandemic on the internship training through assessing their competency levels in different aspects. Self-perception requires one to reflect on their own performance and judge how well they have done. As it is considered self-perception about their own competencies will be a better assessment method than other assessment methods, it was decided to use the self-assessment questionnaire.
A total of 113 interns participated in this study. Less than half (35.9%) of their internship duration only was used for their regular training. Among the interns, the overall self-perception levels regarding the competencies were found to be low, moderate, and high in 15.9%, 48.7%, and 35.4%, respectively. In a study conducted by Dias et al. on medical interns revealed that 67.5% were below average, 28.3% were average and only 4% were above average in their competencies. The contrasting results could be due to the methods of assessments used, as self-assessment method was used in this study against the objective assessment method used in the study by Dias et al. It shows that though interns were not in their regular postings, more than 80% of them self-perceived that they were over-all competent enough. This could be due to their self-interest in learning procedures, confidence gained in handling COVID patients and more exposure during nonCOVID postings.
The competency of obtaining information from the patients families was found to be of moderate level in about half (50.4%) of the interns. A similar study done in Kenya showed that 54.7% interns were moderate in history taking competency. However, 30% of interns were unable to obtain the information from the patient is a red flag which has to be addressed most importantly.
The competency of analysis, display, and interpretation of information; and hypothesis formulation was self-perceived to be low among only 11.5% of the subjects. This is as a result of these interns being backed up by postgraduate students and consultants during the COVID times to help them in decision-making in quick time. When competencies in relation to decision-making were assessed, 46.9% of them had a moderate self-perception. Most of the studies suggest that junior doctors are unprepared for the certain aspects of clinical decision-making. About half of the interns felt that they were competent in decision-making and this could be due to them being less exposed to the regular postings where they would have seen more patients and experienced more situations. About 88.5% of the interns had a moderate and high level of perception regarding demonstration of knowledge and skills regarding the care for women. A study by Heitmann et al. showed that 97% of the study participants had catered their services to female patients. A slight decrease in our study could be due to the cultural and regional pattern where women prefer a female intern to examine them.
In relation to interpersonal communication, management, organizing health care system and professionalism, the interns' perception was moderate and high in 86.7%. Since most of these skills are inculcated in them from their initial days in medical college, most of them were positive about these skills. In a study conducted in Oman, 82.6% of the students identified communication skills as the most significant aspect of professionalism. The study on perception of medical professionalism among medical residents showed that an average of 80.9% ± 0.05 residents had positive perception toward professionalism which is similar to this study.
The level of self-perception on procedural skills was moderate and high in 81.4% of the interns. Previous research has shown that most of the interns felt that they were not adequately prepared for their interns' role. Morris et al. conducted a study among the interns which revealed only 68% felt prepared with regard to their levels of competence in procedural skills.
Because of the COVID pandemic, fewer patients got admitted to the general hospital wards and the procedures done on patients were less, and therefore, 18.6% of the interns in this study had a low perception toward procedural skills. Endotracheal intubation and lumbar puncture were the two procedures that more than 75% of the interns had a low perception on. These two procedures are rarely taught during the MBBS training and also very less chances to observe the procedure as well. Central line removal, endotracheal intubation, noninvasive ventilation –continuous positive airway pressure/Bilevel positive airway pressure, chest drain removal, and arterial cannulation are the skills required but not taught to interns according to a study done in, Ireland. Hence, the interns will be under prepared for these procedures. Although there was an ongoing pandemic, restriction on nonemergency cases and less patients got admitted to hospital, most of the interns had a high level of self-perception for procedures like urethral catheterization (84.2%), intramuscular drug administration (76.1%), nasogastric tube insertion (67.3%), cardiopulmonary resuscitation (56.7%), and intravenous drug administration (54.9%). Because most of these are basic procedures and the interns had the scope to learn them in the COVID postings.
The COVID pandemic has affected the learning, teaching, and hand-on training. Contingency plans for effective clinical instruction must be available for future or continued pandemics. The medical education has to transform itself to meet future challenges by establishing academic health systems to facilitate remote learning.
A qualitative study conducted by Draper and Louw revealed that interpersonal skills, theoretical grounding, and intellectual ability as strengths for entering internship. Therefore, the association between the final year MBBS results and competency self-perception was assessed and it revealed that none of the competencies were statistically associated with the grade based on marks obtained in final year part II. An Australian study showed that most of the interns learning the competencies were influenced by the factors related to the work environment, seniors, consultants, and learner. Hence the competencies that a intern is expected to learn, will happen during the course of internship, and the marks they obtained during their final year might not significantly influence their competencies.
| Conclusion|| |
The overall self-perception levels regarding the competencies among the interns were found to be low, moderate, and high in 15.9%, 48.7%, and 35.4%, respectively. This concludes that COVID pandemic has affected the interns training to a significant extent. There was no statistically significant association between final year grades and the competencies.
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Conflicts of interest
There are no conflicts of interest.
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Department of Community Medicine, PES Institute of Medical Sciences and Research, Kuppam - 517 425, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]
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