Each July, the progression of medical students to physicians begins anew at academic medical centers across North America. Despite completion of the medical school requirements in preparation for this transition, the increased autonomy of internship may be frightening for new interns, as well as pose a risk for patients.1 Gawande2,3 summarized this conflict as “the imperative to give patients the best possible care and the need to provide novices with experience.”
In our current model of medical education, we often fail to resolve this conflict. For example, new residents are often responsible for responding to and even leading resuscitations for in-hospital cardiac arrests. However, studies have shown a considerable amount of resident discomfort with this role, even with previous Advanced Cardiac Life Support training.1,4,5 Medical students are generally excluded from the care of critically ill patients.6 Still, each new physician needs to autonomously care for a critically ill patient for the first time—often late in the night and with little support. Further, new interns face many clinical challenges for which they have not received specific previous training. Although most of these challenges are ultimately met, the result is increased stress for the intern and potentially unsafe care for patients.
Is there a way that students can step into the role of intern, with its resulting responsibilities and demands, but do so in a risk-free environment? It is difficult to safely offer such an experience with real patients. However, simulation of situations and decisions that new interns will likely face can allow experiential learning without posing danger to actual patients.6–9 In effect, a student can practice being a new physician. Unlike in real-life clinical encounters, mistakes can be allowed to continue to their ultimate consequences without the need for faculty intervention. Further, students function as a member of a team and can identify resources and individuals who are available for support. Exercises designed specifically to encourage a thoughtful approach to decision making help develop an organized approach to clinical problems. Finally, debriefing after each exercise allows real-time reflection, guidance from faculty, and opportunity to prevent the learning of bad habits.10–12 In analyzing their own performance and that of their peers, students develop the skills needed to become reflective practitioners in whom review of their own practice becomes part of their personal clinical culture.
In this article, we describe a 1-week intensive course entitled “Internship Boot Camp” and report the results of a survey of recently graduated medical students regarding their preparation for internship. The goal of the course is to assist 4th-year medical students with the transition to internship. Acknowledging the limitations of a course 1 week in length, we do not intend to cover the breadth of medical school education. Neither can we prepare all medical students for every possible challenge they will face during their internship. Instead, our goal is to help students apply their knowledge and develop a framework for responding to clinical challenges.
In 1999, the Accreditation Council for Graduate Medical Education adopted six core competencies to guide graduate medical education across all specialties: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice.13 The competencies were developed to embody qualities of good physicians while aligning with the needs of a changing health care system. In designing specific objectives for Internship Boot Camp, we attempted to integrate all six competencies. Throughout the course, each competency is covered and reinforced numerous times.
The course objectives are as follow, with the core competencies each specifically addresses in parentheses:
- Identify whether a problem needs to be addressed in an emergent, urgent, or routine manner and develop a framework for triage and for dealing with a call (patient care, medical knowledge).
- Demonstrate basic resuscitation skills (patient care, medical knowledge, interpersonal and communication skills, professionalism).
- Show basic crew resource management skills and recall their applicability to clinical care, particularly during crisis situations (interpersonal and communication skills, systems-based practice).
- Identify common safety issues that may arise for an intern in a major medical system and develop strategies for dealing with them (professionalism, systems-based practice).
- Recognize barriers in self, colleagues, and the surroundings that may negatively impact patient care (patient care, practice-based learning and improvement).
- Recall common clinical problems for which an intern will be the first person contacted (patient care, medical knowledge, practice-based learning and improvement).
Beginning in March 2006, an intensive 1-week Internship Boot Camp was offered as an elective to medical school students during their final year. The initial session was limited to 6 students and expanded to 12 in 2007 and 2008. Each year, demand for the course has exceeded capacity. At the request of the Mayo Medical School leadership, beginning in 2009, Internship Boot Camp is now offered to all 4th-year medical school students. Both from our own recollections and from conversations with new residents, we identified common themes that result in discomfort and a feeling of lack of preparation for new interns. These common themes were then developed into the clinical scenarios that form the basis of the Internship Boot Camp curriculum.
During the course, students are taught with a combination of high-fidelity medical simulation, standardized patients, procedural task trainers, and problem-based learning sessions generally initiated with a simulated call about a patient. The course is taught at our institution’s multidisciplinary simulation center with state-of-the-art audio and video capabilities, numerous patient rooms, and high-fidelity medical simulation mannequins and task trainers. Physician faculties are from the specialties of anesthesiology, emergency medicine, internal medicine, and pediatrics, bringing a breadth of skills to the course. Other participants include nurses, respiratory therapists, other physicians, and a psychologist. Templates specific to each case are given to participating faculty to guide both the debriefing discussion and ensure consistent coverage of the material. Group sizes are limited to seven students. The students are introduced to the “patients” they will observe longitudinally during the week. They participate in rotated on-call responsibilities, as well as admission and hospital dismissal of patients, code coverage, cross-coverage for other residents, and the handling of phone calls from nurses, family members, and staff. The Mayo Clinic Institutional Review Board approved this study.
Description of Internship Boot Camp
Each day consists of a combination of simulated patient care encounters followed by debriefing sessions and problem-based learning sessions that are usually initiated by a phone call from an actor portraying a nurse, family member, or staff member. Procedural task trainers are also used to reinforce airway management and lumbar puncture skills. Table 1 gives examples of the domains and topics covered in the most recent 2009 session. Although the course is refined and altered each year, the general organization and majority of topics have not changed significantly since 2007.
The objective of the course is to develop the students’ problem-solving abilities and their application of knowledge, rather than simply to increase their medical knowledge base. For example, instead of stressing the description of the treatment of pulmonary embolism, the development of an approach to a patient with shortness of breath is emphasized. The course is designed to be solely educational and not a means of assessment, with all feedback formative rather than summative. Care is taken to ensure that all feedbacks during the debriefing sessions are given in a nonthreatening manner. A complete outline of the course is beyond the scope of this article; some highlights of the course are mentioned below and an example of a day’s schedule is also included in Appendix, Supplemental Digital Content 1, http://links.lww.com/SIH/A8.
The week begins with an orientation to the service and rules. On the 1st day, students must care for a visiting medical student, portrayed by an actor, who is found in respiratory distress after an opioid overdose. In addition, they must determine how to approach the issue of substance abuse in this impaired colleague. Later in the day, they must address the challenge of an intoxicated father arriving to drive home his infant son who is being discharged from the hospital. Throughout each day, students are presented with many phone calls about patients. The calls and the clinical questions are of varying urgency, providing opportunities for students to demonstrate appropriate triage and to discuss a framework for response to these calls. Patients on the service have numerous problems that the teams deal with throughout the week.
On the 2nd day, students are faced with a patient whose symptoms have worsened since her hospital admission the day before. Her health deteriorates into cardiac arrest, and she dies. During the session with the patient and the later debriefing session, students use and become familiar with a defibrillator, review Advanced Cardiac Life Support algorithms, and reflect on her nausea of the day before. Later in the day, the on-call intern receives a call from the deceased patient’s husband, who does not yet know what has occurred. This course may represent the first time its participants have to break bad news to a family member in a realistic situation.
At the morning handover rounds on the 3rd day, students are told, among other things, that physical restraints were ordered for a patient with dementia who was hospitalized the day before. The students are later called to a code and find this patient strangled by her restraints. This event leads to a discussion on the indications of restraint use and the rationale of restraint policies. The students are further challenged with a call from a source asking inappropriately for information about this episode.
The following day includes a call to resuscitate an unknown patient who, it is ultimately learned, has a do-not-resuscitate order in place. In the afternoon, students attend a session that focuses on stress and personal wellness, presented by a psychologist. Among other topics covered during this session, reference is made to the impaired colleague from the 1st day, followed by a discussion of substance abuse in oneself, as well as in one’s colleagues.
On the final day, students are individually given the opportunity to manage an unknown, short clinical encounter entitled “Fifteen Minutes of Fame,” with a group debriefing at the end of each case. In these brief sessions, students demonstrate what they have learned, as well as provide nonthreatening feedback to their peers. In contrast to the rest of the course, which is designed to provide general training, these sessions are tailored to an individual student’s chosen specialty. The course concludes with an open and informal question-and-answer session with the faculty about any areas of concern. Discussion topics may relate to specific clinical scenarios, such as the appropriate selection of antibiotics; intern responsibilities; and issues of professionalism, including dealing with difficult colleagues and interpersonal relationships with allied health staff.
2007 Intern Survey
We undertook a qualitative and quantitative Web-based survey of our institution’s medical school graduating class of 2007 (40 graduates). The survey’s purpose was to (1) assess new interns’ perception of preparation for internship, (2) identify areas of future curriculum focus, and (3) assess whether new interns would recall Internship Boot Camp as helpful in their preparation for residency. The Web-based survey was sent to the graduates early in their internship. An identical written survey was sent shortly thereafter to those students who had not yet completed the Web-based survey.
The survey included four questions to be answered on a five-point Likert scale, followed by three open-ended questions (Appendix, Supplemental Digital Content 2, http://links.lww.com/SIH/A9). The quantitative questions addressed preparation for internship overall, on the basis of medical knowledge, emotional preparedness, and clinical experience. The qualitative questions asked for (1) specific aspects of the student’s medical education that helped in preparation for internship, (2) areas of deficiency, and (3) suggestions for improvement. Students were informed that the survey’s purpose was to identify aspects of medical education that helped in preparation for internship. The curriculum questions were included for the benefit of the medical school, as well as to disguise an association of the survey with Internship Boot Camp. Respondents were not required to answer the open-ended questions.
The time period of the survey—between August and October of 2007—was chosen to allow reliable recall of the medical school’s contribution to preparation for internship and to decrease confounding by what students subsequently learned in residency. The survey was conducted by the institution’s survey research center. With permission, the source of the survey was identified as the Mayo Medical School to blind the respondents to any involvement by us or the institution’s multidisciplinary simulation center. The survey results were anonymous; the sole identifier was whether the respondent had completed the 2007 Internship Boot Camp (Boot Camp) or not (non–Boot Camp). We did not have access to survey results until after the survey period had ended. Survey results are being used to modify and improve the medical school curriculum, and they were considered in the design of the 2008 and 2009 Internship Boot Camp.
Evaluations on completion of Internship Boot Camp have been consistently positive. The 12 participants of the March 2007 course gave it an overall mean score of 4.8 on a five-point Likert scale. Their evaluation included 15 questions with answers rated on a five-point Likert scale. The overall mean of the individual mean scores was 4.7 (range, 4.3–4.9). The areas that received the lowest mean score (4.3) were “technical skills” and “debriefing”; the area that received the highest mean score (4.9) was “faculty knowledge of the subject matter.”
Of the 40 surveys, 32 were completed for an overall response rate of 80%. The response rates for Boot Camp and non–Boot Camp groups were 83% (10 of 12) and 79% (22 of 28), respectively. Overall, 44% of respondents felt “very well prepared” for internship and 47% felt “somewhat well prepared.” Only one respondent reported being “somewhat unprepared,” and no respondent reported being “extremely unprepared.” A two-sided exact Wilcoxon rank sum test was used to compare each of the four initial quantitative questions (with ordinal scales) among the Boot Camp and non–Boot Camp groups. As summarized in Table 2, there was no statistically significant difference (P < 0.05) for any of the four quantitative questions.
The first open-ended question on the survey stated “Please list specific aspects of your medical school training (ie, courses, instructors, rotations, readings) that stand out as being particularly helpful in preparing you for internship.” The most common responses are summarized in Table 3. The nine Boot Camp respondents who answered this question provided 20 items, with the “Internship Boot Camp” response representing 40% of responses (8 of 20). Their next most frequent response was “subinternship.” Subinternships are clinical rotations 4 weeks in length in either internal medicine or surgery. In the non–Boot Camp group, the 20 respondents to the question provided 53 items, with the most frequent response being “subinternship.”
No significant differences were found between the Boot Camp group and the non–Boot Camp group in the self- assessment of preparation for internship. In open-ended responses, Internship Boot Camp was recalled as the single most important aspect in preparation for internship.
We describe an innovative 1-week curriculum designed specifically to help 4th-year medical students with the transition from student to intern. Medical simulation involving role playing, simulated patients, and the use of mannequins is not new, but it is being used with increasing frequency in medical education.8,12 However, we are likely only at the beginning of the full potential of medical simulation in teaching.6,14 To our knowledge, there are no published descriptions of a medical school curriculum similar to Internship Boot Camp. Fisher et al15 describe a course designed to help prepare students for internship with four major domains: managing acutely ill patients, teaching, communicating, and coping with stressors. Although it has many similarities to our course, it is not an intensive course (taught in 1- to 3-hour blocks during 2 weeks), does not appear to use medical simulation to allow experiential learning, and does not involve longitudinal care of simulated patients. Courses specific to surgery, obstetrics and gynecology, and pediatric critical care have also been described.16–20 Although specialty-specific Boot Camps offer advantages of being more narrowly focused to one’s chosen specialty, we feel that medical schools should aim to produce qualified, undifferentiated physicians. Despite recommendations from program directors, chairs, and residents that students obtain a breadth of experience, senior medical students often fill their final year with rotations in their chosen specialty in what has been described as “preresidency syndrome.”21–25 Internship Boot Camp neither replaces nor is replaced by specialty-specific courses.
The transition from medical school to internship presents many unavoidable challenges. However, many problems are predictable and may be prevented with appropriate training. The purpose of this course is to provide medical students with the opportunity to practice being interns in a safe and nonthreatening environment. Faculty instructors are present to facilitate the development of a framework for how to prioritize clinical care. The simulated clinical cases allow active, experiential learning without risk of harm to real patients. The result is a unique learning environment that helps foster a culture of reflection and self-scrutiny.
The subinternships at our institution are designed to give students a chance to assume a role similar to that of an intern and are required for all 4th-year students. Therefore, it is not surprising that these experiences would be recalled as helpful in preparation for internship. However, the Internship Boot Camp was recalled as helpful in preparation for internship at a higher rate compared with the subinternship. One possible explanation is that the Internship Boot Camp allows complete autonomy for the students, even when potentially dangerous for the simulated patients. As subinterns, on the other hand, patient safety must be maintained and real patient care decisions must be supervised at a higher level for students than interns. Medication orders, for instance, cannot be given by a student during a subinternship, but they can during the Internship Boot Camp.
There are limitations to our Internship Boot Camp and 2007 survey. The number of students involved is small, primarily because our institution’s medical school is one of the smallest medical schools in the United States.26 A simulation-based curriculum such as the one described herein is resource intensive, requiring numerous faculty participants and actors and the use of a modern simulation center. Table 4 summarizes the resources required each day. Because the costs of faculty and facilities are different for each institution, it is challenging to assign an actual dollar value to the cost of the course. The cost of disposables was <$500.00. Because of financial and resource limitations, some medical education centers may not be able to undertake such a course, especially those with larger classes. The groups—Boot Camp and non–Boot Camp—were not randomized. Although 89% of the Boot Camp respondents mentioned Internship Boot Camp as helping prepare them for internship, they did not report higher overall ratings of preparation for internship than the non–Boot Camp group. This finding could be secondary to a selection bias, resulting in students who felt less prepared for internship being more likely to enroll in the course. Further, data on whether Internship Boot Camp improves clinical performance in internship are lacking and would be difficult to obtain given the small group size, the multiple confounders for internship performance, and the lack of an acceptable assessment tool. Finally, as we transition Internship Boot Camp from being a highly sought, after 4th-year elective to a required rotation, enthusiasm for and the efficacy of the courses may diminish.
Despite these limitations, Internship Boot Camp is highly regarded among our institution’s medical school students and is recalled as the most helpful of all components of their medical school education in preparing them for internship. The faculty resources we require appear to be less than those described in a nonexperiential internship preparation course.15 In fact, the ratio of one clinical instructor to five to seven learners, as used in our course, is not significantly different from small group exercises that are common in most medical schools. The medical school leadership continues to support the Internship Boot Camp because it is a unique opportunity to bring together all the skills that the students have been developing and “try them out” on their own, without risk to actual patients. For medical schools that have the capability for such a course, an internship boot camp can integrate the Accreditation Council for Graduate Medical Education core competencies and help students prepare for internship. Although the transition from student to intern will always be difficult, the model of an internship boot camp helps prepare students for the challenges they will face as interns and may potentially improve patient safety.
The authors thank Amy Weaver for her help with statistical analysis. We also thank Nadia Laack, MD for her contributions to the manuscript. Finally, the Internship Boot Camp would not be possible without the continued help of the entire staff at the Mayo Clinic Simulation Center and support of the Mayo Medical School leadership.
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