The Internship Year: A Potential Missed Opportunity to Expand Medical Access in International Settings

Health care systems that address the needs of local populations are critical to the health and well-being of nations.¹ They need to address the global undersupply and maldistribution of physicians geographically and by specialty.² Discrepancies in accreditation standards and medical education quality across nations contribute to disparities in physicians' knowledge and skills.³ In response, initiatives have been created to reform curricula, identify key physician competencies, and align medical education with the health care needs of populations.^3–5

For undergraduate and postgraduate medical education, accrediting bodies in North America, Europe, and Australia have developed competencies that define the knowledge and skills expected of physicians.⁶ A parallel reform has been observed in other countries,⁷ and countries such as Singapore and the United Arab Emirates (UAE) have introduced competency-based curricula into residency training.⁸ In contrast, the internship year, which serves as a transition between medical school and residency in many nations, has received limited attention from educators and innovators.

In this article, we suggest that educational innovation focused on the internship could represent a transformative opportunity for health systems in many global settings. We describe the significant role of the internship from a health systems level. Internship is designed to aid medical students' transition into general practitioners⁹ and is mandatory in at least 52 countries.^9–18 Upon completion of the internship year, physicians in these countries are eligible for licensure as general practitioners or can pursue residency. Collectively, the health systems of these nations serve more than 4 billion people or more than half of the world's population.^9–18 In many nations, the internship year is the last formalized training prior to practice, given the scarcity of more advanced residency training. Internship-trained physicians represent the majority of the physician workforce in many nations, serving as general and primary care physicians and points of access to the health system.^9–18 In the online supplemental material, we provide links to documents about the internship year from a range of nations.

Although it remains mandatory in many nations, the internship year was eliminated in the United States and Canada. Key factors in this decision were the availability of residency positions, stricter licensing requirements, and added funding to finance longer postgraduate training periods.¹⁹

However, the context is different in many developing nations that lack health system and medical education infrastructure and need to expand the number of physicians on the ground with adequate generalist skills.²⁰ Moreover, strategic placement of internships has enhanced the supply of physicians in underprivileged and remote areas of Norway.¹⁴

Thus, from a global perspective, the internship year may have significant potential to impact population health and currently represents a missed opportunity for medical education reform. There is a need for global efforts to enhance the internship year as the critical transition to practice in many settings across the world. We propose an instructional design model to align the internship year with local health systems' needs.

Reforming the Internship Year: A Roadmap for Developing and Emerging Nations

We used a 4-step systematic approach (as shown in figure 1) toward internship reform implemented by our institution, a US-based, multispecialty, tertiary health care center in the UAE.

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In Step 1, we determined the tasks that medical interns need to master by the completion of the internship year. These tasks should correlate to clinical activities that regulatory bodies expect graduates to perform upon completion of their training. In many cases, those activities may not be defined, highlighting the internship as an opportunity to align academic and health systems expectations. In the UAE, internship is a requisite to residency and entry into general practice. As our competency framework, we adopted the 13 entrustable professional activities (EPAs) established by the Association of American Medical Colleges (AAMC), which describe minimum competency standards for medical school graduates in the United States prior to entering residency.²¹

In Step 2, we determined competencies required to achieve the tasks identified in Step 1. In many countries, these competencies are not defined. In our case, the 13 EPAs by the AAMC²¹ were mapped to align with the Accreditation Council for Graduate Medical Education (ACGME) 6 competencies (table).²²

table ACGME Competencies Mapped to AAMC EPAs

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In Step 3, we identified learning topics and instructional methods for the tasks and competencies specified by the AAMC and the ACGME:

• We appointed a lead clinical subject matter expert for each core rotation. Subject matter experts are full-time, independently practicing physicians in their specialties with teaching experience.

• We developed a step-by-step curriculum template (figure 2) for subject matter experts to map learning topics and instructional methods to EPAs and competencies for each week in their core rotation.

• We appointed a learning and development expert to review and adjust the completed templates to ensure conformance with learning objectives.

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In Step 4, subject matter experts and the learning and development expert determined assessment tools based on selected instructional methods and identified learning objectives. To ensure the reliability and validity of those assessment tools, all assessments used were selected from previously validated tools in the literature for the specific clinical tasks or behaviors being evaluated.

In many developing and emerging nations, the physicians graduating from internship represent the access point to the health care system. Therefore, deliberate efforts to reform and enhance the internship year will improve the quality of care delivered by the health system as a whole. We described a systematic approach as an initial step toward reforming this critical juncture in physician training for consideration by other health systems. We acknowledge that potential barriers include inadequate resources, such as expertise, physical facility, and funds for training. Another barrier is the relatively undefined regulatory environments that may contribute to a lack of standardized scopes of practice.

The successful implementation of our model requires well-defined performance objectives for learners and faculty, an expertise in competency-based education, and iterative program evaluation efforts. To define the effectiveness of this approach, future research needs to explore short-term outcomes such as learner competence attainment, graduation rates, and availability of programs. Long-term educational outcomes worthy of study include longitudinal measures of quality of care delivered by graduates, patient satisfaction, and contribution to workforce demands.