Proposal of the Sri Lanka Medical Council for a Change in ...



ANNEXES

Annex 1

Supervised Hands On Training -‘SHOT’

Reasons for a Change in Internship

By Prof. Sanath P Lamabadusuriya

Format of Supervised Hands On Training (SHOT)

1st Year - Six months each of 2 of the 4 major disciplines (eg.General

medicine and general surgery)

2nd Year - Three months each of the other 2 major disciplines (eg. Paediatrics

and obstetrics and gynecology)

Three months each of 2 sub specialties such as psychiatry,

cardiology, neurology etc. or community medicine or attachment

with general practitioner.

Advantages of SHOT

• Better foundation - exposure to all 4 major disciplines

• For a future specialist - exposure to subspecialties during training

• For future G.Ps - exposure to general practice under supervision,

and wider exposure to all major clinical disciplines

• For a community physician - exposure to community medicine

• Supervised training for 2 years in a teaching environment

• Employment ensure for 2 years (Ministry of Health will not e employing all medical graduates after 2010)

• Can embark on Post Graduate training soon after SHOT

• Preliminary grade salary would be paid during second year.

Possible rotations ( in 2nd year )

• For a future cardiologist - Three months of cardiology

Three months of intensive care

• For a future G.P - Three months of general practice

Three months of psychiatry

• For a future paediatrician - Three months of paediatric surgery

Three months of intensive care

• For a future community physician - Three months of community medicine

Three months of psychiatry

Potential logistic problems

• Provision of quarters during SHOT

Solution - provision of on-call rooms

renting houses for accommodation

As SHOT would extend training by one year, the following issues should be dealt with –

a) Reduce the initial of six months between completion of ‘O’ level

examination and commencement of ‘A’ level course.

b) Reduce period between completion of ‘A’ level examination and admission to universities (currently about 1 year)

c) Reduce the period between completion of Final MBBS examination and commencement of SHOT (sometimes up to 1 ½ years)

d) Streamline Final MBBS examination of different faculties so that allo examinations are held within the shortest possible period.

e) Overlapping of internship until backlog is cleared.

Annex 2

Supervised Hands On Training -‘SHOT’

A Short Presentation

by Dr Ananda Samarasekera

Vice President, SLMC

Internship

History

1905- Legislative provision for certain categories of persons to practise medicine and surgery.

1907- Actual registration commenced.

1927- Became mandatory to have registration for practise of medicine and surgery.

1942- University Ordinance made provision for recognition of the MBBS (Ceylon) degree which replaced the LMS.

1955- Legislative provisions were brought in to provide provisional registration and pre-registration experience.

This made provision to recognize MBBS (Ceylon) and other special qualification as a prerequisite for provisional registration.

Also made provision to obtain a certificate of experience and stipulated the rights of provisionally registered medical practitioners.

This certificate of experience became a mandatory requirement for full registration.

Who is an Intern Medical Officer?

Also call pre- registered medical practitioner

A medical graduate who is provisionally registered as a medical practitioner with the SLMC to obtain a certificate of experience by working in an approved hospital or institution by engaging in employment in a resident medical capacity for a prescribed period in an field of medicine approved by the Medical Council for the purpose of obtaining full registration.

Law

Legal provisions applicable to internship

Must be engaged in employment in a resident medical capacity for the prescribed period* in one or more approved hospitals or institutions**

(*In relation to the practice of medicine or surgery or other approved fields by the Medical council having regard to the medical needs of the country

** hospitals or institutions approved by the medical council from and among lists of hospitals and institutions submitted by the DGHS.)

During his/her aforementioned employment must be engaged for:

an approved period in the practise of medicine,

an approved period in the practise of surgery,

AND

for an approved period in the practise of other approved fields;

AND

have rendered satisfactory service while so employed.

Midwifery

The period , without exceeding the prescribed period, spent in the practice of midwifery shall for the purpose of experience be deemed to be a period spent in the practise of medicine and surgery as he/she may elect.

Resident medical capacity

In accordance with the terms of his/her employment in a prescribed hospital or an institution, residing conveniently near that hospital or institution, his employment in that hospital or institution shall be deemed to be employment in a resident medical capacity not withstanding his residence in that hospital or institution.

Rights of an intern medical officer

Approved period and fields at present

* Total period of 12 months

* Six months each in surgery, medicine, gynaecology & obstetric and paediatrics, paediatric surgery.

* Combination of medicine and paediatrics, paediatric surgery and surgery cannot be done to complete 12 months

In the past…..

• The first batch of interns was appointed from the 1st May 1956 to 30th April 1957.

• Approved hospitals for internship included Chest Hospital, Welisara, District Hospital, Haputale.

• Three months of midwifery was recognized as part of medicine or surgery.

• Working as a house officer in a district hospital under a DMO with no specialists had been recognized as an internship.

Annex 3

Proposal of the Sri Lanka Medical Council for a Change in Internship

-Dr S Sivakumaran

A doctor

has a recognized degree having followed a recognized course

• Has satisfactorily completed recognized appointments during the pre registration period.

Continues professional development (CPD)

Pre registration clinical training

• The main objective is to provide supervised hands on training before they are allowed to practise on their own.

• Work horse or Trainee

Need for Revisi(on)t

With multiplication of specialties,

rapid advancement in medical practice ,

vast changes in medical curriculum and training –internationally

Greater expectations from the patients

Train adequately and appropriately

There is a need for reorganization of the current pre-registration training programme to prepare our graduates adequately and appropriately for them to:

– practise independently

– excel in their future career

– remain globally competitive and sought after

– Keep in mind D.O.B

The clinical training which is supervised and “hands on” should aim to provide:

– adequate training in the important specialties the graduate needs to have experience in, if he/she wishes to take up to general practice

– some training in the field and fields related to, in which the trainee wishes to specialize in.

– Provision of adequate exposure to career options

– Opportunity to work in a field, which the graduate would consider

– specializing in but not offered in List 1.

.

Effective Shot

In essence SHOT should include:

– providing practical experience,

– education with particular reference to the subjects mentioned above and

– appraisal and assessment

Formal lectures

Communication skills, interpersonal relations and counseling

Continuous professional development

Training in medical record keeping

Information on professional ethics

Current practice

At present the 1-year internship consists of a six months period of training in two of the following specialties:

List 1

Medicine /Paediatrics

Surgery/ Paediatric Surgery

Obstetrics and Gynaecology

The present practice does not fully serve the objectives as envisaged – to practise independently, excel in their future career and remain globally competitive and sought after. It gives training in only two fields. A trainee who wishes to take up to general practice would also benefit from training in other fields not listed in List 1 in which he did not have training, plus some training in specialties such as eye, ENT, psychiatry, etc.

Similarly a trainee who wishes to specialize in a particular specialty may not get an opportunity to do that specialty during his internship period - e.g. he may have done six months internship in surgery but would like to specialize in O&G.

Alternatively he may consider specializing in some fields not given in List 1 during his internship but would like some exposure to that specialty before making up his mind. For instance a trainee might like to specialize in radiology or eye but would like some exposure in those specialities to make up his mind.

In order to accommodate these objectives and aspirations of the trainees the supervised hands on training need to include more specialties.

Therefore, to accommodate additional specialties the SHOT period needs to be longer. It is proposed to have an additional year of SHOT to achieve the objectives mentioned earlier.

Two Six-Month Appointments

Considering the responsibility the House Officer is expected to shoulder, it is recommended that the first two appointments during the SHOT period should continue to be six months each.

Shorter periods of training in basic specialties during the first year may have a significant deleterious impact on patient care. Further, it may not meet the PGIM requirements to apply for selection test in many specialties.

Proposed Programme

First Year

Foundation

Objectives:

To provide:

– hands on training in 2 major specialties

– Formal lessons and training in communication skills, ethics and medical record keeping

The first year will be similar to the current one year internship, offering six months period of training in two of the following specialties.

List for 1st year

Medicine /Paediatrics

Surgery

Obstetrics and Gynaecology

Note: Paediatric surgery has been shifted

to the 2nd year.

Second Year

Career development

Objectives:

To provide training in:

– the other two major specialties

– some fields related to the specialty the trainee would like to specialize in

– some specialities the trainee would consider specializing in (helping to make up his mind)

The trainee could select any four appointments from Lists 2 and 3, (other than the two appointments which he had already done.)

List 3

Anaesthetics

Cardiology

Community Medicine

Dermatology

ENT

Eye

Forensic Medicine

Intensive Care Unit

Neurology

Orthopedics

Paediatric Surgery

Pathology/Haematology

Psychiatry

Radiology

Trauma (Accident and emergency)

Assistant to DMO in a district hospital

You Choose

He could opt to do the two specialties in List 2, which he missed during the first year; e.g. if a candidate has done medicine and surgery during the first year he may be able to do three months each of paediatrics and three months of obstetrics and gynaecology in the 2nd year). The other two appointments shall be chosen from List 3. He is expected to make this selection depending on his future plans.

For those determined trainees who have not done six months appointment in a field they wish to specialize in and have not done the six months, may be allowed a 2nd three months in that specialty provided there are no contenders from those who have not done the appointment in that field.

Opportunities galore

Examples of opportunities provided

If a trainee wishes to take to general practice in the future he may consider doing psychiatry, dermatology, eye or ENT.

• A trainee who had done 6-months surgery during the first year and wishes to specialize in surgery, may wish to do three months in orthopedics and three months in trauma.

• A trainee who wishes to make up his mind before deciding to specialize in ophthalmology may opt for a three months appointment in ophthalmology.

Concerns

The answers to the concerns that may arise in the minds of the trainees are considered below.

Salary

Q: What will be my allowance during the second year of training?

A: It is proposed to pay the salary of the first year medical officer.

Q: Will I be entitled to overtime payments during the second year?

A: It is recommended that you should be entitled to overtime payments.

Q: What will happen to my departmental service seniority

A: Back dated registration should be recommended by the SLMC.

Specialization

Q: Have I to wait for the completion of the 2- year training before sitting any PGIM exam?

A : You should be allowed to sit for any PGIM examination according to the PGIM regulations at that time and it will be ensured that these new proposals do not delay your post graduate training.

General practice & Resignation

Q: Will I be able to resign from the department and start general practice before I

complete the two years of SHOT?

A : You may resign at any time you wish but you will be registered by the SLMC

only when you complete the required 2- year stipulated appointments. Therefore, you will not be able to practice.

On call duty

Q: Will there be on call duty during the second year.

A: All doctors in hospital clinical practice have on call duties independent of their designations. If you are doing an appointment in a field in List 2, you will certainly have first on call duties. With regard to appointments in specialties in List 3, it will depend on the individual appointment but most will have on call commitments. The on call duty is necessary for your appointment to be recognized by the PGIM for selection tests in certain specialties.

Duties

With regard to basic specialties this will be similar to the duty of an intern with on call either one in three or one in four. As regards the specialty in List 3 the trainee would be expected to be on call if on call commitments are expected in the specialty (not exceeding a one in three rota)

Accommodation

On call room should be made available for the trainee when he/she is on call.

Remuneration

Would be that of a first year Medical Officer.

Sitting for Post-graduate Exam

The trainee should be allowed to sit for these exams during the second year provided he/she fulfills the PGIM criteria as at present.

Implementation

Applications shall be called at the end of the seventh month for the second year appointments

The appointments for the second year will be made known within 4 weeks with 2 weeks period to appeal.

At least 12 weeks notice for the appointments in the second year.

Vacancies and accommodation

Their will be about 1000 interns at any given time

About 40 institutions will be training them.

It is proposed to create about 300 vacancies from List 3. The balance 700 vacancies will be from List 2. This means there should be an additional 180 vacancies created in each basic specialty. That amounts to about additional 6 vacancies in each institution for each specialty.

It is recommended that vacancies in basic specialties should be confined to Base Hospital and District General Hospitals (excluding Teaching Hospitals).

Annex 4

Supervised Hands-on Training

(Internship)

Placement of Interns

Dr. S. Terrence G. R. de Silva

DDG(MS)I

Doctors Graduated from following Medical Faculties apply for internship

Faculty of Medicine, Colombo

Faculty of Medicine, Peradeniya

Faculty of Medicine, Karapitiya

Faculty of Medicine, Kelaniya

Faculty of Medicine, Sri Jayawardenapura

Faculty of Medicine, Jaffna

In addition there are foreign Medical Graduates.

Names of the hospitals provided with interns

NHSL

LRH

DMH

CSHW

TH Mahamodara

TH Karapitiya

TH Peradeniya

SBSCH

TH Colombo South

GH Sri Jayawardena

CNTH- Ragama

TH Kandy

GH Anuradhapura

GH Badulla

TH Kurunegala

GH Kulutara

GH Ratnapura

BH Avissawella

BH Chilaw

BH Gampaha

BH Kegalle

GH Matara

DGH Matale

DGH Negambo

BH Nawalapitiya

BH N’Eliya

BH Panadura

BH Polonnaruwa

BH Watupitiwala

BH Kuliyapitiya

BH Trincomalee

BH Puttalam

BH Homagama

BH Hambantota

BH Monaragala

BH Horana

BH Dambulla

TH Jaffna

GH Batticaloa

BH Diyatalawa

GH Ampara

BH Mahiyangana

Kalmuai South

GH Vavuniya

BH Marawila

BH Embilipitiya

(Total 46)

Total number of Consultant Units

General Medicine 82

General Surgery 78

Paediatrics 71

Gyn. & Obs. 85

Total 316

If three interns appointed to each unit we need 948.

Number of Intern appointed during the last two years

2006 October Main batch 765

2007 May, Repeat batch 176

Total 941

2007 October, Main batch 746

2007 November, Repeat batch 181

Total 927

Distribution of Consultants

Consultant General Surgeons 72

Consultant General Physicians 84

Consultant Paediatricians 89

Consultants Obs. & Gyn. 94

Consultant Eye Surgeons 43

Consultant Dermatologists 17

Consultant Radiologists 39

Consultant Psychiatrists 13

Consultant JMO. O 23

Consultant Anaesthetists 63

Consultant Histopathologists 24

Consultant Otolaryngeologists 20

Consultant Haematologists 11

Consultant Orthopaedic Surgeons 21

Consultant Rhumatologists 13

Consultant Clinical Microbiologists 22

Consultant Neurologists 14

Consultant Cardiologists 23

Consultant Neuro Surgeons 08

Consultant Oncologists 14

Consultant Vascular Surgeons 02

Consultant Veneriologists 09

Consultant Paediatric Surgeons 06

Consultant Neuro Physiologists 01

Consultant Nephrologists 03

Consultant Oncological Surgeons 07

Consultant Geni. Urinary Surgeons 09

Consultant Chest Physicians 11

Consultant Cardio Thora. Surgeons 08

Consultant Gastro Entro. Surgeons 04

Consultant Gastro Entro. Physicians 01

Dr. Terrence de Silva

DDG(MS)I

Annex 5

Proposed Supervised Hands on Training (SHOT)

by

Prof. Jayantha Jayawardana

What are the Advantages?

• Educational and Academic

• Personal

• Patients and society

• Country

• Global

Educational and Academic

• Strengthen knowledge

• Manage acutely ill patients in a variety of settings

• Risk management

• Hands on skills

• Communication skills

• Critical thinking skills

• Personal and Professional skills

• Administrative skills

• Develop generic skills such as team work, infection control, …

• Positive influence on motivation

• Identify strengths and weaknesses

• Recommend remedial action

• Improve assessments/examinations

• Academic work – seminars, SGD, workshops

• Clinical skills

* History

* Examination

* Judgment

* Investigations

* Management plan

* Note keeping

* Reflective writing

* Operative and practical skills

* Able to identify limitations

* Decide when to summon help

Postgraduate Education

• Time to select the specialty

• Complete requirements

• Time for studies

• Opportunities for help and supervision

• Access to facilities : library, IT, SGD

• Desirable maturity

• Be closer to other postgraduate training programmes

* Eg: PMETB (UK)

Personal

• Opportunity for training in all four specialties with full salary

• To do two other appointments

• Remain in a “hospital in the centre”

• Fulfill PGIM entry requirements

• Medico-legal implications

• If not employed by MOH an opportunity to remain for extra year

• If only option is Family Practice better trained

• More time to organize the future professional life

• Benefits to the family

• Positive impact on your private practice

• Income may improve

Advantages – Patients

• More medical officers in a ward

• MO with experience (when no Registrar/SHO)

• MO with experience in hospitals in the periphery

• Quality of care will improve in PH

• Quality of care will improve in GP practice

• Reduce referrals and transfers to the centre

Advantages – Country

• Improve quality of care and standards

• Improve statistics

• Manpower requirements

• Cost savings

Advantages – Global

• Postgraduate training posts for Board Certification

• Recognition of training for exceptions

• Recognition of MBBS for Registration

• Entry examinations

• Employment

What are the Advantages?

• Educational and Academic - YES

• Personal - YES

• Patients and society - YES

• Country - YES

• Global - YES

TIME TO VOTE YES BEFORE

IT IS TOO LATE

What will be offered?

• Total of two years paid training period

• Remain in a main hospital

• Trained by six consultants

• Exposure to all four major specialties

• Exposure to two other specialties

• Pre-arranged educational programme

• Monitoring during implementation

• Plan for appraisal and evaluation

What are the Educational Objectives of Internship?

• Knowledge

• Academic work – seminars, SGD, workshops

• Competence in Clinical Skills

• Communication skills

• Administrative skills

• Personal and Professional skills

Annex 6

Position statement of the AMS

- SHOT proposals for medical graduates

1. The AMS accepts and endorses in principle that supervised training in diverse fields would be beneficial for both medical practitioners and patients.

2. The AMS recommends that certain disciplines be made compulsory whereas others can be optional. The AMS endorses the opinion that Accident and Emergency medicine and Medical Ethics are two of the disciplines which should be made compulsory. The training courses in these fields should be well structured and targeted with precise objectives.

3. The AMS endorses in principle that the SHOT program is acceptable so long as it is supplemented in a manner which does not materially affect the career progress of medical graduates in:

a) Postgraduate opportunities

b) Remuneration

c) Departmental seniority

4. The AMS endorses the opinion that a feed back is required from the following groups indicating their perceived deficiencies in training:

i) Immediate post interns.

ii) Registrars in different specialties

iii) Grade MOO in “difficult” areas

iv) MOO OPD

This feed back data is required so that the training slots offered reflect these

perceived deficiencies.

5. As an incentive to the medical graduates it is proposed that internship be a

placement within the preliminary grade. The placement of a MO in grade II soon

after completion of the SHOT program is also proposed for consideration.

6. The AMS endorses the view that a formal ‘exit’ type of assessment at the end of

the SHOT program, or preferably at the end of each training slot, has many

commendable points.

The high quality performers at this exit assessment may be positively rewarded by the issue of a certificate of merit but a punitive element is not required as this is anyhow inbuilt in the present system by the supervising consultant’s right to repeat the appointment.

7. The AMS is of the view that on call rooms alone would be an inadequate facility

and the construction of suitable accommodation must commence immediately.

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