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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