Should we embrace a return of the rotating internship?
The rotating internship was abolished in the early 1990s, mainly at the prompting of the College of Family Physicians of Canada to address shortages in Family Medicine. Prior to this, newly graduated medical students completed a one-year internship to obtain a general license to practice medicine and were then free to pursue further specialty training if they so desired. With the removal of the rotating internship, training requirements became two years for Family Medicine and 4-5 years for specialties.
After this change, concerns were raised about pressures on medical students to make premature career choices. As the CaRMS season descends upon the medical community for the 2013 residency match process, this discussion is particularly pertinent for fourth-year medical students (including myself) looking to make critical decisions regarding our future careers.
My first day of medical school was immediately marked with intense discussion surrounding which one of ‘The Big Three’ career paths I would choose. Was I destined to become a Surgeon? A Primary Care physician? Or perhaps I was interested in one of the many subspecialties of Internal Medicine? This was a topic that tirelessly dominated all conversation over the next 4 years. I asked my fellow classmates, ‘what is the single biggest source of stress and anxiety you have experienced during medical school thus far and what solution(s) would you propose for it?’ Over 70% of the people I asked said that concerns over the pressures related to early selection of residency was a source of constant distraction. One of my colleagues captured this particularly well:
I hate the idea that we need to commit to making the “right” connections and doing the “right” research before we even get close to a real patient. It undermines the whole idea of using clerkship (and especially our electives) to explore all the aspects of medicine and find what is right for us. I thought I was through all that the day I got into medical school, but it’s just getting worse. I am curious what would happen if they brought back the rotating internship year.
A study done at the University of Alberta examined students’ elective choices before and after the elimination of the rotating internship. 13% of the class of 1992 (prior to removal) and 52% of the class of 1994 (after removal) indicated that residency had a primary influence on their elective choices. 33% of the 1992 class had a narrow elective focus, compared with 49% in 1994. They concluded that residency concerns did have a significant influence on elective choices and that the choice of electives was narrower after the abolishment of rotating internships. This data is further supported by the fact that 59% of residents from the 2000-2006 CaRMS pool indicated that they had completed more than 50% of their electives in their first-choice discipline.
But would the return of a rotating internship really make a difference on premature career choices? The national colleges of family doctors and specialists have studied this issue, and their focus groups concluded:
No matter what type of selection takes place in the final year, the selection process will involve choosing electives, letters of references and interviews – delaying entry will not delay the decision-making process.
Beyond impacting elective choices, the rotating internship did more than just delay the decision of whether and in which field to specialize. It also exposed future specialists to the full spectrum of medicine. Some have argued that the elimination of general education has lead to a cultural and intellectual divide between family doctors and specialists, where specialists no longer ‘understand’ what family doctors do in their daily practice, and what kinds of health issues can be managed in the community setting. This leads, in their opinion, to a communication breakdown between specialties and the undermining of primary care.
In the 5 weeks I have spent in a family doctors office, I have learned enough to realize that there is an incredible breadth of knowledge required of them. They manage all spectrums of chronic disease. A post-graduate year spent in general practice would undoubtedly make me a more competent physician, but I believe at this point I have had adequate exposure to make an informed decision as to which field I wish to pursue for my career.
The direct effects on our health care system of the increasingly focused electives sought by medical students and the reduced exposure to generalist practice before becoming specialty-driven residents are certainly not clear at this point in time. I can say that I do not support the return of the rotating internship in its original form – this simply delays the inevitable. I prefer to imagine a system where residents in all training programs are exposed to a wide array of medicine and are given ample opportunity to switch to another program if they find themselves in one not suited to their interests or skills. This will require a percentage of current resident spots to be dedicated for switching and a culture within the system that accepts it. In an ideal world, we could all adopt the notion taken by past president of the Canadian Medical Association, Dr. Jeff Turnbull:
In providing the best health care for our patients and community, we must stop thinking of generalism and specialization as two opposing dichotomies, but consider them in a spectrum, with each uniquely contributing to the integrated delivery of health care. For optimal health care to be provided, a critical balance between generalism and specialization is needed. Neither can exist in isolation.
Kieran is a medical student at Queens University.