What Does It Mean to Be a “Good Intern?"

Key Learning Objectives

• Based on APDS, ASE, and the ACS guidelines and associated curricula, surgical interns are expected to be prepared to work a variety of clinical rotations and hours, should have a foundation of basic technical skills, and be entrustable with clinical competencies regarding patient care (such as writing orders, giving and receiving handoffs, and obtaining informed consent, as outlined by the AAMC EPAs).²⁰
• While these guidelines can help define expectations and prepare medical students entering their surgical intern year, little is known about whether these programs translate to a successful internship.
• Further, there is no standardized feedback between the residency program directors and the medical schools regarding the students’ preparedness and performance as an intern or throughout residency.
• There is a need to delineate expectations beyond the minimum and clarify what it means to be a “good intern.”

Introduction

The general surgery internship can be a challenging year. Notably, the highest rate of attrition throughout general surgery training occurs during intern year.¹ These high trainee attrition rates may be associated with inadequate preparation or unrealistic expectations for residency.² Indeed, there has been an increasing number of medical educators and surgical program directors calling for curricular reform given the stark variation in medical student preparedness for residency.^3-7 In response to this need, the Association of Program Directors in Surgery (APDS) published a consensus statement on ideal medical student experiences in preparation for General Surgery residency,⁸ and the ACS, in conjunction with the Association for Surgical Education (ASE), published a simulation-based surgical skills curriculum for medical students.⁹ Based on these guidelines, many medical schools have developed intensive “bootcamps” focusing on key skills and experiences specifically for medical students entering surgical specialties.^15-20 

While these programs can help define expectations and prepare medical students entering their surgical intern year, little is known about whether these programs translate to a successful internship. Further, there is no standardized curriculum or set expectations to guide residents through their intern year. As a result, the transition from medical student to intern can be particularly challenging. While medical students may be beginning their surgery internship better prepared, they then face a new practical challenge: defining for themselves what it means to be a “good intern” at the start of residency.

Lack of Reported Transitional Data

Despite the importance of the transition from medical student to surgical intern, there is a lack of published data regarding the best methods to prepare and excel as a surgical intern. To a certain extent, this stems from a lack of communication between medical schools and surgical residency programs following the start of residency. While medical schools have begun to develop curricula specifically designed to better prepare students heading into surgical specialties, there is no standardized feedback between the residency program directors and the medical schools regarding the students’ preparedness and performance as an intern or throughout residency. Further, the literature that does exist regarding intern preparedness polls the interns themselves, without including senior resident, faculty, or program director perspectives.^3,21 This paucity of faculty feedback widens the divide between the evolution from senior medical student to a strong surgical intern.

Association of Program Directors in Surgery Consensus Statement

The APDS recognized the need to address this discrepancy and in 2021 published a consensus statement on the ideal experiences for preparedness for General Surgery internship.⁸ The goal of this statement was to highlight the essential minimum standard for senior medical students interested in pursuing a General Surgery residency. While these standards were published to guide medical school curricula, they can be used to extrapolate the expectations of a general surgery intern.

One of the foci of the APDS recommendations was on providing experiences for senior medical students that would mimic intern life, including dedicated critical care rotations, and opportunities to experience night, weekend, and holiday shifts.⁸ This is supported by studies that have highlighted how interns who displayed realistic expectations for work hours throughout residency and as attendings are more likely to complete their surgical training.² However, it is unclear to what extent these clinical experiences assist with the growth of personal skills, including balancing ambition with patient care, dedication to stay at the patient’s bedside, and resilience in the face of adversities. These personal attributes are likely just as important in a good intern but may be difficult to teach, improve, and assess.

ACS/ASE/APDS Curricula

The ACS/ASE Simulation-Based Surgical Skills Curriculum is an example of essential clinical and technical skills that should be performed “safely and effectively on arrival”⁸ to residency. This skills curriculum includes 13 modules and was developed in 2014 and informed by needs assessment data collected from medical school surgical clerkship directors and fourth year medical students.¹⁰

Similarly, the ACS/APDS Resident Skills Curriculum is divided into three phases of modules, beginning with basic surgical skills, then advance skills and procedures, and lastly team-based skills.²² This curriculum is a component of the more comprehensive ACS/APDS/ASE Resident Prep Curriculum, which additionally includes relevant clinical skills, such as managing shock, writing orders, and obtaining informed consent.²³ The ACS publication “Successfully Navigating the First Year of Residency” was created in the early 2000’s and nicely outlines knowledge and skills expected of an incoming surgical intern in an ACGME core competencies format. Unfortunately, there is no corresponding curriculum to help incoming medical students achieve these competencies.

Based on these modules, incoming surgical interns should be proficient in both technical and non-technical skills. Unfortunately, it is up to individual medical schools to provide the resources for this curriculum and assess its outcomes. Once resident physicians start intern year, many residency programs offer components of Phase 1 of the ACS/APDS Surgery Resident Skills Curriculum. However, which skills are taught and evaluated are not standardized throughout different training programs. Further, there is no clear expectation for which of the established or newly acquired skills should reach proficiency by the end of the year. As a result, interns may have a poor understanding of how their skills compare to their peers and are left wondering if they are falling behind.

Surgical “Bootcamps”

Many medical institutions have begun to establish “Surgical Bootcamps” with the goal of preparing medical students entering surgical specialties, following with the APDS consensus statement’s strong recommendation. While there is variation between institutions, the curriculum usually includes intensive technical skills training with suturing, knot tying, and laparoscopy.^15-19 Additionally, many have adopted a competency-based component using the Association of American Colleges (AAMC) Core Entrustable Professional Activities (EPAs) to guide the curriculum.^17-20 In doing so, students are also trained on clinical skills such as writing orders, managing shock, and answering mock pages. Institutions that have adopted these bootcamps have reported significant improvement in student surgical knowledge, technical skills, and confidence.^15-20

In a multi-institutional study investigating the effects of these intensive preparatory courses, surgical interns that had participated in a “bootcamp” reported higher self-assessed ratings of surgical technical skills, professionalism, interpersonal communication, and overall preparation.³ However, these were only self-reported assessments, and overall, all interns reported feeling underprepared with regards to their technical skills, managing simultaneous demands, and responding to critically ill patients.³ These results highlight how there is a paucity in the literature regarding faculty perceptions of intern preparedness. This likely translates to clinical practice in that interns similarly have poor insight into their own preparation as well as senior resident and attending perspectives.

Conclusions and Next Steps

There is currently no consensus on expectations of a surgical intern, however, the minimum required expectations can be extrapolated from national standards from the APDS, ASE, and the ACS. Based on these guidelines and associated curricula, surgical interns are expected to be prepared to work a variety of clinical rotations and hours, should have a foundation of basic technical skills, and be entrustable with clinical competencies regarding patient care (such as writing orders, giving and receiving handoffs, and obtaining informed consent, as outlined by the AAMC EPAs).²⁰ While this is the basic standard for interns beginning their residency, there is no standard guidance on expectations going forward from their first day.

While studies suggest that interns feel overall underprepared despite receiving dedicated training as students,³ there is little insight into the perceptions of their senior residents and attending faculty. Further, while most curricula for students focus on technical and clinical skills, there is limited discussion regarding the development of interpersonal qualities and behaviors. Overall, while there is rising dedication to preparing medical students entering surgical residency, there is a need to delineate expectations beyond the minimum and clarify what it means to be a “good intern.”

References

1. Yeo H, Bucholz E, Sosa JA, et al. A national study of attrition in general surgery training: which residents leave and where do they go? Ann Surg. 2010;252(3):529-534.
2. Abelson, Jonathan S., et al. "Association of expectations of training with attrition in general surgery residents." JAMA surgery8 (2018): 712-717.
3. Minter, Rebecca M., et al. "Transition to surgical residency: a multi-institutional study of perceived intern preparedness and the effect of a formal residency preparatory course in the fourth year of medical school." Academic Medicine8 (2015): 1116-1124.
4. Sachdeva AK, Loiacono LA, Amiel GE, Blair PG, Friedman M, Roslyn JJ. Variability
   in the clinical skills of residents entering training programs in surgery. Surgery. 1995;118:300–308.
5. Coates WC, Crooks K, Slavin SJ, Guiton
   G, Wilkerson L. Medical school curricular reform: fourth-year colleges improve access to career mentoring and overall satisfaction. Acad Med. 2008;83:754–760.
6. Lyss-Lerman P, Teherani A, Aagaard E, Loeser H, Cooke M, Harper GM. What training is needed in the fourth year of medical school? Views of residency program directors. Acad Med. 2009;84:823–829.
7. Teo AR, Harleman E, O’Sullivan PS, Maa J. The key role of a transition course in preparing medical students for internship. Acad Med. 2011;86:860–865.
8. LaFemina, Jennifer, et al. "APDS consensus statement: ideal senior medical student experiences for preparedness for general surgery internship." Journal of Surgical Education1 (2021): 69-75.
9. Olasky, Jaisa, et al. "ACS/ASE medical student simulation-based skills curriculum study: Implementation phase." Journal of Surgical Education4 (2019): 962-969.
10. Glass CC, Acton RD, Blair PG, Campbell AR, Deutsch ES, Jones DB, Liscum KR, Sachdeva AK, Scott DJ, Yang SC. American College of Surgeons/Association for Surgical Education medical student simulation-based surgical skills curriculum needs assessment. The American Journal of Surgery. 2014 Feb 1;207(2):165-9.
11. Todd, S. Rob, et al. "Surgical intern survival skills curriculum as an intern: does it help?." The American journal of surgery6 (2011): 713-719.
12. Antonoff, Mara B., et al. "A novel critical skills curriculum for surgical interns incorporating simulation training improves readiness for acute inpatient care." Journal of surgical education5 (2009): 248-254.
13. Klingensmith, Mary E., and L. Michael Brunt. "Focused surgical skills training for senior medical students and interns." Surgical Clinics3 (2010): 505-518.
14. Acosta, Danilo, et al. "Surgical practical skills learning curriculum: implementation and interns' confidence perceptions." Journal of Surgical Education2 (2018): 263-270.
15. Karmali, Riaz J., et al. "The Surgical Skills and Technology Elective Program (SSTEP): a comprehensive simulation-based surgical skills initiative for preclerkship medical students." The American Journal of Surgery2 (2018): 375-381.
16. Schmitt, Françoise, et al. "Preparatory surgical bootcamp: an effective form of training with a positive impact on self-confidence and procedural skills of the residents." Surgery in Practice and Science(2022): 100095.
17. Bamford, Richard, et al. "110 Surgical bootcamps-the future of surgical training." BMJ Simulation & Technology Enhanced Learning2 (2016): A62.
18. Zhang, Jifeng, et al. "The use of a surgical boot camp combining anatomical education and surgical simulation for internship preparedness among senior medical students." BMC medical education1 (2022): 1-11.
19. Antonoff, M. B., M. A. Maddaus, and J. D'Cunha. "Beyond the surgical bootcamp: evaluation of a competency-based curriculum for senior medical students entering surgical internship." Journal of Surgical Research2 (2011): 277.
20. Heimroth, Jamie, et al. "Utilizing surgical bootcamps to teach core entrustable professional activities to senior medical students." The American Surgeon6 (2018): 783-788.
21. Engelhardt, Kathryn E., et al. "A national mixed-methods evaluation of preparedness for general surgery residency and the association with resident burnout." JAMA surgery9 (2020): 851-859.
22. “ACS/APDS Surgery Resident Skills Curriculum.” American College of Surgeons, 2022. https://www.facs.org/for-medical-professionals/education/programs/acs-apds-surgery-resident-skills-curriculum/
23. “ACS/APDS/ASE Resident Prep Curriculum.” American College of Surgeons, Aug. 2022. https://www.facs.org/media/qdhbmmiw/resident-prep-brochure.pdf