The present study explored perceived adequacy in the preparation of recent Kenyan medical school graduates for their roles as interns in district hospitals in order to inform the emergent design of the Aga Khan University undergraduate medical education curriculum. As the majority of graduates are likely to be posted to district hospitals, their ability to function effectively in district hospital settings is an important curriculum objective. The conditions of work i.e., clinical support services, training and social support, which interns face in these settings are also important considerations as they influence performance.
Perceptions of competencies in relation to interns’ roles
Even in developed countries medical graduates have been perceived to be deficient in the basic clinical skills of history taking, physical examination and clinical reasoning, indicating a failure of the medical curriculum [24, 25]. Defective clinical reasoning continues to be an important cause of diagnostic error . Arguably, basic clinical skills and clinical reasoning assume greater importance in district hospitals in Kenya because interns need to be more autonomous. Also they have limited access to diagnostic tests. This places an onus on medical schools in Kenya and other developing countries to ensure that students’ basic clinical skills including clinical reasoning, are adequately developed.
The cost and availability of tests in the relatively resource poor environment of district hospitals are important considerations for reducing the reliance on investigations. Indeed, education programmes that emphasize appropriate ordering of investigations have been shown to reduce health care costs without negatively impacting patient care [27, 28]. Such programs should be adopted in teaching hospitals in Kenya. The absence of pathologists and radiologists in district hospitals in Kenya place a responsibility on medical schools to ensure that students learn to interpret test results.
Medical students are expected to learn to perform basic ward procedures. In the current study, interns described filling log books as evidence of achieving competence in medical school but did not describe undergoing objective skills assessment. We propose that validated competency assessment tools requiring Direct Observation of Procedure Skills should supplement log books in both medical schools and during internship training in order to confirm demonstrable competence in performing procedures.
Internship supervisors’ expected interns to do surgical procedures independently after an orientation period. Heavy workloads in district hospitals as compared with the size of the medical staff may explain why interns are obliged to perform surgery independently, but does not justify compromise in the quality of care that might occur unless the interns were carefully supervised. In the present study there was debate about the availability of supervision; the interns claimed that it was not readily forthcoming while their supervisors disagreed. If the high Maternal Mortality Ratios in Africa are anything to go by, then certainly a lack of well-trained/ well-supervised staff in obstetrics is at least part of the reason .
Many studies have alluded to new medical graduates’ deficiency in prescribing skills in both developed [30, 31] and developing country contexts . Prescribing errors are responsible for a substantial proportion of all medication errors and contribute to injury and death .
Many ways of improving prescribing efficiency have been proposed e.g., the use of smartphone pharmaceutical apps to support hospital based prescribing and pharmacology education. However, this approach has to be accepted with caution as the apps designers may not have sufficient medical knowledge . Similarly, a limited ‘student formulary’ to enable learning around a core list of commonly used drugs has been advised for medical students . In a systematic review of educational interventions to improve prescribing by medical students and junior doctors it has been shown that ‘The WHO Good Prescribing Guide’ is effective across a wide range of trainees in international settings . The increasing use of multiple drugs as a result of the rising incidence of NCD related comorbidities necessitates awareness of drug interactions.
Basic communication and interpersonal skills
A lack of efficient communication between interns and nurses was perceived in the present study. It has been observed that medical errors are commonly due to communication errors between caregivers . Hence, best practice tools for standardized health care like SBAR (Situation, Background, Assessment and Recommendation) have been introduced to minimize errors in North America and should be considered for adoption in hospitals in East Africa. The difficulties interns faced in communicating with their supervisors might reflect insufficient opportunity to practice such communication during the clerkships. A change in the nature of the clerkship to an apprenticeship model with direct patient care responsibility would require students to communicate with their immediate supervisors.
In a multi-ethnic population with variable levels of education there are substantial challenges to obtaining an informed consent or developing an effective therapeutic relationship with patients. Many international studies have developed and assessed the skills of medical trainees to communicate with colleagues and especially with patients who have low levels of health literacy [38–40]. Contextual studies with socioeconomically and culturally diverse patient populations in Kenya would be required in order to develop effective programs for communication training.
Most new interns felt they were well prepared for new-born and paediatric emergencies, as a result of the ETAT (Emergency Triage and Treatment) training they received in medical school. This perception is supported by a study at the Kenyatta National Hospital, which demonstrated significant improvement in documented clinical practices following the introduction of ETAT . The interns in our study expressed the need for other emergency medicine courses such as ATLS (Advanced Trauma Life Support), ACLS (Advanced Cardiovascular Life Support) and ALSO (Advanced Life Support in Obstetric). Dauphin-McKenzie et al.  have demonstrated how an ALSO orientation better prepared new residents for managing obstetrical and gynaecological emergencies.
Unfortunately in public hospitals including national referral hospitals in Kenya, the sickest patients are often transferred to the ward without any resuscitation efforts in the emergency room . The chances of this happening could potentially be reduced if medical and other personnel were uniformly trained in resuscitation. Although ACLS and ATLS training and implementation require expensive equipment, basic resuscitation measures for trauma and obstetrics do not.
The district hospital as a training site
Internship is a time to apply knowledge and skills learned in medical school and to learn new skills under supervision in preparation for postgraduate education in a field of choice. This represents the continuum of medical education. Accordingly, the Kenyan MPDB has laid down training objectives of the internship. The suitability of the district hospital as an internship site however, remains contentious.
Availability of clinical support services
There seems to be a contradiction between interns’ and their supervisors’ impressions of lack of support services and equipment at the district hospitals and interns’ observations based on an observation schedule or check list that seemed to suggest that most things were either usually or always available. However, the available support services at a district hospital may not meet the needs for adequately diagnosing and managing patients with common clinical problems encountered at that level of service and for referring patients appropriately. The supervisors’ comments based on the observation schedule may have shed more light on availability vs. needs, but unfortunately were not elicited. Thus despite the interns’ opinions based on the observation schedule, the service facilities could still be well short of training expectations.
Perceptions about the extent of supervision differed widely between the interns and their supervisors. This difference in perception may be attributed to the “hidden curriculum”  which embraces an unspoken tradition of praising trainees as being “strong” when they are able to carry heavy workloads with little supervision, and “weak” when they call for help, or even when they realize they need help. Steep hierarchies in medicine, not limited to Kenya, have caused trainees to be reluctant in voicing their concerns in critical situations . Hafferty advises that changes to medical education are inadequate if undertaken only at the level of the curriculum; necessitating a redress of the hidden curriculum both implicitly and explicitly . The district hospital training site should be seen as a learning environment and reform should consider what students learn informally as well as formally with equal valuing.
Both interns and their supervisors in the present study observed that interns lacked interpersonal skills especially when it came to working with the nursing staff. Inter-professional education has been strongly advocated by The Global Independent Commission on Education of Health Professionals for a new Century as a means of addressing this deficiency . It involves students from two or more professions learning together, especially about each other’s roles, and respectfully interacting with each other on a common educational agenda. Although effective, collaborative work within a cohesive group should start in professional schools, a team approach must actually be practiced in the workplace to set the example. The aim should be to set up effective communities of practice in all practice settings.
Continuity of care
From the present study, it appears that the interns are providing episodic care which is largely inpatient based; they are inadequately exposed to outpatient clinics. In this respect it was no different from their clerkship experience. By contrast training is dependent on providing continuities of patient care, supervision and membership of a clinical team [48–50]. This could potentially be achieved during internship given that the one year of internship is equally divided between 4 specialties provided that an outpatient experience is also built in. Thus the concepts of inter-professional collaborative teamwork and of continuity of supervision and patient care are applicable across the continuum of medical education from the clerkships through to internship and residency training.
Of the many challenges to training in district hospitals, we would like to discuss the issue of social support which was brought up by both groups of informants in the present study. The interns described the internship as “a shock to the system” and wished they had been better prepared for the gruelling hours of work. Work probably became even more unbearable as social support in the form of good meals, decent accommodation, and adequate time off work were not forthcoming. The sense of inadequate remuneration added to the discontentment.
To some extent interns’ unhappiness could have been alleviated if internship supervisors had served as mentors. However, this did not happen. Providing career guidance in medical school, including information about the internship and how it serves as a step towards residency training, could perhaps also alleviate the sense of disenfranchisement.
Internship supervisors wished they were recognized for their contributions to interns’ training. They felt that it was only fair that they should receive stipends for teaching. They also wished that internship training sites were better equipped for proper training.
The new Constitution of Kenya has devolved health care management which was previously in the hands of the national government, to the level of the counties with the expectation that this will lead to better equipment, staffing and management of district hospitals. It seems that purchase and installation state of art medical equipment in county hospitals has already started . This may contribute towards greater professional satisfaction of the supervisors and lead to a more conducive learning environment. The Kenyan Medical Practitioners and Dentists Board should also do more to develop stringent criteria for district hospitals to serve as internship training sites and accredit only those sites that strictly meet the requirements. One of the criteria should be the educational training of clinical supervisors.
Advice for medical schools
Both interns and their supervisors insisted on more practical experience for medical students and clerkship experience in a district hospital setting. Illing et al.  have attributed the lack of medical graduates’ preparedness to a failure to implement the apprenticeship model of learning or ‘learning on the job’ during medical education. In this model which is based on situated learning theory, students learn by engaging in the processes of patient care within a well-knit clinical team. Illing et al. point out that in the absence of such engagement the skills learned through real life experience are particularly deficient viz. ‘ward work, being on call, management of acute clinical situations, prescribing, clinical prioritizations, time management and dealing with paper work’.
The Longitudinal Integrated Clerkship which has become popular also gives importance to direct patient care within a clinical team and provides for longitudinal patient follow up . Some medical schools provide a sub-internship which allows students greater responsibility for patient management than in a normal clerkship, while still ensuring supervision .
The decentralization of clinical training from tertiary hospitals to district hospitals, which has just started in Kenya , will very likely provide students the opportunity for direct patient care responsibility. However, it requires significant investment of faculty time for supervision. At present in Kenya, the large student numbers compared with supervised clinical sites is one of the main reasons for failure to provide medical students supervised patient care responsibility. This contrasts with the West, where concern for patient safety is regarded as a key reason for not involving medical students as responsible team members .
Our internship supervisors opined that Moi University medical graduates had better practical skills in comparison to graduates from more traditional colleges. This finding was corroborated in a cross sectional study in Kenya  in which medical graduates with a PBL background felt they were better prepared for their roles as interns compared with their peers from traditional curricula.. However, the superiority of PBL in this regard is not a widely accepted . Most modern curricula adopt an outcome-based approach in which learning outcomes and competencies are in keeping with the roles required in a given health care system. Instructional and assessment strategies are then aligned to the acquisition of these competencies. The trouble is that PBL and outcome-based curricula require a strong resource base and rigorous programme management for their success , things that are hard to come by in Kenya.
Strengths and weaknesses of the present study
The main strength of this study is the representativeness of study sites. Currently district hospitals comprise over 50 % of internship training sites in Kenya. There was also adequate sampling of district hospitals from all the geographic areas with one exception.
Perceptions of both interns and internship supervisors were obtained. There seemed to be general agreement between interns and their supervisors that interns had significant weaknesses in their skills. However, the supervisors were more generally critical of the interns’ competencies whereas the interns were more specific about their weaknesses. Others have also observed discrepancies between interns’ self-assessments and their supervisors’ assessments of them . Furthermore, the supervisors seemed more concerned about interns’ skills’ deficiencies that directly affected their work as consultants e.g., ability to perform surgical procedures; in other words the supervisors’ perceptions were tainted by a service perspective. Similarly the interns were more concerned about things that mattered most to them e.g., their abilities to counsel patients and families, and teach ‘clinical officer interns’. From a training perspective a more holistic evaluation of interns’ competencies will be necessary.
Conducting focus group interviews eliminated problems of poor response/participation as may be encountered with mail or online questionnaires; and the group dynamics provided additional insights.
Interns’ observation of the available clinical support services using an observation schedule provided a reference frame against which to judge perceptions. However, an assessment of the appropriateness and quality of the services which the internship supervisors may have been better qualified to comment on was not elicited.
This study did not investigate the backgrounds of the supervisors in terms of their teaching background and experience. Further studies are needed to elicit the competence of internship supervisors to provide training to medical interns.
The present study did not permit a distinction to be made based on the medical school or type of curriculum. The interns had graduated from different medical schools in Kenya and other countries. Within Kenyan medical schools only Moi University Medical College provides PBL whereas other schools provide more traditional curricula. A national medical licensing examination to compare standards between medical schools does not exist in Kenya and at any rate would not necessarily reflect performance at work.
Interns were interviewed at different points in their internship. Not all interns had the same experience of specialties to which they could relate their skills. A prospective study to elicit perceptions at the start and at the end of internship might provide more uniform information.
Internship supervisors raised concerns over interns’ professionalism. Their comments touched on issues of dress, punctuality, availability for, and response to calls points to the challenges of medical schools to impart good values and fitness to practice as described by the General Medical Council . Professionalism was not a focus of the present study.
The present study elicited perceptions of preparedness rather than actual competence and similarly perceptions of support rather than objective measures of support. Assessment of performance at the workplace would be ideal to evaluate the preparedness of medical graduates for internship. Leaving aside the difficulty of conducting work-based assessments at various sites, this would necessitate synchronizing events such that all the interns were having similar experiences at the time of assessment, preferably at the beginning of their internship in order to exclude effects of learning during internship.