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ORIGINAL RESEARCH ARTICLE
Year : 2022 | Volume
: 35
| Issue : 3 | Page : 80-88
Insights of South African medical interns on their intentions towards careers in primary healthcare and child health
Kimesh Loganthan Naidoo1, Jacqueline Van Wyk2
1 Department of Paediatrics and Child Health, KwaZulu-Natal Department of Health, Nelson R Mandela School of Medicine, King Edward VIII Hospital, University of KwaZulu-Natal, Durban, South Africa
2 Department of Clinical and Professional Practice, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
Correspondence Address:
Dr. Kimesh Loganthan Naidoo
Department of Paediatrics and Child Health, KwaZulu-Natal Department of Health, Nelson R Mandela School of Medicine, King Edward VIII Hospital, University of KwaZulu-Natal, Durban
South Africa
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/efh.EfH_62_20
Background: Health provision in South Africa requires a focus on primary health care within the public health system. Medical practitioners continue to migrate from the public health service. Given the need for human resources in primary health care, this study was conducted to explore the perceptions and experiences of newly-qualified medical practitioners (interns) about pursuing a career in primary health care in the public health sector. Methods: This exploratory, qualitative study specifically explored the factors related to interns' perceptions about careers in primary health and child health care in the public health service in five hospitals in KwaZulu-Natal (KZN). Data was collected through focus group discussions with a purposive sample of intern participants, who were chosen for having had the necessary experience to decide on long-term careers. The data were coded, categorised and themed using a combination of manual and computer-assisted methods. (NVivo 11 software). Results: Themes both external and specific to the intern-supervisor relationship were identified that influences intern career intentions. A high disease burden in resource-constrained institutions that are perceived to be poorly managed and sub-optimal intern-supervisor relationships lead to inadequate participation within 'communities of practice' during internship. Interns viewed careers related to primary health care negatively, preferring to specialise in other fields. Discussion: Multiple challenges are identified when participating in caring for adults and children in KZN's public health service. This coupled with a perceived inadequate supervisor support favour interns to see medical specialisation as a more feasible career option rather than primary health care. Experiences during internship possibly influence future career intentions that are discordant with SA's national health priorities. Improving the intern working environment may be a way forward to stimulate interns' interests in careers congruent with SA's health needs, specifically careers in primary health care.
Keywords: Career intentions, junior doctors, primary healthcare
South Africa (SA) faces multiple disease burdens, including the prevalence of high childhood illnesses, HIV/AIDS, tuberculosis (TB), and noncommunicable diseases.[1],[2] Within this context, the resource-constrained public health service provides healthcare to 74% of the population.[3],[4] Provision of accessible and effective primary health care (defined as the provision of the first contact, undifferentiated care) underpins the sustainable functioning of the SA public health service.[4],[5] For such a system to be effective, it largely depends on the availability of a sustainable workforce to provide appropriate care at the primary health-care level.[4],[5] The SA National Department of Health's (DoHs) strategic plans, therefore, prioritize the retention of productive and retainable primary health-care medical practitioners for public service.[6]
Curricula developed for undergraduate medical training across SA's higher education institutions (HEIs) have included greater focus and attention to students' experiences at the primary health-care level and in public health settings. This ensures that newly graduating practitioners develop a passion and commitment to primary health care and understand their crucial role in improving health-care outcomes for the SA population. The service-learning exposures of the newly graduated medical practitioners in their first two years of clinical service (referred to as internship in SA) should, therefore, ideally be focused on strengthening the primary health-care system, and it should develop their passion and commitment to care for patients, including children, in public health facilities. The need for promoting generalist care as a career choice has been noted outside of SA, with factors ranging from changing demographics to focusing on patient-centered care and managing chronic illness as major factors.[7] However, research into career choices on the African continent, SA, and elsewhere indicates an increasing trend among medical practitioners to aspire toward specialty practice while abandoning the public health service and rural practice.[8],[9],[10]
All newly qualified medical graduates in SA enter the internship period, which falls outside HEI's jurisdiction. Training in this period occurs in specifically accredited and largely urban-based hospital complexes with a predominant specialty-based focus. While the need to focus on exposure to primary health care during the internship has been supported, the intern enters into an already existent specialty-based practice.[6] Interns work and learn in these communities of practice as they proceed through the various stages of their training. These teams operating in a community of practice (COP) with common goals are often led by specialists well-recognized in the discipline. These medical practitioners who have served longer in the specific discipline largely serve as mentors and clinician supervisors to the new intern.
New interns can only be placed at hospital sites which have been accredited for having sufficiently qualified staff, patients, and resources to be allowed to train junior doctors. This accreditation process of hospitals for internship training is overseen by a national professional accreditation body, namely the Health Professional Council of South Africa. The learning and practice environment during the internship reflects large urban-based hospitals' predominant acute curative care setting. Interns, therefore, train in and forge their first working relationships with seniors within this specialty-driven context. However, various SA studies have reported accounts of suboptimal standards of supervision and assessment during internship training within SA's local resource-constrained public hospitals.[11],[12]
Interns' perceptions of their service-learning environment during internship have been shown to influence their choices regarding possible future career tracks.[13] The environment within which the interns train and learn has been assessed using validated tools such as the Postgraduate Hospital Educational Environmental Measure.[14] Studies have furthermore identified the influence of environment on the intern's perceptions and the impact of these perceptions on career choices as health-care practitioners.[13],[15],[16] While many of these studies used mainly quantitative strategies to assess career intentions within a particular specialty choice, more qualitative studies are needed to explore and understand the perceptions of interns towards their training environment and how their perceptions may influence their career intentions.[8],[17] Qualitative studies can help researchers to gain a deeper understanding of the phenomenon and enable the generation of meanings to explore complex issues.[18] Given the dearth of research into the educational experiences of interns working in environments with multiple disease burdens and constrained resources, this qualitative inquiry allowed the researchers to explore the phenomenon. It also allowed them to gain a deeper understanding of the factors influencing career intentions and enabled the generation of meanings to explore complex issues.[19]
The “communities of practice” framework, as a possible theoretical model, views learning in internship as being situated, co-constructed, and in co-participation between the “newcomer” (the intern) and “experts” (experienced senior clinicians) within a clinical unit.[20] Theoretical models, as used in educational and social studies, help to frame the understanding and interactions of concepts being studied and offer possible solutions to the challenges. In this way and with application to the interns' journey from novice to expert medical practitioners, it puts the intern on a trajectory from an initial experience often termed “peripheral participation” to eventually gaining “full membership” within this COP.[20],[21]
This study explored the factors present within the KwaZulu–Natal context during the pediatric internship with the view to understand how factors in the interns' learning environment influenced their perceptions towards SA public health service. It specifically explored their willingness to serve as primary health-care clinicians and their intentions to care for children in their future careers. In this study, the “primary health care clinician” is defined as a clinician who manages undifferentiated patients on a point of entry into the health-care context. In particular, this study explored the experiences and perceptions of interns who had completed the pediatric component of their 24-month internship.
Research design
This study explored the experiences, perceptions, and factors influencing the intern's career intentions and an interpretive and exploratory research strategy was adopted.
MethodsEthics
Ethical approval was obtained from the University of KwaZulu–Natal Biomedical Research Ethics Committee. Participants were informed of the study and of their right to withdraw at any stage. Written informed consent was obtained before data collection. Participation in the study was voluntary, and anonymity and confidentiality were assured.
Participants and setting
The study recruited interns who were working in KwaZulu–Natal, the second-most populous province in SA.[22] Participants were purposively sampled in the last few months of their 24-month internship period. They were all completing the pediatric block and, therefore, most suited to share experiences of their training and perceptions toward caring for children. All interns in the five largest hospitals in the Durban and Pietermaritzburg regions of KwaZulu–Natal were invited to participate in focus group discussions (FGD). Collaboratively, these hospitals serve large populations with high disease burdens of HIV/AIDS, TB, noncommunicable diseases, and trauma-related injuries, and the hospitals also serve as some of the largest intern training complexes in SA.
Data collection
Five FGDs were conducted in English during the interns' lunchtime, and lunch was provided to participants. Each focus group consisted of 6–8 interns. The primary researcher facilitated all FGDs through open-ended questions, which allowed an exploration of research objectives [Figure 1]. The FGD questions guided the exploration into the interns' experiences in internship and their career intentions for the future. A discussion guide included trigger questions to explore participants' perceptions of their environment and factors in the environment that influenced their career intentions. Each FGD was audio-recorded with the permission of the participants.
Participants
The interns (n = 33) who participated in the FGD constituted a convenient sample of the interns who were available on the day.
Data analysis
The focus group data were audio-recorded and transcribed verbatim. The transcripts were read and checked by the primary researcher and a research assistant for accuracy. The primary researcher re-read the transcripts on multiple occasions to become familiar with the data before the inductive coding process.[23] The primary researcher used content and thematic analysis to determine patterns in responses and to identify and code frequently expressed ideas. This process was initially done manually, and NVivo 11 was subsequently used in the analysis to enter transcribed data within codes, subthemes, and major themes.[23] A second independent investigator (a professional health educationist) verified the codes derived from the data by crosschecking these against the original transcripts. This process was conducted independently to enhance the credibility and trustworthiness of the data.[24],[25] Each coder developed a list of descriptive subthemes and major analytical themes. The consensus was then achieved by an iterative process between the two investigators about the number, overarching themes, and their relationships emerging from the data.
Trustworthiness
In qualitative research, concepts of “validity” and reliability are represented as trustworthiness. We applied the general criteria for the trustworthiness of qualitative research of Lincoln and Guba.[25] Triangulation of data was enabled by having five different focus groups where participants were recruited across different hospitals, which allowed the pooling of a wide variety of views. This process assisted in gathering a range of “thick descriptions” to understand the context.[24],[25] Reflexive bias was decreased through data analysis involving an additional investigator, an educationist who was not involved in intern training and who independently co-coded the data.
ResultsThe demographic characteristics of the focus group participants are indicated in [Table 1].
The sampled participants (n = 33) were representative of interns in KZN and SA, with a slight predominance of females (58%) and an increasing representation of Black Africans (24%). In addition, all five hospital complexes in KZN's two major metropolitan centers were proportionally represented.
The various codes and descriptive subthemes derived are listed in [Table 2]. All themes were consistently articulated across the five focus groups.
Table 2: List of codes and inductive themes derived from the focus group dataThe descriptive subthemes and major analytical themes determined and their proposed relationships are presented in [Table 3].
Table 3 provides a summary of the codes and descriptive and major analytical themes to explain the factors identified that influenced the career intentions of the sampled interns.
Perspectives associated with the major analytical themes are presented, and quotations are included for verification. Quotations are coded for gender and focus groups to highlight the spread across diverse participants and hospital sites. It became evident that the experiences gained during the internship served as a major factor when interns contemplated their future.
”Internship opens your mind…because in medical school your life is still about reading from a book, and then in internship, you enter to the real world” (M2, FG3).
External factors influencing the intern's perceptions of their experiences in the internship
There were several factors identified by interns as being beyond the control of both interns and their supervisors and these affected perceptions of the internship. These included challenges posed by challenges in providing care in hospitals, a high disease burden in KZN, and the poor social circumstances of patients that presented for care.
Challenges to providing care in hospitals
Interns articulated several challenges in the public institutions where they worked, that hindered their daily tasks of caring for the sick. These included resource constraints that affected their ability to care for their patients on a daily basis, for example, lack of daily needed consumables, lack of adequately caring and supportive nurses, and lack of access to intensive care unit beds. Having to work without daily essentials led them to perceive the managers of public hospitals as inefficient and hindering doctors from providing a good service.
”The lack of resources, like when you see patient dying. Where's the ICU? Where's the high care in this hospital? Who is going to survive a heart attack?”(F1, FG3).
”I don't want to ask someone ten times to be efficient …this is often the struggle…struggling makes your work environment very unpleasant” (M1, FG2).
”I was thinking I would never go into private but when you are running around in the middle of the night looking for (IV lines), things that should not be a problem, you get frustrated” (F3, FG2).
High disease burden
The impact of high mortality primarily due to the HIV/AIDS and TB epidemics coupled with a fear of needle stick injuries and contracting TB steered many interns away from considering a possible career in the SA public sector. Some interns, however, saw the exposure to a high disease burden as a means to develop the necessary experience for effective practice in their future.
”If it comes to internal medicine then you just don't care …. When it's the ninetieth HIV/TB patient…” (M4, FG4).
”If I do internal medicine or paediatrics, I wouldn't do it in SA, I don't want to be a specialist in HIV and TB…” (F2, FG4).
”The heavy workload makes you a better doctor with more capacity for later practice” (F3, FG5).
Socioeconomic status of patients
Interns expressed antagonism and an apparent lack of empathy toward patients and the contexts surrounding the patients' presentation. Late presentation to the hospital of illness, poor patient compliance to medication, child neglect, rampant interpersonal violence, and partner and child abuse presented obstacles to a future in the public health system and to caring for children in particular. Interns additionally indicated that unrealistic expectations from their patients further strained the relationships that they developed with their patients.
”I cannot believe how parents choose to treat their children and how people treat children” (F3, FG5).
”When you see babies who are HIV positive, I mean it's just not right-you think there's some element of parental irresponsibility” (M2, FG5).
”Just because I am a doctor, does not automatically mean, I have to be compassionate and all self-sacrificing” (F3, FG1).
Internal factors within clinical units that influence internship
Two subthemes emerged based on the factors identified by interns as pertaining to the intern–supervisor/mentor relationship in the clinical units where they had been working.
Restricting interns from full participation in clinical units
The interactions and experiences gained within a unit (clinical department, ward, or clinic) where interns worked were highly influential of their perceptions of the quality of the internship supervision. In this study, interns viewed a well-functioning and robust clinical unit as one that welcomed and facilitated their participation. Such a unit provided a well-organized structure where interns felt part of a team and where clinical leaders were visible and provided guidance and direction in managing various challenges, many of which required a primary health-care approach. Interns' experiences, however, led them to perceive their role in the unit as that of “pawns in a system”. They felt restricted within the strict, unrelenting hierarchies of the clinical unit that prevented their full participation in shared work. They also highlighted the importance of supervisors' being available for feedback, being approachable, and being perceived as supportive during the training period.
”I also feel like you know when you do internship, you feel like you are at the bottom of the food chain, 'and that's a given!” (M1, FG3).
”Interns are treated as the work-horses” (M1, FG3).
”If you are going into ward rounds whereby you know you won't be part of it, you just go there and just wait for them to tell you what to do… You don't care now” (M1, FG5).
”Very often that consultants tend to speak to you like you're an idiot …they don't want to include you in the ward discussion” (F3, FG5).
”Nobody is willing to listen to you when you are in internship” (M3, FG1).
Influence of role models on career intentions
Interns indicated that role models had a significant influence on their career decisions. The experiences gained while working closely with registrars and medical officers were cited as having a lasting effect on the intern specifically shared negative perceptions related to primary healthcare.
”In terms of job satisfaction look at your seniors, it gets honest at 2 am in the morning, and they are honest enough to give you advice and tell things that no one else will tell you” (M1, FG2).
”When you look at them (registrars), and they're all worn out …it makes you wonder because I put myself right in their shoes” (F1, FG2).
Reluctance to consider primary health care and child health in future career decisions
There was a widely held perception that primary health care was a burden that they, as junior doctors, were being forced to manage.
Perceived coercion towards primary health care
There was an expressed reluctance by many interns towards pursuing a career in primary health care, working with children and rural health. Interns voice a widespread perception that the National DoH was coercing medical doctors into accepting careers in primary health care in poorly resourced rural facilities by limiting their access to specialization options. Interns proposed alternative, collaborative models of rotation through rural areas and the use of clinical associates to alleviate inequities and inefficiencies within the health sector. Their negative perceptions of the public health system were based on their personal experiences of inefficiencies during the intern-and community service placement processes.
”There's no give and take, it's just take, take, take … it's from government to consultants and all the way down” (M2, FG1).
”I can understand it from their (government) point of view, I wouldn't mind going to a rural areas for a while, not perpetually, but I don't want to be forced into doing it” (F2, FG1).
”To make a difference, it needs to be small things that happen quickly; clinical associates, rotation systems, incentives …” (F3, FG1).
Emotional burden and increased stress associated with caring for children
The emotional burden of coping with death, children suffering, and perceptions that pediatric care generated greater stress and constant worry prevented many interns from considering a future that possibly included caring of children.
”I don't know if I will be able to handle the emotional burden in looking after sick children … And another thing there's very little room for error. So you really can't make any mistake, as that can cost a child's life” (F2, FG5).
”Paediatrics it really kills me-you don't learn how to cope with death and loss; it's stressful doing lumbar punctures and repeat blood draws on children” (M1, FG1).
”In Paediatrics I find myself more stressed than I've been and you take that stress home with you … …it takes its toll on you” (M4, FG5).
Interns' preference to specialize in disciplines other than primary care
This was influenced by the positive personal outcomes seen with entering specialization outside of primary health care. There was widespread agreement that the future would include a decision regarding specialization. The choice of a specialist field received much consideration. Aspirations toward an excellent work-life balance, the desire to raise a family and concerns over access to specialty programs in SA influenced specialty choices. Primary health-care practice in public health facilities was viewed as a less popular careers option compared with various other specialties.
”I always thought I had a plan…like finish medical school and internship then start with specialisation because you get bored with doing the same thing over and over …now internship has been too hectic, I can't wait to take time off” (F2, FG4).
”Internship also helped me to realise that I would never, not for all the money in the world, do certain specialities” (M2, FG1).
”I like surgery, but after marriage, I am having second thoughts about it. Once you have a family, being a female, then you want to give equal time to both (career and family)” (F3, FG2).
”I think it used to be a lot easier to get into a specialty. Within a year or two you were generally in the program I think based on the cut in registrar numbers it's so competitive now” (M2, FG2).
”You personally want to better yourself, you want something better, and you want to be driven, that why I want to specialise” (M3, FG1).
”For me, the main thing determining what I want to do eventually is quality of life. That's what's driving my decisions at the moment. I'm looking at my life at 45 and 50. I don't want to be doing 24-hour calls at the hospital as a general doctor” (M4, FG5).
DiscussionThis study identified multiple factors and intern experiences which coalesce and influence interns' career intentions. Some factors were external to the intern–supervisor relationship and others were central to this pivotal relationship within this formative period.
Interns perceived of themselves as additional “workhorses” in specialty-driven care and fail to see themselves as part of the team. The interns felt excluded from co-participation within hospital-based clinical units. The unwelcoming experiences upon entering the future COP left many isolated and feeling marginalized. The interns also did not experience the COP in the clinical wards enabling their involvement from peripheral to full participation in clinical tasks which may lead to their lack of confidence to operate in an unstructured environment. The lack of appropriate encouragement, support and mentoring specifically with regard to using a primary health-care approach could have added to their inability to develop adequate resilience within the milieu of resource limitation and high disease burdens.[26]
The lack of support from appropriate role models to advocate for primary health care contributes to the failure to develop and sustain the intern's interest and passion in primary health care in SA public health settings. In fact, intern's exposure to specialist role models during their clinical rotations seems to have reinforced the negative bias of the specialist on the “intern newcomers” towards public health and primary health care settings. Interns fail to view the need, important role primary health care can play in managing health care challenges they are inundated with.
In addition, interns' experiences with the national health authorities led to their perceptions of inadequate support which further entrench their antagonism towards both the public health system and its associated need for primary health-care driven workforce. These perceptions are exacerbated by poor participation, inclusion, and feedback in clinical service work. These factors were shown to manifest in poor relationships with seniors, increased stress and burnout.[27] The high levels of burnout among interns can already be seen in the “depersonalised” views expressed by interns toward society and their patients.[27]
Interns expressed positive reinforcement from role models within some specialty tracks. The overwhelming need to specialize in fields other than primary care was also reflected in various studies across differing contexts.[22],[28],[29] Interns shared a widely held perception that specialists enjoy a better work-life balance than non-specialist staff in public hospitals and these stereotypes persist throughout undergraduate medical training into an internship in SA.[28],[29] Thus, the specialist-driven internship training model does not prioritize or promulgate a primary health-care driven service. In fact, it fails to demonstrate an approach and quality of service and care in the public setting for interns to emulate. Instead, internship experiences reinforce a specialist, acute care and hospital-centric bias, perpetuating career intentions among interns far removed from the needs of SA. The impact of clinical and place-based exposures influencing career choice has been corroborated in studies elsewhere.[30] The factors within the internship period thus reinforce the status quo of specialty-based practice.
Both external environmental factors and internal dynamics during the internship period thus act as barriers for interns to develop the necessary inclination for the fields of primary health care and child health. This then results in interns not favoring careers in the priority areas as needed concerning SA health -care priorities. The proposition is that if factors within the internship period can be modified, this can act as a catalyst to influence career intentions toward addressing national needs. Improving the relationships between interns and their seniors within clinical units, supporting interns to understand the social milieu of disease, developing resilience among interns, and increasing exposure to undifferentiated primary care should be considered. This calls for a well–managed public health service which recognizes the importance of creating a supportive service-learning environment for interns. These changes thus hold the potential to enable interns to develop the skills, social accountability, resilience, and ultimately, the vision to see primary health-care practice in public hospitals in SA and caring for children as a priority. The findings of this study support recent moves to introduce primary health-care exposure within an internship by the inclusion of a full 6 months of exposure to undifferentiated care within the 24-month SA internship.[31]
Study limitations
The study was conducted in a single province with a purposive sample of interns from only one discipline. Educators are requested to compare the similarity of internship training in their contexts when considering our results and conclusion. Translation to other provinces, disciplines, and training centers will be needed. The use of the primary researcher in conducting the FGD could have restricted the depth of data obtained. Using multiple investigators and in-depth interviews in future studies could thus add further value. This study explored career intentions and was not positioned to study career choice behavior, which could be done by a prospective longitudinal follow-up study.
ConclusionThis study highlighted challenging environmental factors during internship training which are confounded by resource challenges and dysfunctional “communities of practice” operating within the clinical setting. These conditions have been shown to inhibit interns from considering possible careers in primary health care in public hospitals in SA. This study highlights the need to understand the context of internship training and the value of positive health system experiences to retain our future healthcare workforce for primary healthcare and public health service. We advise that systematic changes at system, site, and clinical-service-levels must be aligned to improve interns' experiences to address SA national health needs. Increased exposure to primary health care within the internship will hopefully enable this alignment.
Ethical and legal
The Biomedical Research Ethics Committee (BREC) of the University of KwaZulu Natal approved the research (BE177/15). All participants provided written, informed consent to participate in this study.
Acknowledgements
The authors would like to express their gratitude to the interns and intern supervisors in KwaZulu–Natal hospitals who participated in this study, Dr. Petra Gaylard (DMSA) for assistance with the statistical analyses.
Financial support and sponsorship
MEPI Funding: This publication was made possible by grant number: R24TW008863 from the Office of the US Global AIDS Coordinator and the US Department of Health and Human Services, National Institutes of Health (NIH OAR and NIH ORWH). “Its contents are solely the responsibility of the Authors and do not necessarily represent the official views of the government.”
Conflicts of interest
There are no conflicts of interest.
References
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