Guideline for Undergraduate Medical Internship Program in ... · Guideline for Undergraduate Medical . Internship Program in Bhutan 1. Background 1 Introduction 1 Purpose 1 Scope

Guideline for Undergraduate Medical Internship Program in

Bhutan

Bhutan Medical and Health CouncilMinistry of Health

Royal Government of Bhutan

iii

vBhutan Medical and Health Council

Guideline for Undergraduate Medical Internship Program in Bhutan 1

Background 1

Introduction 1

Purpose 1

Scope 1

Objectives 2

Duration 3

General Rules for internship training in Bhutan 4

ConditionsfordoinginternshipbyBhutanese/Foreigncandidatescomingfromoutsidethecountry:6

Assessment 6

ExpectedoutcomeoftheInternship: 8

General: 8

General Medicine 9

GeneralSurgery 10

ObstetricsandGynaecology 10

Paediatrics 11

Contents

vi Bhutan Medical and Health Council

Orthopaedics 12

Psychiatry 13

Dermatology 14

Ophthalmology 14

Otorhinolarynglogy(ENT) 14

Anaesthesia 15

Radio-diagnosisandImaging: 16

ForensicMedicineandToxicology 16

CommunityMedicine 16

Transfusionmedicine 17

Learningoutcomes: 17

Emergencymedicine 18

1Bhutan Medical and Health Council

Guideline for Undergraduate Medical Internship Program in Bhutan

Background

AsamandatedbytheMedicalandHealthAct(ChapterIII,section3)theBhutanMedicalandHealthCouncilherebyformulatesthisguidelineto set out procedures and requirements for Internship Program in MedicalEducationinBhutan.

Introduction

Internshipisthephaseofcompulsoryundergraduatemedicaltrainingleading to award of bachelor’s degree and/or medical licensingregistration.

Internship is undertaken to improve professional knowledge andacquirepracticalskillsundersupervisionandguidanceofaqualifiedsupervisorinareaofmedicalandhealthcaretoenablethegraduatetofunctionindependently.

Purpose

ThisguidelineisdevelopedtofacilitateInternshipProgramfor;

a. MedicalstudentsgraduatingfrominstitutionswithinBhutan.

b. Bhutanese medical students graduating from Institutionsoutsidethecountry

c. ForeignmedicalstudentswhowishtodointernshipinBhutan1

Scope

This Internship program helps the young doctor develop clinicalcompetence, skills, evidence based clinical decisionmaking processandfinallyintomakingofarationalhumandoctor.

1Note: Foreign medical students completing internship in Bhutan do not guarantee them to work or get employment in Bhutan

2 Bhutan Medical and Health Council

Objectives

Attheendoftheinternshipprogram,thegraduateshallbeableto:

a. Takeproperhistory,performclinicalexaminationand initiateimmediatemanagementandadviseappropriateinvestigations

b. Diagnoseandmanagecommondiseaseconditionsandmaketimelydecisionforreferraltohigherlevel

c. Practicetherationaluseofessentialdrugs,infusions,bloodoritssubstitutes

d. To interpret basic laboratory and other investigation reportsand take suitable decision on management

e. Diagnose and initiate immediatemanagement for alltypesofemergenciesandtimelyreferraltoappropriatespecialty.

f. Developskillsinbasicmedicalandsurgicalprocedures.

g. Acquire skill in proper documentation of the healtheventsofthepatients.

h. Learntotakeprecautionstoprotectoneselfandothersduringpatientcare.

i. Learntocommunicateeffectivelywiththepatientsandtheirrelatives.

j. Inculcate due professionalism by developing selfdiscipline,sympatheticapproachtowardspatientsandtheirrelatives.

k. Imbueprofessionalsensitivitytosocio-culturalnormsandpracticesofthepatientsandtheirrelatives

l. Understand the use of National Guidelines andprotocols.


m. Understandtheconceptofprimaryhealthcareapproachforhealthpromotion,diseasepreventionandrehabilitation.

n. Topracticeevidencebasedmedicine

o. Tolearnbasicclinicalhealthresearch

Duration

Durationof internship shall be one year full time.Durationof dailyworkinghourswillbedecidedbytheinstitutes.

The internship program shall be on rotation basis in differentdepartmentsasshowninthetablebelow:

Department Duration1. General medicine 8weeks2. Paediatrics 6weeks3. Psychiatry 2weeks4. Dermatology 1 week

Surgery 1. GeneralSurgery 6weeks2. Ophthalmology 2weeks3. ENT 2weeks4. Orthopaedics 4 weeks5. Anaesthesia 1 week

Obstetrics and Gynaecology 1. Obstetrics 6weeks2. Gynaecology 4 weeks

Emergency and Casualty Dept 4 weeksForensic Medicine 1 weekRadio-diagnosis 1 weekCommunity medicine 3 weeksTransfusion medicine/Laboratory Medicine 1 week


General Rules for internship training in Bhutan

a. Internship training shall be conducted only in hospitals/institutes/or any other health centres authorised by thecouncilasteachinginstitute.

b. Every Intern shall complete the rotational posting in alldepartmentsmentionedabove;

c. The concerned university/Institute shall award the degreeonlyaftercompletionoftheinternship;

d. Aprovisional registration shall be issuedby the council toenableaninterntodotheinternship;

e. If the candidate fails to complete the internship training duringthestipulatedtimeofoneyear,furtherextensionmaybegrantedbythecouncilafterproperjustificationfromtheheadoftheinstitute;

f. Theinternshallworkdirectlyunderasupervisoridentifiedbytheinstitute;

g. Internshallnotbeallowedtoissueanymedical/medico-legalcertificate;

h. TheInternshallmaintainalogbookforallperformedineachdepartment;

i. Timetable for rotationalpostingshallbedevelopedby theinstitute;

j. Granting of leave is at the discretion of the Institute, butperiod of leave granted has to be adjusted by additionalpostingtofulfiltherequireddurationofpostinginrespectivedepartment;

k. Acoordinatorfor internshipprogramshallbeappointedbyJDWNRHtillUniversityofMedicalSciencesstarts


l. During the training period the Intern shall be directlyresponsibletotheHeadofdepartment/supervisor;

m. The internshallmaintainprofessionalconfidentialityof thepatientsandtheInstitute;

n. TheInternshallmaintainstandardcodeofethics,etiquetteand professionalism while dealing with patients and co-workers;

o. Theinternshall,atalltimes,beinproperattireandmaintainaacceptablelevelofpersonalhygiene,behaviourandconduct;

p. Internshipcompletioncertificateshallbeissuedbytheheadofthehospital;

q. Intern shall be allowed towrite prescriptionon the adviceofthesupervisor,butinternshallmentionthenameofthesupervisorintheprescription;

r. Internshallwritehisnameandcouncilregistrationnumberclearlyintheprescription;

s. Unlessauthorisedotherwise,theinternshall not:

i. Prescribecontrolleddrugsandhighendantibiotics;

ii. Interferewiththelineofpatientmanagement;

iii. Independentlycarryoutinvasiveprocedures;

iv. Interact with the media on issues concerning the hospital/institutionsorpatientcare;

t. The interns shall have the option of reporting any conflictof interests concerning the supervisors/department to theHeadoftheHospital/institute;


Conditions for doing internship by Bhutanese/Foreign candidates coming from outside the

country:

a. Institute where the candidate has passed shall have beenrecognizedbytheBhutanMedicalandHealthCouncil;

b. Internship training shall be conducted only in hospitals/institutes/or any other health centres authorised by thecouncil;

c. The candidate shall produce offer letter from the hospital/institutewhere the candidate is opting for internship at thetimeofapplyingfortemporaryregistration;

d. The host Institute of the candidate must have issued anundertaking to the effect that the candidate’s internshipprogram in Bhutan shall not hamper conferment of the degree tothecandidate;

e. ApplicationwithreasonfordoinginternshipinBhutanshallbesubmittedwithinonemonthofpassingthefinalexaminations;

f. Thecandidateshall submitanaffidavit statingtocompletetheinternshipprogram;

Assessment

Theinternshallbeguidedbythesupervisorineachdepartmentandfinalassessmentshallbedoneatthecompletiononthetrainingonthecorecompetencies:

a. Knowledge: Knowledge on clinical management of patientsin terms of history taking, clinical examination, appropriateinvestigations,treatmentoptions,recentadvances,preventiveandpromotiveaspects,andtheirlimitations;

b. Aptitude: Professionalism,empathy,compassion


c. Behaviour:Behaviourwithpatients, colleagues,nursing staff,andotherhealthworkers,teamwork:

d. Communication:Communicatewiththepatientsandrelatives

e. Professional Skills: Competency on performing medical andsurgicalprocedures.

f. Punctuality/ Responsibility: Coming on time, follow up ofcases.

Assessmentshallbedonewiththescoreof1-5asgiveninthetablebelow:

Score Grade1 Unsatisfactory2 Satisfactory3 Good4 VeryGood5 Excellent

Any intern who scores a total of only 12 points or less in eachdepartmentshallnotbeeligibleforregistrationwiththecouncil.

Core Competency Score RemarksKnowledgeAptitudeBehaviourCommunicationProfessional SkillsPunctuality/responsibilityTotal


Expected outcome of the Internship:

General:

a. Acquire the competency on history taking, physicalexamination, diagnosis and institute appropriate line ofmanagementofcommondiseases;

b. Acquire competency to advise appropriate laboratory andotherdiagnosticinvestigations,andinterpretthemaccordingly;

c. Acquirecompetencytoresuscitateseriouslyillpatients;

d. Assistinmanagementofcasesintheintensivecareunit;

e. Develop competency on proper advice and follow up of allpatients;

f. Familiarizewiththelifesavingequipmentsandprocedures;

g. Familiarizewithinterpretationofmonitoringdevices;

h. Acquirecompetencyinperformingminorprocedures;

i. Knowtofindclinicalevidencebasedonresearch

j. Acquire competency on IV access, Urinary Catheterization,insertion of Ryles tube, administration of oxygen, insertingairwaytube;

k. Participateactivelyindiscussionforgeneralpatientcare;

l. Acquire competency in preparing patients for diagnosticinterventionssuchasGIendoscopy,colonoscopy,interventionalanddiagnosticradiologicalprocedures(IVU,Bariumswallow,barium enema, Hystero-salpingography), contrast enhancedimaging(CT/MRI)andultrasonography;

m. Familiarisewithprocedureinobtaininginformedconsents;

n. Acquirecompetencyinbasiccardiaclifesupport(BCLS);


o. Familiarizewithemergencyresuscitationsinlinewithadvancedcardiaclifesupport(ACLS)andadvancedtraumalifesupport(ATLS)protocols;

p. An intern shall be allotted at least 5 indoor beds and 8outpatientcasesinmajordepartmentsforworkupandfollowupandcasepresentation.

Inadditiontotheabovegeneralexpectedoutcomes,theinternshallberequiredtoachievethelearningoutcomesspecifictothedepartments,asfollows:

General Medicine

i. Acquire competency on Pleural and Ascitic tap, LumbarPuncture, Urethral catheterization, femoral vein access,nasogastrictubeinsertion,ambubagplacementandoxygentherapy.

ii. Developcompetencyonhistorytaking,diagnosis,investigationandmanagementofcommonmedicalproblems;

iii. Assist and familiarise with bone marrow aspiration,Pericardiocentesis,SCVaccesscatheterizationandIJVaccesscatheterisation;

iv. Acquire competency in interpretation of basicElectrocardiographs(ECG);

v. Understand the indication for transfusion of Blood and itsproducts,andfluidreplacement;

vi. Followupofcasesintheintensivecareunits

vii. Casepresentationinthewardandoutpatientdepartment.


General Surgery

a. Institutefirst-linemanagementofsurgicalemergencies;

b. Develop competency in proper history taking, diagnosis,investigationofcommonsurgicaldiseases;

c. The intern develop competency on Central line insertion,Incision and drainage of abscess, urinary catheterisation,excision of superficial lumps, suprapubic cystostomy, chesttubeinsertion,digitalrectalexaminationandproctoscopy;

d. Gainknowledgeonhaemorrhoidbanding,observevenesectionprocedures, and major surgical procedures and upper andlowerGIprocedures.

e. Casepresentationoncommonsurgicalcases

f. Counsel pre and post-operative surgical patients regardingprocedures,process,outcomeandfollowup;

g. Observeandassist in theoperationtheatre,writeoperationnotesandfollowuppostoperativecases;

h. Followupofcasesintheintensivecareunits

Obstetrics and Gynaecology

a. Acquire competency in: conducting Normal and Assisteddeliveries, performing Dilation and curettage, Partographuse,Activemanagementof thirdstageof labour, Immediateneonatal resuscitation, Amniotomy, Repair of perineal tearsandEvacuationandCurettage;

b. Develop competency in proper history talking, diagnosis,investigationandmanagementofcommongynaecologicalandobstetricdiseases;

c. If cases are present the Intern shall also observe and assistMRPandPPHmanagement;


d. The intern shall observe and assist in Obstetric andgynaecological surgeries like Caesarean section, TAH, VH,Laparoscopy,HysteroscopyanddofollowupofpostoperativepatientsinthewardandICUs.

e. DocasepresentationinwardandOPDObsandGynecases;

f. Acquire competency in pelvic assessment; Speculum andbimanualexaminationingyeneandObstetricpatients

g. Learnbasicgynae-obsultrasound;

h. Understandthebasisofrationalprescribinginpregnancyandlactation.

i. Familiarise with gynaecological cancer screening andprevention;

Paediatrics

a. Acquire competency on following paediatric procedures:neonatalresuscitation,newbornexam,exchangetransfusion,Nebulisation; IV insertion, heel stick puncture,OG andUVCinsertion, Lumbar puncture, Intubation, PPV, NG insertion,Urethral catheterization, plural tap ascetic tap, and bonemarrowaspiration.

b. Acquire competency on Screening of newborn babies forcongenitalabnormalities;

c. Assess nutritional and dietary status of infants and childrenand recognise growth and psychomotor developmentabnormalitiesinpaediatricagegroup;

d. Develop competency in proper history taking, diagnosis,investigation and management of common paediatric andneonatalproblems;


e. DevelopcompetencyinPaediatricsmedicinedosageandoralrehydrationtherapy;

f. FamiliarisewithnationalguidelineonIntegratedManagementof Neonatal and Childhood Illnesses (IMNCI) and nutritionmanagement.

g. Observe and assist in the management of patients in thePaediatricandneonatalICU;

Orthopaedics

a. Initiatefirst-lineofmanagementfororthopaedicemergenciesandmakeappropriatereferrals;

b. Develop competency in proper history talking, diagnosis,investigation and management of common orthopaedicproblems;

c. Acquirecompetencyon:

i. Irrigationanddebridementofsimplelacerationsandopen fracture wounds

ii. Closed reduction of simple fractures and commondislocations

iii. SkintractionandSkeletaltractiontechniques,

iv. Plasterapplicationandsplintingtechnique

v. Jointaspirationsandcastingofupperandlowerlimbinjuries

vi. Incision and drainage of abscesses and excision of toe nails;

d. Shall assist in orthopaedic surgical procedures and do post operativefollowupoforthopaedicpatients;

e. Counselpreandpost-operativeorthopaedicpatientsregardingprocedures,processes,outcomeandfollowup;


f. Understand about long term rehabilitation of orthopaedicpatients;

g. DocasepresentationofwardandOPDorthopaedicpatients;

Psychiatry

a) Acquirecompetencyin

I. Psychiatrichistorytaking,assessmentincludingmentalstate examination and formulation of diagnosis andmanagement

II. Assessmentandformulationofmanagementplanforalcoholanddrugdependence.

III. Assessment,screeningandmanagementofpatientspresenting with acute psychiatric emergencies suchas deliberate self harm/suicidal ideation/attempt,acutealcoholwithdrawalsymptomsincludingalcoholwithdrawalseizures.

b) Familiarizewith

I. The diagnosis andmanagement of commonmentaldisorders in the country such as: Psychosis, BipolarAffective Disorder, Depression, different types ofAnxiety disorders including Dissociative ConversionDisorder and Somatoform Pain Disorder, Epilepsy,AlcoholandDrugAddictionsaspertheMentalHealthManual2010.

II. Withtheuseofcommonpsychotropicdrugsavailablein the essential drugs list such as anti-psychotic,antidepressant, anti-anxiety, mood stabilizer, anti-epileptic and drugs for detoxification of alcohol anddrugsabuseandantidotesfordrugoverdose.


c) Onecasepresentationduringwardround

d) Record at least five different cases with different diagnosisseen inthePsychiatryOPDandWardduringthedurationofposting.

Dermatology

a) Acquireknowledgeon:

i. History taking, diagnosis, investigation andmanagement of common and emergencydermatologicalconditions;

b) History taking,diagnosis, investigationandmanagementofcommondermatology disease.

c) FamiliarizewithnationalprotocolsonmanagementofSTDandHIVinfections

Ophthalmology

a. Acquire competency on: Ocular bandaging, Lids repair;SyringingforFB,Fluoresceinstainingofcornea;Visiontesting;Directophthalmoscopy

b. Assessment and management of common ocular problems

c. ObserveandassistinMajorOphthalmicsurgeriesandfollowuppostoperativecases.

d. Familiarisewithprimaryeye care services ;( communityeyecare)

e. CasepresentationinwardandOPD

Otorhinolarynglogy (ENT)

a) Acquirecompetencyin:Management of epistaxis, Aural syringing, Ear toileting, Emergency airway, Removal of the foreign bodies from the nose and ear;


b) Acquire competency on historytaking,diagnosis,investigationandmanagementofcommonandemergencyENTconditions;

c) Observe and assist in various ENT surgeries including endoscopic procedures and tracheosotomy, and post-operative follow up

d) UnderstandtheENTrehabilitativeprogrammes.

e) Do case presentation on Ear, Nose and head and neck cases inWard and OPD

Anaesthesia

a. Learn a procedures and requirements for pre-anaestheticcheckup;

b. Develop competency to monitor patients during generalanaesthesia;

c. Familiarise with various types of anaesthetic equipments,anaesthetic agents, their mechanism of actions and sideeffects;

d. Develop skills to monitor patients and understand theproblems associated with anaesthesia and post operativerecoveryperiod;

e. Observe and assist in endotracheal intubation, spinalanaesthesiaandsimplenerveblocks;

f. Familiarizewiththemaintenanceofanaestheticrecords;

g. Developcompetencytorecognizecardiacarrestandperformcardio-pulmonarybrainresuscitation;

h. Casepresentation


Radio-diagnosis and Imaging:

a. Develop competency to interpret normal and abnormalfindingsinX-raysandultrasound;

b. GainknowledgeonindicationsandcontraindicationforRadio-diagnosticinvestigations;

c. Gainknowledgeonpatientandhealthworkerssafetyonuseofradio-diagnosticinvestigations;

Forensic Medicine and Toxicology

a. Familiarise with General principles and concept of medicalethicsandmedicallaws;

b. Developcompetencyinperformingexaminationsandwritingforensicreports;

c. Understandtheproceduresformedicolegalcasereporting;

Community Medicine

a. Acquirecompetencyon:

i. ChildhoodImmunizationschedule;

ii. Diagnosis and management of adverseeventsfollowingimmunization(AEFI);

iii. Completing themother and child healthrecordbook;

iv. CopperTinsertion;

v. Antenatal&postnatalcheckup;

vi. Identificationofhigh riskpregnancyandtimelyreferral;

b. Acquire knowledge on indication and contraindications ofcommonly practiced family planning methods (Copper-T, Oral


Contraceptive Pills (OCP), and Dehydro-medroxyprogesteroneAcetate(DMPA);

c. ObserveVasectomyprocedures;

d. Participateinhealtheducationprograms;

e. DevelopskillsinvoluntarycounsellingforHIVtesting;

f. Familiarise with National guidelines and protocols for variouspublichealthprograms(e.g.,TB,HIV/AIDS,EPI,RH,OccupationalHealth,Nutrition,etc.);

g. Familiarizewithallreporting/recordingformsandmechanismofreporting.

Transfusion medicine

Learning outcomes:

a) Blood Donor management

I. Acquired knowledge on medical aspects in donor screeningprocesstodecideonsuitabilityofablooddonortodonateblood.

II. Acquired knowledgeand skills to adequatelymanageablooddonoradversereaction.

III. Acquiredknowledgeandskillsinconductingpre-donationandpost–donationdonor counsellingandmanagementofdonorswith ‘reactive’ test resultsofbloodscreeningfortransfusiontransmittedinfections(HIV,hepatitisB&Candsyphilis)

IV. Acquiredknowledgeonthebasicprinciplesofimmunologyandimmuno-hematology


b) Clinical transfusion

I. Acquired adequate information on the National BloodPolicy,nationalguidelineson‘AppropriateClinicalUseofBlood’ and standard procedures

II. Beabletopracticetheelementsoftheaboveguidelines.

III. Acquired knowledge on the basic principles of transfusion medicine and clinical transfusion process

IV. Acquire knowledge on the process and basic principles of transfusion medicine

Emergency medicine

a. Acquire competency on emergencymanagement ofmedical, surgical, orthopaedic and other emergencycaseswhichwillincludebasicsofthefollowing:

- BasicLifeSupport(BLS)

- AdvancedLifeSupport(ALS)

- AdultCardiacLifeSupport(ACLS)

- PaediatricAdvancedLifeSupport(PALS)

- NeonatalAdvancedLifeSupport(NALS)

- AdvancedTraumaLifeSupport(ATLS)

- PatientAssessment(pre-hospitalandIn-hospital)

- Emergency/disasterresponse

- Transportationandcommunication

- Documentation

- Skillsrelatedtoemergency

b. Casepresentation

Documents

Guideline for Undergraduate Medical Internship Program in ... · Guideline for Undergraduate Medical . Internship Program in Bhutan 1. Background 1 Introduction 1 Purpose 1 Scope