With a white coat comes enormous responsibility: how doctors guide medical interns

“The main goal for the final internship, in my opinion, is to take that last step from intern to junior doctor”, says Joyce Wouts, a doctor in the emergency department at the Admiraal de Ruyter Hospital in Goes. Students can only choose the emergency department for their final internship. Throughout the year, two students from Rotterdam do their twelve-week medical internship at this department. “When they start, they are already familiar with being at the bedside of a patient. Now they need to learn to make decisions more independently.” Wouts wants them to assess a patient’s complaints on their own, think about a plan, and present it to her. “After that, they need to do it entirely on their own; we build that self-confidence.”

Every year, nearly four hundred students begin their internships as part of the Rotterdam medical programme. The medical internships – along with the master’s research – are the final hurdle, two years designed to turn a student into a good doctor. How do supervisors do that?

“What makes a good doctor is often very subtle. Next to the official requirements that the intern must meet, of course. That subtlety is very important”, explains Anneke Dijkman, a gynaecologist at the Reinier de Graaf Gasthuis in Delft. She is the final assessor for the Rotterdam gynaecology interns, usually two or three at a time, whom she supervises for five weeks. “During your internships, you develop your own style. Doctors are the role models from whom you learn, both positively and negatively. I often ask: what did you take away from this day? What did you notice today while observing me? Sometimes an intern says: ‘I had a clash with a specialist who was unkind. I don’t want to handle cases like that.’ I encourage them: speak out, take that on board, remember this, learn from it. This way, you consciously develop your own style.”

Doctors always guide interns alongside their primary task: caring for patients. For some departments, this poses a greater challenge than for others. As a physician in the emergency department, Wouts gets a good sense of the interns when they are on duty together. If she has a week of night shifts – which is frequent – it becomes considerably more challenging. “Ideally, we have two people here who can make final assessments, but due to staff shortages in the department, that isn’t currently possible. With varying shift patterns and substitute doctors, it can be tough to keep an eye on things.”

On the gynaecology ward at the Sophia Children’s Hospital, the situation is very different. Gynaecologist Suzanne Peeters guides five interns there. The working hours are more regular, and appointments can be prepared in advance, often by the interns themselves. Peeters finds it important that supervisors immediately have a conversation about learning objectives and build a trusting relationship with the student. “Your internships are overwhelming because you enter a department where some quite intense things happen”, Peeters explains. “So, you can certainly be impressed by that at the start of your career.”

An intern must get to know many new people and absorb a great amount of knowledge and skills in a short period, often at different locations. The Delft gynaecologist Anneke Dijkman often observes how new interns can feel lost when they begin in a department. “Sometimes it takes longer for someone to feel comfortable and be able to ask questions or learn effectively. The sooner you address this, the more willing someone is to speak up about what they want to learn.”

Since September 2023, interns are assessed in a new way. The most significant change is that no grades are given anymore. Previously, a single grade was given for each internship. Now, several short forms must be completed for each task or required learning objective. A committee reviews these forms multiple times. If they repeatedly observe the same concerns from doctors, a student may receive additional assignments or even be required to temporarily halt their internships.

This change has several advantages, according to gynaecologist Peeters, who is involved in the revision of medical education as programme director of Erasmusarts2030. It allows even more space for professional development. “To put it bluntly, someone might have received a six in the past if they promised not to pursue that particular specialty. That can’t happen anymore.” Previously, students received a final grade for a medical internship; now they get multiple smaller evaluations focused on skills, such as a catheter procedure. This forces students to practice, says Peeters. “Some students thought: that seems daunting, I’ll avoid it for now. That can no longer happen.”

Cardiologist René Tio has been used to this for years. At the Catharina Hospital Eindhoven, where he works, interns from various medical schools rotate. The interns from Maastricht University have not been assigned grades for years, which he finds a relief. The focus is now more on the development of future doctors. “When assessing an intern, it all boils down to one question: would you want this young doctor by your bedside in the future?”

Dijkman is relieved that there is less discussion about grades. “The average intern wanted an eight or higher. That’s why I’m so glad those grades are gone. It’s not about a grade; it’s about what professional qualities you have developed.”

According to Dijkman, reduced pressure to perform has another benefit: a healthier generation of doctors. “Perfectionism is prevalent in our profession. Burnout complaints are already a major issue in this field.” Recent research shows that 38 per cent of young doctors find the workload too high. A quarter of all medical specialists in training considered quitting their training in the past year. “We need to ensure that perfectionism does not work against us, and that starts with education and supervision.”

General practitioner Martijn Elings has his own practice in Rotterdam south. As a GP, he supervises students at the end of their internships, allowing them to quickly work independently. “On their second day, they already take a portion of the consultations with me. Just go ahead. Every intern does it in their own way – sometimes with ample preparation, sometimes with many stumbles and interruptions, and sometimes very smoothly.”

Elings always has only one intern at a time. This allows him to quickly see what kind of doctor he is dealing with and gives him time for deeper discussions. “This is the phase in which they should dream about their future career. I try to encourage them to think about why they want to become a doctor. Often, that motivation is more complex than simply wanting to ‘make people better’. It can be a search for fulfilment, wanting to make their parents proud, status, or wanting to do something good in this world.”

Elings believes it is important that the medical programme focuses more on personal development. “That is also part of my role as a GP: to look at the person behind the story. That’s why I also pay attention to the person behind the intern.” He believes this helps students make conscious choices in their actions as doctors and in their choices for further training. Medical students are often highly motivated regarding their studies, but they should not lose sight of themselves, according to Elings. They are more than just doctors, and that’s something they should explore.”

Medical students are known as diligent students with a clear goal: to become doctors. Sometimes they have dreamt about it for years in secondary school. “Studying medicine is different from many other programmes”, explains gynaecologist Peeters. “Students enter the hospital from day one, where patients are wheeled past in beds or in wheelchairs. People come out here crying, singing, and everything in between. And amidst that, you, as a student, navigate your way.”

For this reason, medical students in Rotterdam undergo an integrity ceremony in their first year. The message is: as a student, you are already part of the profession. “And you must handle that with integrity”, adds Peeters. “The patient sees you as a doctor, especially if you, as a medical intern, wear a white coat. The doctor and patient meet for the first time, and everything must be laid bare immediately. You literally go in with your hands into a person’s life. If you did that on the street, you would be arrested. Students must be aware of that responsibility early on.”

Every supervisor who spoke with EM agrees that the vast majority of students are entirely suited to the medical profession. However, not every intern fits every specialty. “I have never doubted whether an intern would be capable as a doctor”, says Wouts. “But I have thought: the emergency department is not the right place for you.” She always discusses those doubts with the intern. “Students respond to that very well. I would also be perfectly comfortable being their patient in a clinic, where they can calmly prepare for the appointment. These students received a passing grade.”

Dijkman emphasises that students intern to learn. Not only technical skills are important in this regard. “Communication, for instance, relies heavily on subtleties – some words, certain facial expressions. Saying during an anamnesis: ‘I’ll tell you what I have to, then we’ll do the examination’ sounds very different from: ‘I’ll ask you a few questions first, and then we’ll proceed to the physical examination.’ I addressed an intern on this. In our specialty, you ask patients very intimate questions, things you might not even ask your best friends. A more distant person can still be a very good doctor; however, in some fields, you need a bit more communication.” In another specialty, someone could still thrive, she emphasises.

Elings has indeed sent an intern home before. The GP was at his wit’s end. He found the student to be a danger to his patients. “How could it be that someone who knows nothing medically, is not good at communication, has no self-reflection, and is essentially at zero on all core factors, was sitting here? I really felt like I was being humiliated.”

In total, Elings has had doubts about three students’ suitability as doctors. He first engages in conversation. Who knows, something might be affecting them at home. Sometimes this leads to new insights. “I later apologised to one student. I felt that he did not treat my patients with respect. He was quite dismissive about minor ailments. We expressed our views; it wasn’t as dramatic as I perceived. We just weren’t a good match. That can happen too.”

Dijkman recognises this situation. “On the ward, we’ve sometimes said to one another: that person will never become a gynaecologist. On another department, it worked out fine. We assess based on a brief, specific period. An intern, especially early on, has not finished learning. When it comes to both assessing interns and examining patients, the same rule applies: leave your judgements, opinions and assumptions at the door – ask everything, and assume nothing.