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Postgraduate Medical Education

Incorporating The Residency And Internship

When the internship first became an established part of postgraduate medical education in the early part of this century, its purpose was straightforward and uniform: a rotating internship, with nearly equal portions devoted to medicine, surgery, pediatrics, and obstetrics-gynecology, which provided the first extended clinical experience and the first supervised responsibility for the welfare of patients. These experiences were deemed essential and usually sufficient to complete the preparation of a younger physician for independent practice.

With advances in medicine, the purpose of an internship was no longer obvious nor uniform. The internship did not provide the student's first practical experience with problems of diagnosis and treatment; that function is served by undergraduate clinical clerkships. Nor was it adequate to provide the final educational experience preceding independent practice; the additional training of a residency is generally considered necessary to fulfill that purpose.

The nature of the internship also changed over the years. Aside from the original rotating format, in time two other types came into use: mixed internships—providing training in two or three fields with prolonged concentration in one of them; and straight internships—devoting time entirely to single areas, such as medicine, surgery, or pediatrics.

While medical school curricula are the corporate responsibilities of faculties, internship programs were not the corporate responsibilities of hospitals. The responsibility of ensuring a truly educational internship was usually that of an individual head of a service or heads of several independent services. An inevitable result of such highly individualized and fragmented responsibility was that internship programs varied widely in the extent to which they duplicated the experience already gained in the clinical clerkship, in the amount of routine and sometimes menial service required, and in their educational quality.

As a result of the highly questionable value of the internship in the educational process and the very high percentage of physicians taking residencies, its usefulness as a distinct program came into serious question. At its annual convention in December 1968, the AMA adopted a resolution that “an ultimate goal is unification of the internship and residency years into a coordinated whole.” Further steps toward implementation of this resolution were subsequently adopted and the goal was set that by July 1, 1978 all internship programs would be integrated with residency training to form a unified program of graduate medical education which has taken place. This means that the internship year now is the first year of residency and that one person, who is assigned as program director in a specialty at a given institution, is responsible for the entire program. That person has the option of requiring or recommending a specific type of first year program (rotating, mixed, or straight) acceptable as part of the residency program, or even assigning trainees to an outside hospital for their first residency year. A significant amount of flexibility has been introduced so as to permit the graduating physician to secure postgraduate training that is specifically designed for individual interests and career goals. It will also facilitate long-term plans and ensure a more stable personal life.

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