Obstetrics & Gynaecology Forum Volume 29 | Issue 3 | 2019

of abscesses, core surgical skills were unsatisfactory. In comparison, semi-urban interns rated themselves sufficiently skilled in core sur- gical skills. In our study, it was concerning that the hospitals did not take into consideration what CSMOs’ skill and area of preference was. While the provision of health care is a priority, it is also import- ant to enhance the skills and the interests of CSMOs. Various studies and reviews have shown the effectiveness of ES- MOE training in the improvement of surgical skills. 2, 3 It was sur- prising that only 50% of the CSMOs in our study reported having completed the ESMOE training during internship. This may indicate that there are some loopholes in the training during internship that are not ensuring that the ESMOE modules are scheduled at a time during which all interns can attend or steps taken to ensure that those interns who were absent at a specific module are catered for in special sessions. In a study conducted by Mofolo and Botes (2016) in the Free State, responses from interns showed that exposure of medical stu- dents during their clinical years to practical training were inade- quate. 6 It was noted that interns felt prepared for various procedures however lacked the confidence to perform procedures such as cir- cumcisions, episiotomy and perineal repair, assisted delivery and appendectomies. Some procedures in other disciplines were rarely performed. 6 These findings compare with our study (Figure 3) par- ticularly Group 1 as they had the least confidence to perform other surgical procedures. Sein and Tumbo (2012) 7 in another questionnaire based study found that 87.2% of the second year interns felt that the internship had prepared them well for community service. In addition, 65.0% of the interns were positive about the mentorship/supervision. However, only 52.5% felt that they were properly orientated. Sim- ilarly, in our study, 83% felt they were adequately trained for com- munity service. Sein and Tumbo (2012) 7 further reported a condu- cive environment, reasonable workload, personal attributes, good support system and effective supervision from good quality super- visors as factors that influenced effective medical intern training. Kusel et al., (2017) 8 looked at factors influencing the development of practical skills of interns. The outcome of their study showed the importance of adequate supervision for interns to develop the various skills necessary. The importance of increasing procedural skills was also one of the suggestions by the CSMOs in the current study as ways of improving the training of interns. They suggested having simulated skills training labs where they can learn to deal with emergency situations under safe learning environments. Nkabinde et al., (2013) 4 conducted a study evaluating medical internship by CSMOs and showed that most respondents (78%) were satisfied with their training and they felt confident in their ac- quired knowledge and skills in most disciplines, but gaps were rec- ognized in paediatrics, anaesthetics, orthopaedics and obstetrics. Furthermore, the CSMOs commented that they lacked confidence in certain critical anaesthetic and obstetric skills. A national survey of 150 doctors who recently completed their internship showed a serious lack of supervision. This was further worsened by workload issues and a lack of learning opportunities. In addition, there were limited teaching sessions for casualty and family medicine. Thus, compliance with HPCSA rules was not adequate. 9 Reid and co-worker conducted a study to monitor the imple- mentation of community service in general. 9 The CSMOs reported that the community service year offered them a platform to improve on their skill and develop critical thinking. However, there was con- cern that there was not enough supervision and support given to young health care professionals. A need to intensify undergraduate and internship training was identified to ensure that the CSMOs are able to provide the demands that are placed on them. 9, 10 This was similar to the findings in this study as CSMOs felt they need- ed more specialist supervision. Owino (2010) reported that intern skills may vary according to the medical school attended. 10 This was intended to be a feature to be looked into but since the majority of the CSMOs were from UKZN NRMSM it could not be adequately explored. We report that the CSMOs dealt with CDs complications suc- cessfully. This is in variance with another study conducted locally where CSMOs reported inadequate experience in dealing with as- sociated complications, such as uncontrollable hemorrhage follow- ing CDs. 4 A number of studies have reported gaps between medical education or preparation for practice and the actual requirements of medical practice as an intern. All the studies used methodologies such as questionnaire surveys, interviews and focus group discus- sions. Some studies report on interns’ self-assessment of their com- petencies; 11, 12 views of supervisors, clinical teams and patients; 13-15 comparisons of different medical schools 16 and of different curric- ulum designs on preparation for practice. 17, 18 Furthermore, per-in- ternship training 19 and junior doctors’ perception of the internship training site was also assessed. 20 Swaid et al., (2017) evaluated the interns’ views and perceptions during their internship training which showed that satisfaction in their training was more evident in general surgery and paediat- rics however lowest in O&G. 21 More than half of the 85 interns felt prepared for the next phase of training while only 25% of the re- spondents were moderately prepared. 21 A recent study from Kenya showed that interns attributed their deficiencies in some skill sets towards inadequate supervision. Interns were supposed to perform surgical procedures after orientation. 22 Although this study was not assessing a similar group of people, it did highlight that there were gaps in the internship training program. This, therefore, raises the question of whether the HPCSA should review their minimum re- quirements for the number of CDs during internship. Furthermore, the surgical skills of the interns were further enhanced by perform- ing a number of other surgical procedures. The skills and manage- ment of complications and obstetric emergencies acquired during ESMOE training were successfully implemented by majority of the CSMOs in practice. The training program has all the components necessary for suc- cessful training. The feedback received indicates that certain aspects require amendments to ensure that there is improvement in train- ing. The high numbers of complications that occur at CDs make it necessary that junior doctors be adequately prepared to ensure provision of good quality medical services. One of the recommen- dations was that registration with HPCSA should be a completed ESMOE course prior to joining the CSMOs programme. Perhaps at the end of the O&G block, there should be a test based on the ESMOE training program, ensuring this will serve as a solution to improve service provision during community service. Furthermore, the possibility of increasing the minimum required number of pro- cedures, particularly CDs, and there should be fewer restrictions on which CDs they can perform. In addition, a more formal and standardized approach at HPCSA approved intern training sites on the training program. Efforts need to be made to improve the skills of non-obstetricians performing CDs as a large number of CDs will need to be performed by non-obstetricians. This can be achieved by way of in-reach or outreach services and CSMOs did suggest hav- ing the support of specialist obstetricians in district hospitals. The internship training program should be further standardized and ad- justed to meet the needs of CSMOs to provide a better service to pregnant women. Preferences should be taken into consideration as a doctor is more likely to perform well in an area they have chosen to work in or where they feel more confident. Limitations No inclusion of intern trainers/supervisors is a limitation to the study as they have the ability to give feedback from the trainers’/ supervisors’ perspective. Further in-depth studies covering a larger cohort of CSMOs including the intern supervisors (Medical officers, registrars and consultants) and intern curators are needed. This will give a more comprehensive assessment of the training program and lead to more precise methods of improving training to ultimately improve the skill of the health care practitioners and therefore pro- vision of adequate and safe delivery of health care services partic- ularly surgical procedures. Another limitation was the number of O&G Forum 2019; 29: 19 - 23 ORIGINAL OBSTETRICS & GYNAECOLOGY FORUM 2019 | ISSUE 3 | 22