As a new medical intern, the first week of placement in a hospital can be overwhelming. Senior colleagues, who are expected to provide guidance, often leave after midday, leaving interns to manage a heavy workload alone. This includes dealing with a long list of patients, frequent calls from nurses, questions from family members, and even critical procedures like caesarean sections.

Desperate Measures and Unintended Consequences

In their desperation, some interns turn to Google or YouTube for guidance on performing medical procedures. This approach, however, can have serious consequences. One intern recounted a troubling experience: “You go and operate on a patient, you make an incision until you cut intestines, because you don’t know how much pressure to put.” Such incidents highlight the lack of adequate support and training for interns, leading to potentially harmful outcomes.

The Isolation of Interns in the Medical Field

These experiences are not isolated. Many medical and nursing interns report feeling like they have been thrown into the deep end without knowing how to swim. This sense of being overwhelmed and unprepared is a common theme in a recent study conducted in Kenya between 2021 and 2022. The study, led by researchers from the Kemri-Wellcome Trust Research Programme, University of Oxford, University of Warwick, and King’s College London, explored the concept of liminality. This refers to the uncertainty and in-between state that individuals experience as they transition from training to professional practice.

Study Findings: Liminality in Medical Practice

The study involved interviews with 121 newly graduated medical doctors and nurses undergoing internship training, as well as seven focus group discussions. The final paper, titled “Examining Liminality in Professional Practice, Relational Identities, and Career Prospects in Resource-Constrained Health Systems: Findings from an Empirical Study of Medical and Nurse Interns in Kenya,” was published in the Social Science and Medicine journal. The study raises concerns about the quality of internship training in Kenya and the impact of inadequate support on interns’ experiences.

The Reality of Medical Internships in Kenya

In Kenya, health trainees are required to complete a one-year supervised internship before they can be registered to practice. However, the quality of this internship experience is now under scrutiny. One doctor intern described the “confusing” and “terrifying” experience of suddenly transitioning from a medical student to a practicing doctor. “You are taught about the decisions [as a medical student], but you never really make the decisions. Then, one morning, you wake up and it is like: ‘Daktari (doctor), what do we do? ‘Actually, I was terrified’,” the intern said.

Expectations and Realities for Interns

Interns often find themselves expected to perform critical tasks competently without adequate support, while simultaneously being viewed as incompetent by more experienced health workers. A nursing intern shared their experience of being left alone to manage an entire ward without any prior guidance. This sense of being unprepared and unsupported is a common experience among interns in Kenya.

Resource Constraints and Ethical Dilemmas

Kenya posts nearly 5,000 health interns every year. However, the reality on the ground often differs from the training environments interns are accustomed to. Most medical training hospitals are relatively well equipped, and interns are trained to make clinical decisions based on evidence. Yet, during their internships, many find themselves without the necessary resources, equipment, and diagnostics. This forces them to rely on clinical judgment rather than evidence-based medicine, leading to ethical dilemmas and suboptimal patient care.

Ethical Breaches and Senior Staff Conduct

Some nurse interns have observed senior staff engaging in practices that breach nursing standards. For example, one nurse intern reported that senior colleagues administered high doses of oxytocin to induce labor, contrary to doctors’ prescriptions. This was done to expedite births so that nurses could leave early or rest during night shifts. Such practices, described by some as “medical witchcraft,” further undermine the quality of care and the integrity of the profession.

Challenges in Professional Relationships

Many interns also report feeling belittled and having their opinions disregarded by more experienced colleagues. Degree nurse interns, in particular, described how their formal knowledge sometimes “threatened” experienced nurses who had been trained at the diploma level. This tension between different levels of training and experience can create a challenging work environment for interns.

Opportunities for Improvement and Learning

Despite these challenges, the study’s authors believe that these experiences can inform efforts to improve medical internships in Kenya. “A deeper understanding is essential to inform policy and practice that better responds to the changing nature of health care practice and health professions in Kenya, other LMICs, and globally,” they said.

Navigating Professional Hierarchies

Being thrown into the deep end was not entirely negative. Some interns described learning valuable skills in navigating professional hierarchies and building collaborative relationships. One medical intern noted that approaching colleagues as equals helped foster mutual respect and cooperation. “Nurses can really mess you up … but once you approach people as equals, they are able to get to your level. Some of them have been in the profession for, like, thirty years … You are seeing it for the first year,” the intern said.

Collaborative Learning and Communication

Degree nurse interns also highlighted the importance of effective communication and collaboration with their more experienced diploma colleagues. One intern described how they learned to present evidence-based practices in a respectful and persuasive manner: “Convince them in a good way like: ‘You know Sister, while you do this and this, research says this and that and the current protocol says this’. Most of them will buy your idea,” the intern explained. This approach helped bridge the gap between formal education and practical experience, fostering a more supportive work environment.