ANNEXES
Annex 1
Supervised Hands On Training -‘SHOT’
Reasons for a Change in Internship
By Prof. Sanath P Lamabadusuriya
Format of Supervised Hands On Training (SHOT)
1st Year
- Six months each of 2 of the 4 major disciplines (eg.General
medicine and general surgery)
2nd Year
- Three months each of the other 2 major disciplines (eg. Paediatrics
and obstetrics and gynecology)
Three months each of 2 sub specialties such as psychiatry,
cardiology, neurology etc. or community medicine or attachment
with general practitioner.
Advantages of SHOT
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Better foundation
For a future specialist
For future G.Ps
- exposure to all 4 major disciplines
- exposure to subspecialties during training
- exposure to general practice under supervision,
and wider exposure to all major clinical disciplines
For a community physician - exposure to community medicine
Supervised training for 2 years in a teaching environment
Employment ensure for 2 years (Ministry of Health will not e employing all
medical graduates after 2010)
Can embark on Post Graduate training soon after SHOT
Preliminary grade salary would be paid during second year.
Possible rotations ( in 2nd year )
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For a future cardiologist
- Three months of cardiology
Three months of intensive care
For a future G.P
- Three months of general practice
Three months of psychiatry
For a future paediatrician
- Three months of paediatric surgery
Three months of intensive care
For a future community physician - Three months of community medicine
Three months of psychiatry
Potential logistic problems
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Provision of quarters during SHOT
Solution - provision of on-call rooms
renting houses for accommodation
As SHOT would extend training by one year, the following issues should be dealt
with –
a)
b)
c)
d)
e)
Reduce the initial of six months between completion of ‘O’ level
examination and commencement of ‘A’ level course.
Reduce period between completion of ‘A’ level examination and
admission to universities (currently about 1 year)
Reduce the period between completion of Final MBBS examination and
commencement of SHOT (sometimes up to 1 ½ years)
Streamline Final MBBS examination of different faculties so that allo
examinations are held within the shortest possible period.
Overlapping of internship until backlog is cleared.
Annex 2
Supervised Hands On Training -‘SHOT’
A Short Presentation
by Dr Ananda Samarasekera
Vice President, SLMC
Internship
History
1905- Legislative provision for certain categories of persons to practise medicine and
surgery.
1907- Actual registration commenced.
1927- Became mandatory to have registration for practise of medicine and surgery.
1942- University Ordinance made provision for recognition of the MBBS (Ceylon)
degree which replaced the LMS.
1955- Legislative provisions were brought in to provide provisional registration and preregistration experience.
This made provision to recognize MBBS (Ceylon) and other special qualification as a
prerequisite for provisional registration.
Also made provision to obtain a certificate of experience and stipulated the rights of
provisionally registered medical practitioners.
This certificate of experience became a mandatory requirement for full registration.
Who is an Intern Medical Officer?
Also call pre- registered medical practitioner
A medical graduate who is provisionally registered as a medical practitioner with the
SLMC to obtain a certificate of experience by working in an approved hospital or
institution by engaging in employment in a resident medical capacity for a prescribed
period in an field of medicine approved by the Medical Council for the purpose of
obtaining full registration.
Law
Legal provisions applicable to internship
Must be engaged in employment in a resident medical capacity for the prescribed period*
in one or more approved hospitals or institutions**
(*In relation to the practice of medicine or surgery or other approved fields by the
Medical council having regard to the medical needs of the country
** hospitals or institutions approved by the medical council from and among lists of
hospitals and institutions submitted by the DGHS.)
During his/her aforementioned employment must be engaged for:
an approved period in the practise of medicine,
an approved period in the practise of surgery,
AND
for an approved period in the practise of other approved fields;
AND
have rendered satisfactory service while so employed.
Midwifery
The period , without exceeding the prescribed period, spent in the practice of midwifery
shall for the purpose of experience be deemed to be a period spent in the practise of
medicine and surgery as he/she may elect.
Resident medical capacity
In accordance with the terms of his/her employment in a prescribed hospital or an
institution, residing conveniently near that hospital or institution, his employment in that
hospital or institution shall be deemed to be employment in a resident medical capacity
not withstanding his residence in that hospital or institution.
Rights of an intern medical officer
Approved period and fields at present
• Total period of 12 months
• Six months each in surgery, medicine, gynaecology & obstetric and paediatrics,
paediatric surgery.
• Combination of medicine and paediatrics, paediatric surgery and surgery cannot be
done to complete 12 months
In the past…..
 The first batch of interns was appointed from the 1st May 1956 to 30th April 1957.
 Approved hospitals for internship included Chest Hospital, Welisara, District
Hospital, Haputale.
 Three months of midwifery was recognized as part of medicine or surgery.
 Working as a house officer in a district hospital under a DMO with no specialists had
been recognized as an internship.
Annex 3
Proposal of the Sri Lanka Medical Council for a Change in Internship
-Dr S Sivakumaran
A doctor
 has a recognized degree having followed a recognized course
 Has satisfactorily completed recognized appointments during the pre registration
period.
 Continues professional development (CPD)
 Pre registration clinical training
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The main objective is to provide supervised hands on training before they are
allowed to practise on their own.
Work horse or Trainee
Need for Revisi(on)t
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With multiplication of specialties,
rapid advancement in medical practice ,
vast changes in medical curriculum and training –internationally
Greater expectations from the patients
Train adequately and appropriately
There is a need for reorganization of the current pre-registration training programme to
prepare our graduates adequately and appropriately for them to:
 practise independently
 excel in their future career
 remain globally competitive and sought after
 Keep in mind D.O.B
The clinical training which is supervised and “hands on” should aim to provide:
 adequate training in the important specialties the graduate needs to have
experience in, if he/she wishes to take up to general practice
 some training in the field and fields related to, in which the trainee wishes
to specialize in.
 Provision of adequate exposure to career options
 Opportunity to work in a field, which the graduate would consider
 specializing in but not offered in List 1.
.
Effective Shot
In essence SHOT should include:
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providing practical experience,
 education with particular reference to the subjects mentioned above and
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appraisal and assessment
Formal lectures
Communication skills, interpersonal relations and counseling
Continuous professional development
Training in medical record keeping
Information on professional ethics
Current practice
At present the 1-year internship consists of a six months period of training in two of the
following specialties:
List 1
Medicine /Paediatrics
Surgery/ Paediatric Surgery
Obstetrics and Gynaecology
The present practice does not fully serve the objectives as envisaged – to practise
independently, excel in their future career and remain globally competitive and sought
after. It gives training in only two fields. A trainee who wishes to take up to general
practice would also benefit from training in other fields not listed in List 1 in which he
did not have training, plus some training in specialties such as eye, ENT, psychiatry, etc.
Similarly a trainee who wishes to specialize in a particular specialty may not get an
opportunity to do that specialty during his internship period - e.g. he may have done six
months internship in surgery but would like to specialize in O&G.
Alternatively he may consider specializing in some fields not given in List 1 during his
internship but would like some exposure to that specialty before making up his mind. For
instance a trainee might like to specialize in radiology or eye but would like some
exposure in those specialities to make up his mind.
In order to accommodate these objectives and aspirations of the trainees the supervised
hands on training need to include more specialties.
Therefore, to accommodate additional specialties the SHOT period needs to be longer. It
is proposed to have an additional year of SHOT to achieve the objectives mentioned
earlier.
Two Six-Month Appointments
Considering the responsibility the House Officer is expected to shoulder, it is
recommended that the first two appointments during the SHOT period should continue to
be six months each.
Shorter periods of training in basic specialties during the first year may have a significant
deleterious impact on patient care. Further, it may not meet the PGIM requirements to
apply for selection test in many specialties.
Proposed Programme
First Year
Foundation
Objectives:
To provide:
 hands on training in 2 major specialties
 Formal lessons and training in communication skills, ethics and medical
record keeping
The first year will be similar to the current one year internship, offering six months
period of training in two of the following specialties.
List for 1st year
Medicine /Paediatrics
Surgery
Obstetrics and Gynaecology
Note: Paediatric surgery has been shifted
to the 2nd year.
Second Year
Career development
Objectives:
To provide training in:
 the other two major specialties
 some fields related to the specialty the trainee would like to specialize in
 some specialities the trainee would consider specializing in (helping to make
up his mind)
The trainee could select any four appointments from Lists 2 and 3, (other than the two
appointments which he had already done.)
List 3
Anaesthetics
Cardiology
Community Medicine
Dermatology
ENT
Eye
Forensic Medicine
Intensive Care Unit
Neurology
Orthopedics
Paediatric Surgery
Pathology/Haematology
Psychiatry
Radiology
Trauma (Accident and emergency)
Assistant to DMO in a district hospital
You Choose
He could opt to do the two specialties in List 2, which he missed during the first year; e.g.
if a candidate has done medicine and surgery during the first year he may be able to do
three months each of paediatrics and three months of obstetrics and gynaecology in the
2nd year). The other two appointments shall be chosen from List 3. He is expected to
make this selection depending on his future plans.
For those determined trainees who have not done six months appointment in a field they
wish to specialize in and have not done the six months, may be allowed a 2nd three
months in that specialty provided there are no contenders from those who have not done
the appointment in that field.
Opportunities galore
Examples of opportunities provided
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If a trainee wishes to take to general practice in the future he may consider doing
psychiatry, dermatology, eye or ENT.
 A trainee who had done 6-months surgery during the first year and wishes to
specialize in surgery, may wish to do three months in orthopedics and three
months in trauma.
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A trainee who wishes to make up his mind before deciding to specialize in
ophthalmology may opt for a three months appointment in ophthalmology.
Concerns
The answers to the concerns that may arise in the minds of the trainees are considered
below.
Salary
Q: What will be my allowance during the second year of training?
A: It is proposed to pay the salary of the first year medical officer.
Q: Will I be entitled to overtime payments during the second year?
A: It is recommended that you should be entitled to overtime payments.
Q: What will happen to my departmental service seniority
A: Back dated registration should be recommended by the SLMC.
Specialization
Q: Have I to wait for the completion of the 2- year training before sitting any
PGIM exam?
A : You should be allowed to sit for any PGIM examination according to the
PGIM regulations at that time and it will be ensured that these new proposals do
not delay your post graduate training.
General practice & Resignation
Q: Will I be able to resign from the department and start general practice before I
complete the two years of SHOT?
A : You may resign at any time you wish but you will be registered by the SLMC
only when you complete the required 2- year stipulated appointments. Therefore,
you will not be able to practice.
On call duty
Q: Will there be on call duty during the second year.
A: All doctors in hospital clinical practice have on call duties independent of
their designations. If you are doing an appointment in a field in List 2, you will
certainly have first on call duties. With regard to appointments in specialties in
List 3, it will depend on the individual appointment but most will have on call
commitments. The on call duty is necessary for your appointment to be
recognized by the PGIM for selection tests in certain specialties.
Duties
With regard to basic specialties this will be similar to the duty of an intern with on call
either one in three or one in four. As regards the specialty in List 3 the trainee would be
expected to be on call if on call commitments are expected in the specialty (not exceeding
a one in three rota)
Accommodation
On call room should be made available for the trainee when he/she is on call.
Remuneration
Would be that of a first year Medical Officer.
Sitting for Post-graduate Exam
The trainee should be allowed to sit for these exams during the second year provided
he/she fulfills the PGIM criteria as at present.
Implementation
Applications shall be called at the end of the seventh month for the second year
appointments
The appointments for the second year will be made known within 4 weeks with 2 weeks
period to appeal.
At least 12 weeks notice for the appointments in the second year.
Vacancies and accommodation
Their will be about 1000 interns at any given time
About 40 institutions will be training them.
It is proposed to create about 300 vacancies from List 3. The balance 700 vacancies will
be from List 2. This means there should be an additional 180 vacancies created in each
basic specialty. That amounts to about additional 6 vacancies in each institution for each
specialty.
It is recommended that vacancies in basic specialties should be confined to Base Hospital
and District General Hospitals (excluding Teaching Hospitals).
Annex 4
Supervised Hands-on Training
(Internship)
Placement of Interns
Dr. S. Terrence G. R. de Silva
DDG(MS)I
Doctors Graduated from following Medical Faculties apply for internship
 Faculty of Medicine, Colombo
 Faculty of Medicine, Peradeniya
 Faculty of Medicine, Karapitiya
 Faculty of Medicine, Kelaniya
 Faculty of Medicine, Sri Jayawardenapura
 Faculty of Medicine, Jaffna
In addition there are foreign Medical Graduates.
Names of the hospitals provided with interns
 NHSL
 LRH
 DMH
 CSHW
 TH Mahamodara
 TH Karapitiya
 TH Peradeniya
 SBSCH
 TH Colombo South
 GH Sri Jayawardena
 CNTH- Ragama
 TH Kandy
 GH Anuradhapura
 GH Badulla
 TH Kurunegala
 GH Kulutara
 GH Ratnapura
 BH Avissawella
 BH Chilaw
 BH Gampaha
 BH Kegalle
 GH Matara
 DGH Matale
 DGH Negambo
 BH Nawalapitiya
 BH N’Eliya
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BH Panadura
BH Polonnaruwa
BH Watupitiwala
BH Kuliyapitiya
BH Trincomalee
BH Puttalam
BH Homagama
BH Hambantota
BH Monaragala
BH Horana
BH Dambulla
TH Jaffna
GH Batticaloa
BH Diyatalawa
GH Ampara
BH Mahiyangana
Kalmuai South
GH Vavuniya
BH Marawila
BH Embilipitiya
(Total 46)
Total number of Consultant Units
 General Medicine
82
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General Surgery
78
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Paediatrics
71
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Gyn. & Obs.
85
Total
316
If three interns appointed to each unit we need 948.
Number of Intern appointed during the last two years
 2006 October Main batch
765
 2007 May, Repeat batch
176
Total
941
 2007 October, Main batch
746
 2007 November, Repeat batch 181
Total
927
Distribution of Consultants
 Consultant General Surgeons
 Consultant General Physicians
 Consultant Paediatricians
 Consultants Obs. & Gyn.
 Consultant Eye Surgeons
 Consultant
Dermatologists
 Consultant Radiologists
 Consultant Psychiatrists
72
84
89
94
43
17
39
13
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Consultant JMO. O
Consultant Anaesthetists
Consultant Histopathologists
Consultant Otolaryngeologists
Consultant Haematologists
Consultant Orthopaedic Surgeons
Consultant Rhumatologists
Consultant Clinical Microbiologists
Consultant Neurologists
Consultant Cardiologists
Consultant Neuro Surgeons
23
63
24
20
11
21
13
22
14
23
08
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Consultant Oncologists
Consultant Vascular Surgeons
Consultant Veneriologists
Consultant Paediatric Surgeons
Consultant Neuro Physiologists
Consultant Nephrologists
Consultant Oncological Surgeons
Consultant Geni. Urinary Surgeons
Consultant Chest Physicians
Consultant Cardio Thora. Surgeons
Consultant Gastro Entro. Surgeons
Consultant Gastro Entro. Physicians
14
02
09
06
01
03
07
09
11
08
04
01
Dr. Terrence de Silva
DDG(MS)I
Annex 5
Proposed Supervised Hands on Training (SHOT)
by
Prof. Jayantha Jayawardana
What are the Advantages?
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Educational and Academic
Personal
Patients and society
Country
Global
Educational and Academic
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Strengthen knowledge
Manage acutely ill patients in a variety of settings
Risk management
Hands on skills
Communication skills
Critical thinking skills
Personal and Professional skills
Administrative skills
Develop generic skills such as team work, infection control, …
Positive influence on motivation
Identify strengths and weaknesses
Recommend remedial action
Improve assessments/examinations
Academic work – seminars, SGD, workshops
Clinical skills
–History
–Examination
–Judgment
–Investigations
–Management plan
–Note keeping
–Reflective writing
–Operative and practical skills
–Able to identify limitations
–Decide when to summon help
Postgraduate Education
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Time to select the specialty
Complete requirements
Time for studies
Opportunities for help and supervision
Access to facilities : library, IT, SGD
Desirable maturity
Be closer to other postgraduate training programmes
–Eg: PMETB (UK)
Personal
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Opportunity for training in all four specialties with full salary
To do two other appointments
Remain in a “hospital in the centre”
Fulfill PGIM entry requirements
Medico-legal implications
If not employed by MOH an opportunity to remain for extra year
If only option is Family Practice better trained
More time to organize the future professional life
Benefits to the family
Positive impact on your private practice
Income may improve
Advantages – Patients
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More medical officers in a ward
MO with experience (when no Registrar/SHO)
MO with experience in hospitals in the periphery
Quality of care will improve in PH
Quality of care will improve in GP practice
Reduce referrals and transfers to the centre
Advantages – Country
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Improve quality of care and standards
Improve statistics
Manpower requirements
Cost savings
Advantages – Global
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Postgraduate training posts for Board Certification
Recognition of training for exceptions
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Recognition of MBBS for Registration
Entry examinations
Employment
What are the Advantages?
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Educational and Academic
Personal
Patients and society
Country
Global
- YES
- YES
- YES
- YES
- YES
TIME TO VOTE YES BEFORE
IT IS TOO LATE
What will be offered?
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Total of two years paid training period
Remain in a main hospital
Trained by six consultants
Exposure to all four major specialties
Exposure to two other specialties
Pre-arranged educational programme
Monitoring during implementation
Plan for appraisal and evaluation
What are the Educational Objectives of Internship?
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Knowledge
Academic work – seminars, SGD, workshops
Competence in Clinical Skills
Communication skills
Administrative skills
Personal and Professional skills
Annex 6
Position statement of the AMS
- SHOT proposals for medical graduates
1. The AMS accepts and endorses in principle that supervised training in diverse
fields would be beneficial for both medical practitioners and patients.
2. The AMS recommends that certain disciplines be made compulsory whereas
others can be optional. The AMS endorses the opinion that Accident and
Emergency medicine and Medical Ethics are two of the disciplines which should
be made compulsory. The training courses in these fields should be well
structured and targeted with precise objectives.
3. The AMS endorses in principle that the SHOT program is acceptable so long as it
is supplemented in a manner which does not materially affect the career progress
of medical graduates in:
(a) Postgraduate opportunities
(b) Remuneration
(c) Departmental seniority
4. The AMS endorses the opinion that a feed back is required from the following
groups indicating their perceived deficiencies in training:
(i)
Immediate post interns.
(ii)
Registrars in different specialties
(iii) Grade MOO in “difficult” areas
(iv)
MOO OPD
This feed back data is required so that the training slots offered reflect these
perceived deficiencies.
5. As an incentive to the medical graduates it is proposed that internship be a
placement within the preliminary grade. The placement of a MO in grade II soon
after completion of the SHOT program is also proposed for consideration.
6. The AMS endorses the view that a formal ‘exit’ type of assessment at the end of
the SHOT program, or preferably at the end of each training slot, has many
commendable points.
The high quality performers at this exit assessment may be positively rewarded by
the issue of a certificate of merit but a punitive element is not required as this is
anyhow inbuilt in the present system by the supervising consultant’s right to
repeat the appointment.
7. The AMS is of the view that on call rooms alone would be an inadequate facility
and the construction of suitable accommodation must commence immediately.