Emergency room volunteer internship : an instrument for quality in medical training

Objective: To analyze the influence of medical student’s voluntary internship at the Emergency Room of the Workers Hospital (ER-WH) in the choice of medical specialty and its importance during graduation. Methods: A questionnaire was given to doctors and medical students that performed internships at ER-WH for e” 500 hours, from March 2000 until March 2012. Results: A total of 765 medical students and doctors performed e” 500 hours of practical activities at ER-WH and 390 answered the questionnaire – 37,9% chose surgical specialties and 24,1% clinical. Internship was crucial in choosing a career for 82,3%, and was a positive influence for 83,8%. Regarding the increment in interpersonal relationship, grade e” 8 was given by 61% of the participants for relationship with other professionals, 71% for relationship with colleagues and 63% for relationship with patients. The internship increased self-confidence for 92% and 75% reported an increase in technical knowledge. The training was considered useful and necessary for medical education to 80% of participants. Conclusion: Contribution provided by ER internships is undeniable for medical education and often influences students on choosing their medical specialties. The situations faced by students during these activities enable the development of intelligence in areas other than purely technical, which reflects in their medical


INTRODUCTION INTRODUCTION INTRODUCTION INTRODUCTION INTRODUCTION
M any extracurricular activities develop the important role of assisting the student in their career choices.A study of interns in intensive care medicine in Salvador showed that interest in following in the area after graduation rose from 32% to 65% after the internship 1 .Besides the fact that extracurricular internship is closely linked to practical and social learning essential to good work practice, it provides an experience that goes beyond the academic realm, as reflected in interpersonal relationships and selfconfidence 2 .
Within this context, the Academic Leagues play a key role, as they effectively participate in medical education, assisting in the promotion of knowledge and experience in specific areas through graduating internships 3,4   .The leagues, as well as other extracurricular activities, may actually contribute to expansion of medical practice by promoting student activities with the community, he/ she being an agent of health promotion and social transformation 5 , a vehicle to encourage scientific production and extension projects.In addition, the student has the opportunity to experience the multidisciplinary and multiprofessional work, which certainly contributes to ones professional and personal development 5 .
However, the validity of extracurricular activities in the training of students is still questioned and, although considered beneficial, is concerned about early specialization 6 and reinforcement of academic bad habits 5 that can be induced.In addition, a misconception may be committed by the student when choosing the traditional, more theoretical training over the practical, more dynamic training of the leagues 6 .
In order to analyze the influence of voluntary internship at the Emergency Room (ER) of the Workers Hospital (WH) on the choice of medical specialty and its importance for academic training, we proposed this analysis.

METHODS METHODS METHODS METHODS
The study was carried out by the analysis of a questionnaire answered by doctors and medical students who were interns in the Emergency Room of the Workers Hospital (ER-WR).We selected only those interns who completed 500 hours or more of volunteer internship for medical students, performed between the sixth and ninth semester of medicine graduation, extracurricular, from March 2000 to March 2012.The choice of the internship period was due to the format also recognized by universities as university extension.
The selection of interns was made from the records of the Center of Studies of WH, which contains full name, phone and e-mail addresses of students of four universities in Curitiba.
The online questionnaire sent by email or answered by phone covered the following aspects: influence of internship on the career choice and whether it was positive or negative; information about the validity of the internship for the academic formation; current utility of what was learned in the internship by the interviewee; usefulness of the internship in the relationship with physicians, other health professionals and patients; contribution to technical knowledge; acquisition of self-confidence; encouragement for studies; and whether the student was member of the Academic Trauma League (LiAT) WH-UFPR.

RESULTS RESULTS
The data were collected from 765 students who performed 500 hours or more of practical activities in the emergency department.Telephone or e-mail contact was possible with 500 students, the other had insufficient or outdated data in the records.Of these, 390 actually completed the proposed questionnaire.
When asked about the specialty that they currently follow or plan to take after graduation, 37.9% of respondents revealed inclination towards a surgical career, 24.1% chose a clinical one and the rest of the participants reported another specialty or did not specify one (Table 1).
The internship was decisive in choosing a career for 82.3% (321) of respondents.Of these, 83.8% reported a positive influence in the decision, even when the career choice was not related to the internship in the emergency room.
In relation to the increase in various scales of interpersonal relationships, as well as in self-confidence, decision about the career and motivation to study, we proposed numerical scales from one to ten, trying to quantify the role of internship in each question.Sixty-one percent of respondents gave grades of not less than eight in relation to the experience with dealing with other health professionals, 71% doing the same about relationship with colleagues and 63% also giving grade higher or equal to eight for relationship with patients.Regarding the direct influence in the specialty choice, 35% of participants reported grade equal to or greater than eight.Selfconfidence has been increased thanks to the practical training of the emergency room in the opinion of 92% of ex-interns, who reported grade equal to or greater than eight on this issue.Scores equal to or greater than eight were given to the increase in technical knowledge by 75% of the participants.
ER training was considered useful and necessary for the medical formation for 80% of the participants.Thirty percent of respondents were sitting members of the Academic Trauma League of the institution.

DISCUSSION DISCUSSION DISCUSSION DISCUSSION
The literature shows that up to 93.7% of medical students perform extracurricular internships until the end of the six-year course, the emergency room being the most performed internship 7 .
These data point to the fact that students pursue extracurricular activities in a supplement to fill curricular gaps 8 .Despite the demand for a more comprehensive curriculum, the students are faced with an internship that appears as a field for growth not only professional but also personal, because, as shown by the results of this work, the students gain confidence, increase in interpersonal relations and motivation to study.
Likewise act the Academic Leagues, which represent the extracurricular activity chosen by the majority of medical students during the first four years of the course, being overtaken by voluntary shifts in the last two years of 8 .In WH the Academic Trauma League coordinates the ER internship and mediates the activities of the league internship.LiAT capacitates medical students who enter the hospital and participate in the initial care to patients, in the analysis of laboratory tests, in the discussion of diagnosis and in the realization of sutures, bandages, fixed orthopedic immobilizations, and watching of Orthopaedics and General Surgery procedures.There is also the possibility of the senior intern to participate in specialized treatment of ALS -Advanced Life Support -as a Volunteer in trauma.
Medical students claim that their involvement in extracurricular activities are an attempt to fill curricular gaps, integrate with colleagues, supplement the course, get welfare, answer professional questions, and other motivations 8 .This raises a discussion about the need to adapt the curriculum to the growing demand of the medical student and labor market itself.The high demand for internships shows that students' expectations are not met in formal curricula, reflecting their belief about the inadequacy of the curriculum to the market that will receive them 6 .The question is which failures, effectively filled by extracurricular activities, could be met by regular courses and which failures would be reinforced by non-curricular activities.The subjectivity of this action is the responsibility of the potential didactic structure that is offered on the internship and the individual interest which leads the intern to seek knowledge.
In this study, we found that the experience of an extracurricular internship in the ER develops, through the optics and the judgment of the students themselves, many varied and important skills to the practice of general practitioners, not just tied to a particular specialty, as shown by the variety professional options.Moreover, the numbers found on the influence of the specialty choice show that the internship is also an important way of understanding the everyday medical practice and its many nuances.
According to this study, the internship was considered in determining career choice for 82.3% of respondents.This shows that the ER internship contributes to the future of medical expertise and that the it should be attractive to make the majority of medical students (93.7%) participate in internships, as mentioned by Taquette et al. 7 .Moreover, when asked about the need for academic training, 80% considered the internship necessary, which reinforces the idea that the ER internship is preferred by the student, as it is a practical 2 and dynamic field of performance in which there is professional and personal learning 5 .
The present study also revealed that the ER internship contributed to future physicians in acquiring confidence in 92% of cases (grade equal to or greater than eight), and is valuable for a better relationship with health professionals and patients.Due to insufficient data, it was not possible to assess the negative influences of internships on career choices, but some considerations can be inferred regarding critical situations experienced by the intern, with negative impacts, such as complicated medical cases, behaviors repudiated by the student and the emotional impression of the chaos experienced in a very busy emergency room.
We can thus conclude that the contribution of the ER internship is undeniable for quality medical education and presents, in most cases, an influence on the choice of medical specialty.The various situations that the students face make them develop intelligence in many areas other than purely technical and applied.Finally, although we can reveal flaws in the regular medical training, the extracurricular training in emergency services is a key tool for the construction of solid and complete medical knowledge, of present and future utility for the medical student.

Table 1 -Table 1 -Table 1 -Table 1 -Table 1 -
Medical specialty of choice of the interviewed participants.