What to Do About the Transition to Residency? Exploring Problems and Solutions From Three Perspectives

Inequities at the Transition to Obstetrics and Gynecology Residency

OBJECTIVE

Although approximately one-fifth of obstetrics and gynecology (OBGYN) residents matriculate from osteopathic or international medical schools, most literature regarding the transition to residency focuses on allopathic medical school graduates. To create comprehensive interventions for this educational transition, we must understand the needs of all incoming residents. Our objective was to examine OBGYN residents' perceptions of their transition to residency, and to understand how residents' background and medical school environment influence their perceived sense of readiness.

DESIGN

A 16-item survey asked questions about demographics, the transition to residency, resident well-being, burnout, and the transition to fellowship. Perception of preparedness was assessed with the question "I felt that I was well-prepared for the first year of residency" (1=strongly agree, 5=strongly disagree). Chi-squared and Fisher's exact tests and logistic regression explored association of perceived preparedness with residents' backgrounds.

SETTING

Survey administered at time of the in-training examination in 2022.

PARTICIPANTS

All OBGYN residents.

RESULTS

Of 5761 eligible participants, 3741 (64.9%) provided consent and completed the survey. Of the 3687 participants who answered the question, 2441 (66.2%) either agreed or strongly agreed that they felt well-prepared. Fewer osteopathic graduates reported feeling prepared compared to allopathic graduates (379/610, 62.1% vs 1,924/2,766, 69.6%) (OR 0.72, 95%CI 0.60-0.86, p < 0.01). International medical school graduates were seven times less likely to report feeling prepared compared to those from allopathic institutions (137/304, 45.1% vs 1924/2776, 69.6%) (OR 0.60, 95%CI 0.53-0.68, p < 0.01). Respondents from underrepresented racial and ethnic backgrounds were less likely to report feeling prepared compared to White respondents (276/535, 51.6% vs 1738/2387, 72.8%) (OR 0.39, 95%CI 0.33-0.48, p < 0.01).

CONCLUSIONS

Differences in residents' perceptions of their transition to residency highlight the need to begin offsetting pervasive inequities with comprehensive and accessible resources.

Evaluating the Impact of Coaching Through the Transition to Residency

BACKGROUND

Coaching has been proposed to support the transition to residency. Clarifying its impact will help define its value and best use.

OBJECTIVE

To explore the experiences of residents working with coaches through the residency transition.

DESIGN

A cohort comparison survey compared experiences of a coached resident cohort with coaches to the prior, uncoached cohort.

PARTICIPANTS

Post-graduate year (PGY)-2 residents in internal medicine, obstetrics and gynecology, emergency medicine, and pathology at a single academic center.

INTERVENTIONS

Faculty trained as coaches had semi-structured meetings with graduating medical students and residents throughout the PGY-1 year.

MAIN MEASURES

An online anonymous survey assessed effects of coaching on measures of self-directed learning, professional development, program support and impact of coaching using existing scales (2-item Maslach Burnout Inventory, Brief Resilient Coping Scale, 2-item Connor-Davidson Resilience Scale, Stanford Professional Fulfillment Inventory), and novel measures adapted for this survey. Bivariate analyses (t-tests and chi-square tests) compared cohort responses. MANOVA assessed the effects of coaching, burnout and their interactions on the survey domains.

KEY RESULTS

Of 156 PGY2 residents, 86 (55%) completed the survey. More residents in the "un-coached" cohort reported burnout (69%) than the "coached" cohort (51%). Burnout was significantly and negatively associated (F = 3.97 (df 7, 75); p < .001) with the learning and professional development outcomes, while being coached was significantly and positively associated with those outcomes (F = 5.54 (df 9, 75); p < .001). Significant interaction effects were found for goal-setting attitudes, professional fulfillment, and perceived program career support such that the positive differences in these outcomes between coached and un-coached residents were greater among burned out residents. Coached residents reported a positive impact of coaching across many domains.

CONCLUSIONS

Residents experiencing coaching reported better professional fulfillment and development outcomes, with more pronounced differences in trainees experiencing burnout. Coaching is a promising tool to support a fraught professional transition.

Achieving 'something that everybody has invested in': perspectives of diverse stakeholders during co-creation of a transition to residency curriculum

Co-creation of education within the context of student inclusion alongside diverse stakeholders merits exploration. We studied the perspectives of students and teachers from different institutions who participated in co-creating a transition to residency curriculum. We conducted post-hoc in-depth interviews with 16 participants: final-year medical students, undergraduate, and postgraduate medical education stakeholders who were involved in the co-creation sessions. Findings build on the Framework of Stakeholders' Involvement in Co-creation and identify the four key components of co-creation with diverse faculty: immersion in positive feelings of inclusivity and appreciation, exchange of knowledge, engagement in a state of reflection and analysis, and translation of co-creation dialogues into intended outcomes. Despite power dynamics, participants valued open communication, constructive feedback, mutual respect, and effective moderation. The study broadened our understanding of the co-creation process in diverse stakeholder settings. Incorporating key elements in the presence of power relations can enrich co-creation by leveraging wider expertise.

Graduating Medical Students' Perceptions of the COVID-19 Pandemic's Impact on Their Medical School Experiences and Preparation for Careers as Physicians: A National Study

PURPOSE

The COVID-19 pandemic resulted in unprecedented changes to the medical education learning environment. The graduating class of 2021 was particularly affected. To better understand how students were affected, the authors explored positive and negative experiences described by graduating U.S. medical students.

METHOD

Using the conceptual framework of affordances, the authors examined narrative responses to 2 new open-ended questions on the Association of American Medical Colleges 2021 Graduation Questionnaire in which graduating students described the pandemic's positive and negative effects on their medical school experiences and career preparation. Conventional content analysis was used to identify affordances and themes in responses.

RESULTS

Of 16,611 Graduation Questionnaire respondents, 8,926 (54%) provided narrative responses. Of these 8,926 respondents, responses from 2,408 students (27%) were analyzed. Students described positive and negative perceptions of affordances, centering around virtual learning, social connection, and transition to residency. Fewer in-person and increased virtual clinical rotations offered students flexible scheduling, allowing them greater opportunity to explore academic and professional interests. Additionally, students' sense of isolation from their medical school was alleviated when schools exercised intentional open communication and student involvement in decision making. Although many described a diminished sense of preparedness for residency due to limited access to in-person clinical experiences and to assessing residencies largely through virtual away rotations and interviews, the sense of community, adaptability, and resiliency gained through varied activities reinforced students' professional identity and commitment to medicine during a time of much uncertainty.

CONCLUSIONS

This national exploration of students' pandemic experiences highlights what students value as fundamental elements of medical education and student support and describes how innovation can improve long-standing practices. These findings, guided by students' insights, can help inform the work of educational leaders as they consider which innovations should remain to continue enhancing student learning, engagement, and well-being.

The Inconspicuous Learner Handover: An Exploratory Study of U.S. Emergency Medicine Program Directors' Perceptions of Learner Handovers from Medical School to Residency

Phenomenon: Central to competency-based medical education is the need for a seamless developmental continuum of training and practice. Trainees currently experience significant discontinuity in the transition from undergraduate (UME) to graduate medical education (GME). The learner handover is intended to smooth this transition, but little is known about how well this is working from the GME perspective. In an attempt to gather preliminary evidence, this study explores U.S. program directors (PDs) perspective of the learner handover from UME to GME. Approach: Using exploratory qualitative methodology, we conducted semi-structured interviews with 12 Emergency Medicine PDs within the U.S. from October to November, 2020. We asked participants to describe their current perception of the learner handover from UME to GME. Then we performed thematic analysis using an inductive approach. Findings: We identified two main themes: The inconspicuous learner handover and barrier to creating a successful UME to GME learner handover. PDs described the current state of the learner handover as "nonexistent," yet acknowledged that information is transmitted from UME to GME. Participants also highlighted key challenges preventing a successful learner handover from UME to GME. These included: conflicting expectations, issues of trust and transparency, and a dearth of assessment data to actually hand over. Insights: PDs highlight the inconspicuous nature of learner handovers, suggesting that assessment information is not shared in the way it should be in the transition from UME to GME. Challenges with the learner handover demonstrate a lack of trust, transparency, and explicit communication between UME and GME. Our findings can inform how national organizations establish a unified approach to transmitting growth-oriented assessment data and formalize transparent learner handovers from UME to GME.

Patterns of Medical Residents' Preferences for Organizational Socialization Strategies to Facilitate Their Transitions: A Q-study

Introduction

To facilitate various transitions of medical residents, healthcare team members and departments may employ various organizational socialization strategies, including formal and informal onboarding methods. However, residents' preferences for these organizational socialization strategies to ease their transition can vary. This study identifies patterns (viewpoints) in these preferences.

Methods

Using Q-methodology, we asked a purposeful sample of early-career residents to rank a set of statements into a quasi-normal distributed grid. Statements were based on previous qualitative interviews and organizational socialization theory. Participants responded to the question, 'What are your preferences regarding strategies other health care professionals, departments, or hospitals should use to optimize your next transition?' Participants then explained their sorting choices in a post-sort questionnaire. We identified different viewpoints based on by-person (inverted) factor analysis and Varimax rotation. We interpreted the viewpoints using distinguishing and consensus statements, enriched by residents' comments.

Results

Fifty-one residents ranked 42 statements, among whom 36 residents displayed four distinct viewpoints: Dependent residents (n = 10) favored a task-oriented approach, clear guidance, and formal colleague relationships; Social Capitalizing residents (n = 9) preferred structure in the onboarding period and informal workplace social interactions; Autonomous residents (n = 12) prioritized a loosely structured onboarding period, independence, responsibility, and informal social interactions; and Development-oriented residents (n = 5) desired a balanced onboarding period that allowed independence, exploration, and development.

Discussion

This identification of four viewpoints highlights the inadequacy of one-size-fits-all approaches to resident transition. Healthcare professionals and departments should tailor their socialization strategies to residents' preferences for support, structure, and formal/informal social interaction.

Applicant Experience in Communication With Residency Programs After the Introduction of Program Signaling

OBJECTIVE

Examine the applicant experience after introduction of program signaling for the 2023 obstetrics and gynecology (OBGYN) residency application cycle.

DESIGN

Responses to an online survey of OBGYN applicants participating in the 2023 match who participated in residency program signaling were compared to responses from a similar survey conducted in 2022. Demographic information included personal and academic background and how applicants and advisors communicated with programs. Numbers of applications and interviews, second look visits, away rotations, manner of contact, and timing of communication was compared. Statistical analysis included ANOVA for interval data, and χ2 and Kruskal-Wallis tests for categorical data.

RESULTS

A total of 711 of 2631 (27%) applicants responded in 2022 and 606 of 2492 (24.3%) responded in 2023. Approximately 2/3 of gold signals and 1/3 of silver signals led to an interview. There was no change in number of applications or interviews per applicant, but there was a broader distribution of interviews per applicant in 2023. Applicants in 2023 were less likely to engage in preinterview communication or do an away rotation to indicate interest in a program. There was decreased communication between applicants and programs after signaling was introduced. Informal communication continued to differ by racial and medical school background. Applicants from DO programs and international medical graduates (IMG) had more communication with programs than MD applicants but received fewer interview invitations. Fewer Black and Latin(x)/Hispanic applicants had faculty reach out to residency programs on their behalf compared to White and Asian applicants. There were differences in the number of interviews received based on racial and ethnic identity.

CONCLUSIONS

In the first year after implementation of program signaling, there was a decrease in preinterview communication and a broader distribution of interviews among applicants. Further efforts to create standard means of program communication may help to begin leveling the uneven playing field for applicants.

The medical internship as a meaningful transition: A phenomenographic study

BACKGROUND

The transition from student to doctor is often depicted as a struggle in the literature, and previous research has focused on interventions to minimise difficulties in transitioning from undergraduate to postgraduate training. In considering this transition as a potential transformative experience, we intend to produce new insights into how junior doctors experience the transition to clinical work. The aim of this study was to explore medical interns' conceptualisations of the transition from student to doctor through studying the Swedish medical internship, which serves as a bridge between undergraduate and postgraduate studies. The research question was formulated as follows: How do medical interns perceive the meaning of the medical internship?

METHODS

The data were collected through in-depth interviews with 12 senior medical interns in western Sweden. The transcribed interviews were analysed using a phenomenographic approach, which resulted in four qualitatively varying ways of perceiving the meaning of the internship, organised hierarchically in a phenomenographic outcome space.

RESULTS

The interns perceived the meaning of the internship as an opportunity to work and learn in an authentic setting (internship as in-service training) and in a protected environment (internship as a space). The internship guaranteed a minimum level of competence (internship as a quality marker) and allowed the interns to gain new insights into themselves and their world (internship as an eye-opener).

DISCUSSION

Being allowed to be learners in a protected space seemed pivotal for the interns to develop into competent, confident and independent practitioners. The medical internship studied here could be viewed as a meaningful transition into new ways of experiencing, allowing for an increased understanding of oneself and the world. This study adds to the scientific literature on what constitutes a transformative transition.

A Qualitative Study on How Entrustable Professional Activities Support Medical Students in Their Transitions across Clerkships

Introduction

Medical students regularly transition between clerkships. These transitions can lead to discontinuity in their development because of the need to adapt to a new environment. The use of entrustable professional activities (EPAs) might facilitate less disruptive transitions across clerkships, as they could provide support at the start of a clerkship. This study aims to shed light on how an EPA-based curriculum contributes to medical students' learning processes during transitions.

Methods

The authors used a constructivist rapid ethnographic design. They conducted observations and interviews with 11 medical students in their Pediatrics clerkship; six of them were in clerkships not utilizing EPAs, and five were using EPAs. Data collection was followed by template analysis such that all data were coded with a template that was continually updated until the authors all agreed upon a definitive template.

Results

Four themes proved important when considering the impact of EPAs during transitions between clerkships: transitions as a learning opportunity, building relationships in context, taking leadership in the landscape of practice and feedback-seeking behavior.

Discussion

EPAs smooth clerkship transitions, as they establish continuity in the student's development and facilitate navigating discontinuity in transitions. Students build skills and confidence in order to grow and work with increasing independence within the clerkships. Transitions offer important learning opportunities for students, which can be fully exploited by using EPA guidance.

The American College of Surgeons Entering Resident Readiness Assessment (ACS ERRA): Validity Evidence From a Three-Year National Study

OBJECTIVE

To gather validity evidence supporting the use and interpretation of scores from the American College of Surgeons Entering Resident Readiness Assessment (ACS ERRA) Program.

SUMMARY AND BACKGROUND DATA

ACS ERRA is an online formative assessment program developed to assess entering surgery residents' ability to make critical clinical decisions, and includes 12 clinical areas and 20 topics identified by a national panel of surgeon educators and residency program directors.

METHODS

Data from 3 national testing administrations of ACS ERRA (2018-2020) were used to gather validity evidence regarding content, response process, internal structure (reliability), relations to other variables, and consequences.

RESULTS

Over the 3 administrations, 1975 surgery residents participated from 125 distinct residency programs. Overall scores [Mean = 64% (SD = 7%)] remained consistent across the 3 years ( P = 0.670). There were no significant differences among resident characteristics (gender, age, international medical graduate status). The mean case discrimination index was 0.54 [SD = 0.15]. Kappa inter-rater reliability for scoring was 0.87; the overall test score reliability (G-coefficient) was 0.86 (Ф-coefficient = 0.83). Residents who completed residency readiness programs had higher ACS ERRA scores (66% versus 63%, Cohen's d = 0.23, P < 0.001). On average, 15% of decisions made (21/140 per test) involved potentially harmful actions. Variability in scores from graduating medical schools (7%) carried over twice as much weight than from matched residency programs (3%).

CONCLUSIONS

ACS ERRA scores provide valuable information to entering surgery residents and surgery program directors to aid in development of individual and group learning plans.

Goal co-construction and dialogue in an internal medicine longitudinal coaching programme

BACKGROUND

Longitudinal coaching in residency programmes is becoming commonplace and requires iterative and collaborative discussions between coach and resident, with the shared development of goals. However, little is known about how goal development unfolds within coaching conversations over time and the effects these conversations have. We therefore built on current coaching theory by analysing goal development dialogues within resident and faculty coaching relationships.

METHODS

This was a qualitative study using interpretive description methodology. Eight internal medicine coach-resident dyads consented to audiotaping coaching meetings over a 1-year period. Transcripts from meetings and individual exit interviews were analysed thematically using goal co-construction as a sensitising concept.

RESULTS

Two themes were developed: (i) The content of goals discussed in coaching meetings focused on how to be a resident, with little discussion around challenges in direct patient care, and (ii) co-construction mainly occurred in how to meet goals, rather than in prioritising goals or co-constructing new goals.

CONCLUSIONS

In analysing goal development in the coach-resident relationships, conversations focused mainly around how to manage as a resident rather than how to improve direct patient care. This may be because academic coaching provides space separate from clinical work to focus on the stage-specific professional identity development of a resident. Going forward, focus should be on how to optimise longitudinal coaching conversations to ensure co-regulation and reflection on both clinical competencies and professional identity formation.

How Medical Students Apply Their Biomedical Science Knowledge to Patient Care in the Family Medicine Clerkship

Medical students enter clerkships with the requisite biomedical science knowledge to engage in supervised patient care. While poised to apply this knowledge, students face the cognitive challenge of transfer: applying knowledge learned in one context (i.e., preclinical classroom) to solve problems in a different context (i.e., patients in the clinic). To help students navigate this challenge, a structured reflection exercise was developed using Kolb's experiential learning cycle as an organizing framework. Students selected a patient encounter (concrete experience), wrote and addressed biomedical science learning objectives related to the care of the patient (reflective observation), reflected on how addressing the learning objectives influenced patient care (abstract conceptualization), and described their attending engaging in a similar process (active experimentation). A directed content analysis of students' written reflections revealed that most students wrote clinical science learning objectives in addition to biomedical science learning objectives. When viewed through the lenses of knowledge encapsulation theory and illness script theory, some students recognized knowledge encapsulation as a process beginning to occur in their own approach and their attendings' approach to clinical reasoning. Students readily applied their biomedical science knowledge to explain the pathophysiologic basis of disease (fault illness script domain) and signs and symptoms (consequence illness script domain), with fewer addressing predisposing conditions (enabling conditions illness script domain). Instances in which students observed their attending applying biomedical science knowledge were rare. Implications for using structured reflective writing as a tool to facilitate student application of their biomedical science knowledge in clerkships are discussed.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40670-022-01697-5.

Longitudinal exploration of students' identity formation during the transition from pre-clinical to clinical training using research poetry

BACKGROUND

Transitions are critical periods that can lead to growth and, or, distress. Transitions are a sociocultural process, yet most approaches to transitions in practice and research do not explore the social or developmental aspects of entering a new training phase. Wenger reminds us that identity development is crucial when newcomers navigate change. In this paper, we use Wenger's modes of identification: engagement, imagination and alignment to explore students' identity development (as a student and professional) during the transition from pre-clinical to clinical training.

METHODS

We enrolled nine 2nd-year medical students who generated 61 entries comprising audio diary (or typed) reflections over 9 months (starting 3 months before clinical clerkships began) and interviewed them twice. We used research poems (transcripts reframed as poetry) to help construct a meaningful, emotive elicitation of our longitudinal data and analysed data using sensitising concepts from Wenger's modes of identification.

RESULTS

Students described their transition as a journey filled with positive and negative emotions and uncertainty about their current and future careers. Students navigated the transition using three mechanisms: (1) becoming more engaged through taking charge, (2) shaping their image of self through engagement and finding role models and (3) learning to flexibly adapt to clerkship norms by managing expectations and adopting a journey mindset.

CONCLUSIONS

We successfully narrated students' identity formation during their transition to clinical training. We learned that students became more engaged over time by learning to take charge. They shaped their image of self by engaging in team activities and reflecting on role models. They learnt to adapt flexibly to clerkship norms by managing expectations and adopting a journey mindset. We suggest that institutions provide a safe opportunity for medical students to reflect, allowing students' transition periods to be lived, reflected on and supported.

Facilitating an Optimal Transition to Residency in Obstetrics and Gynecology

The transition to residency in obstetrics and gynecology is difficult, threatening the well-being of residents as well as their preparedness to care for patients. In addition to essential foundational knowledge and skills, obstetrics and gynecology interns must develop professional identity and a growth mindset toward learning to acquire the self-directed learning skills required of physicians throughout their careers. The transition to residency is a critical opportunity for learning and development. A group of educators and learners from around the country created a preparedness program building on available resources. The result is a national curriculum for improving the transition to obstetrics and gynecology residency on three levels: self-directed learning, facilitated small-group workshops, and coaching. Sharing tools for preparing matched applicants for residency in obstetrics and gynecology ensures adequate residency preparation for all interns, independent of medical school attended. This program aims to address potential threats to equity in the training of our future workforce and to ensure that all obstetrics and gynecology interns are prepared to thrive in residency training.

Becoming a doctor-The potential of a change laboratory intervention

In a previous ethnographic field study, we found that newly graduated doctors (NGDs) found their first months of practice challenging and overwhelming. By including an organisational perspective (Cultural Historical Activity Theory), we were able to identify contextual factors within the hospital organisation, which influence the NGDs' challenges. This raised the question: What can be done about it? To address this, we designed a Change Laboratory intervention (CL), consisting of six sessions, involving NGDs, junior doctors, and consultants across eight departments (on average, 18 doctors participated in each session). Through the CL, the participants were able to get a mutual understanding across departments and develop two initiatives to support the NGDs: An NGD introduction day with a 'need-to-know' focus, where the NGDs meet their future collaborators, and are introduced to important work procedures, and are given the opportunity to establish a peer network. This is followed up by a monthly NGD forum with a 'nice-to-know' focus, where new topics are introduced, allowing time for reflections, and supporting the further strengthening of a peer community. The CL approach promoted agency among participants and the results show how CL offers a unique opportunity for stakeholders to challenge and rethink their work practices within the hospital organisation.

In pursuit of a better transition to selected residencies: a quasi-experimental evaluation of a final year of medical school dedicated to the acute care domain

BACKGROUND

Medical schools seek the best curricular designs for the transition to postgraduate education, such as the Dutch elective-based final, 'transitional' year. Most Dutch graduates work a mean of three years as a physician-not-in-training (PNIT) before entering residency training. To ease the transition to selected specialties and to decrease the duration of the PNIT period, UMC Utrecht introduced an optional, thematic variant of the usual transitional year, that enables the development of theme-specific competencies, in addition to physicians' general competencies.

METHODS

We introduced an optional transitional year for interested students around the theme of acute care, called the Acute Care Transitional Year (ACTY). This study aimed to evaluate the ACTY by judging whether graduates meet postgraduate acute care expectations, indicating enhanced learning and preparation for practice. In a comprehensive assessment of acute care knowledge, clinical reasoning, skills, and performance in simulations, we collected data from ACTY students, non-ACTY students interested in acute care, and PNITs with approximately six months of acute care experience.

RESULTS

ACTY graduates outperformed non-ACTY graduates on skills and simulations, and had higher odds of coming up to the expectations faculty have of a PNIT, as determined by global ratings. PNITs did better on simulations than ACTY graduates.

DISCUSSION

ACTY graduates show better resemblance to PNITs than non-ACTY graduates, suggesting better preparation for postgraduate acute care challenges.

CONCLUSION

Transitional years, offering multidisciplinary perspectives on a certain theme, can enhance learning and preparedness for entering residency.

Competency-Based Frameworks in Medical School Education Programs: A Thematic Analysis of the Academic Medicine Snapshots, 2020

PURPOSE

Educational program objectives (EPOs) provide the foundation for a medical school's curriculum. In recent years, the Liaison Committee on Medical Education (LCME) endorsed an outcomes-based approach to objectives, to embrace the movement toward competency-based medical education (CBME). The purpose of this study was to explore the CBME frameworks used by medical schools in formulating their EPOs. A secondary aim was to determine factors related to the selection of specific frameworks.

METHOD

The authors performed a quantitative content analysis of entries to the 2020 Academic Medicine Snapshot. Publicly available data gathered included demographic features of each program (e.g., year founded, accreditation status, affiliation, etc.), participation in national medical education consortia, and presence of specific CBME frameworks identified in EPOs. Descriptive statistics were used to examine trends in frameworks used by medical schools. Bivariate comparisons between factors and frameworks were conducted using chi-square tests. Logistic regression was used to examine factors predicting use of more recently developed CBME frameworks.

RESULTS

A total of 135 institutions submitted Snapshots (RR = 88%). All institutions endorsed 1 or more CBME frameworks, with 37% endorsing 2 and 20% endorsing 3 or more. The most common was the Accreditation Council for Graduate Medical Education core competencies (63%). In addition to published frameworks, 36% of institutions developed their own competencies. Schools with pending LCME visits were 2.61 times more likely to use a more recently developed curricular framework, P = .022.

CONCLUSIONS

Medical schools in the United States have embraced the CBME movement through incorporation of competency-based frameworks in their EPOs. While it is encouraging that CBME frameworks have been integrated in medical school EPOs, the variability and use of multiple frameworks identifies the pressing need for a unified CBME framework in undergraduate medical education.

Understanding Health Care Graduates' Conceptualizations of Transitions: A Longitudinal Qualitative Research Study

PURPOSE

Although transitions have been defined in various ways in the higher education literature (e.g., inculcation, development, becoming), little research exists exploring health care learners' conceptualizations of transitions across their transition from final year to new graduate. How they understand transitions is important because such conceptualizations will shape how they navigate their transitions and vice versa.

METHOD

The authors conducted a 3-month longitudinal qualitative research study with 35 health care learners from 4 disciplines (medicine, dietetics, nursing, and pharmacy) across their final year to new graduate transition to explore how they conceptualized transitions. Data collection occurred between July 2019 and April 2020 at Monash University in Victoria, Australia. The authors employed framework analysis to interrogate the interview and longitudinal audio diary data cross-sectionally and longitudinally.

RESULTS

The authors found 10 different conceptualizations of transitions broadly categorized as time bound and linear (one-off events, systems, linear, adaptation, linked to identities), ongoing and complex (ongoing processes, multifaceted, complex), or related to transition shock (labor, linked to emotions). The adaptation conceptualization increased in dominance over time, the linear conceptualization was more apparent in the interviews (time points 1 and 3), and the multifaceted and emotion-linked conceptualizations were more dominant in the longitudinal audio diaries (time point 2).

CONCLUSIONS

This novel study illustrates conceptualizations of transitions as broadly consistent with existing higher education literature but extends this research considerably by identifying differences in conceptualizations across time. The authors encourage health care learners, educators, and policy makers to develop expanded and more sophisticated understandings of transitions to ensure that health care learners can better navigate often challenging graduate transitions. Further research should explore stakeholders' transition conceptualizations over lengthier durations beyond the new graduate transition.

Hopes and fears: A qualitative analysis of the intern perspective at the start of EM residency

OBJECTIVES

Most emergency medicine (EM) residency programs have orientation curricula to guide interns through the transition from medical school to residency, although no standard components are required. This transition is recognized as a challenging time for young physician learners; however, there is no current understanding of the perspective of incoming interns as they enter residency. We sought to identify themes, examine the current literature, and reflect on the experiences of our residency leadership to inform the creation of orientation activities that foster positive experiences, as well as directly address intern fears and anxieties.

METHODS

This qualitative study collected free text responses on the first day of EM orientation regarding areas of high excitement and high fear as interns entered residency. Data were collected from 2011 to 2019 in a 4-year EM residency program and a 6-year combined EM-Anesthesia residency program in the Mid-Atlantic. An inductive approach was used to code intern responses and develop themes within each category, and a frequency analysis was performed.

RESULTS

A total of 112 interns participated. Thematic analysis of coded responses yielded 11 themes around "most excited" and 13 themes around "most scared." The most frequent themes for "most excited" were: (1) Forming new relationships, (2) Building and applying knowledge, and (3) Being responsible for the care and education of others. For "most scared," the most frequent themes were: (1) work-life balance and burnout, (2) making harmful mistakes, and (3) knowledge wealth and retention.

CONCLUSIONS

We identified themes of high excitement and high fear for interns entering residency orientation. Based on the themes developed and current literature, recommendations for residency programs regarding intern orientation are provided, specifically that programs intentionally address opportunities for professional identity formation, building relationships with new people/places, emphasizing wellness, and mitigating burnout.

Approaching Training-Practice Gaps After the Transition: A Practice Proposal for Supervision After Training

Transitions within medical, veterinarian, and other health professional training, from classroom to workplace, between undergraduate, postgraduate, fellowship phases, and to unsupervised clinical practice, are often stressful. Endeavors to alleviate inadequate connections between phases have typically focused on preparation of learners for a next phase. Yet, while some of these efforts show results, they cannot obliviate transitional gaps. If reformulated as ‘not completely ready to assume the expected responsibilities in the next phase’, transitions may reflect intrinsic problems in a training trajectory. Indeed, the nature of classroom teaching and even skills training for example, will never fully reflect the true context of clinical training. In various stages of clinical training, the supervision provided to trainees, particularly medical residents, has increased over the past decades. This addresses calls for enhanced patient safety, but may inadequately prepare trainees for unsupervised practice. Transitions often evolve around the question how much support or supervision incoming trainees or junior professionals require. We propose to consider receiving incoming trainees and new employees in clinical workplaces with a conversation about required supervision for discrete tasks, or entrustable professional activities (EPAs). EPAs lend themselves for the question: “At what level of supervision will you be able to carry out this task?”. This question can be answered by both the trainee or junior employee and the supervisor or employer and can lead to agreement about specified supervision for a defined period of time. We expect that this “supported autonomy tool” could alleviate stress and enhance continued development after transitions.

Junior doctors' experiences of the medical internship: a qualitative study

OBJECTIVES

This study aimed to explore medical interns' experiences of medical internships.

METHODS

Situated in an interpretivist paradigm, a qualitative study was carried out to explore medical interns' experiences of the internship. Invitations to participate were sent via email to medical interns currently in their last six months of internship. The first ones to respond were included. The study sample comprised twelve participants, of whom seven were women. Data were collected through individual, semi-structured and in-depth interviews with volunteering medical interns from three different hospital sites. Data were transcribed verbatim and analysed through qualitative content analysis, generating overarching themes.

RESULTS

Four main themes were identified in our data. The interns felt increasingly comfortable as doctors ('finding one's feet') by taking responsibility for patients while receiving necessary help and assistance ('a doctor with support'). Although appreciative of getting an overview of the healthcare organisation ('healthcare sightseeing'), interns were exhausted by repeatedly changing workplaces and felt stuck in a rigid framework ('stuck at the zoo').

CONCLUSIONS

In contrast to previous studies, this study shows that the transition from medical school to clinical work as a professional does not necessarily have to be characterised by stress and mental exhaustion but can, with extensive support, provide a fruitful opportunity for medical interns to grow into their roles as doctors. However, there is still unutilised potential for the medical internship to act as a powerful catalyser for learning, which educators and programme directors need to consider.

Facilitated transitions: coaching to improve the medical school to residency continuum

Background: Current efforts incompletely address the educational, social, and developmental aspects of a learner's transition from medical school to residency.Objective: To determine the feasibility and acceptability of a transition to residency (TTR) coaching program.Designs: In March 2019, we designed, implemented, and evaluated a TTR coaching program for students who matched into residency programs at our institution. Goals were to stimulate reflection on successes and challenges encountered during medical school, develop strategies to problem-solve barriers and address concerns, identify professional and personal resources, improve confidence, and make an action plan.Results: Of eligible learners, 42% (10/24) enrolled in TTR coaching. Learners were most interested in coaching in the following areas: wellbeing (70%, 7/10), interpersonal/communication skills (60%, 6/10), and learning plan development (50%, 5/10). The majority (90%; 9/10) expressed satisfaction with the program and would recommend participation. One month after starting internship, 90% (9/10) of learners stated the program helped facilitate their transition. Learners who did not enroll in TTR cited concerns around the coach selection process (72%, 8/11), upcoming travel (45%, 5/11), insufficient time/competing demands (27%, 3/11), and lack of perceived benefit (18%, 2/11).Conclusion: This pilot study demonstrated preliminary feasibility and acceptability for TTR coaching.

Perspectives of Clinical Teaching Fellows on preparedness for practice: a mixed-methods exploration of what needs to change

Supporting medical students in their transition to newly qualified doctor is an important educational priority. Clinical Teaching Fellows (CTFs), as both recent graduates and trained educators, are uniquely positioned to suggest curricular enhancements to support preparedness for practice. Our mixed-methods approach involved CTFs across eight UK teaching hospitals. We conducted five activity-oriented focus groups to explore what CTFs felt needed to change to increase preparedness for practice. We analysed these focus groups to create a dataset of their suggestions followed by a survey. The survey invited CTFs to rate and rank these suggestions in relation to their own self-rated preparedness for practice, with qualitative insights into their choices. We explored commonalities and differences between high and low confidence participants, with findings qualitatively illuminated. 24 CTFs attended focus groups from which we identified 28 curriculum items and 10 curriculum agendas. We collected 23 complete survey responses. All confidence groups rated communicating with colleagues and managing working life as unmet needs, whereas core clinical competencies such as history and examination were well met. Participants with low confidence identified more complex clinical competencies including clinical decision making, task prioritisation and end-of-life care as unmet needs, with decision making and prioritisation being the most important. Confident graduates rated higher professional competencies such as quality improvement, career planning and education as unmet needs but of low importance. Graded transition of responsibility was the highest ranked curriculum agenda. Qualitative insights included suggestions for how learning in clinical environments could be enhanced. Our findings suggest that transitioning from student to newly qualified doctor could be supported by graded entrustment and enhanced shadowing opportunities. Other recommendations include prioritising more complex clinical competencies, identifying wellbeing as part of preparedness for practice, equipping students to communicate with colleagues and aligning higher professional competencies with learners' needs.

Transitioning from university to postgraduate medical training: A narrative review of work readiness of medical graduates

CONTEXT

Work readiness is often described in terms of the clinical competence medical graduates bring to day 1 of internship. Despite being increasingly viewed as a key graduate outcome, work readiness has remained poorly defined.

OBJECTIVE

This narrative review draws on the international literature to explore how different research methods provide differing insight into what constitutes work readiness of medical graduates. From this, we explored contributory factors and developed a conceptual framework to better understand work readiness.

METHODS

Databases were searched using the terms including "ready," "readiness," "preparedness," "medical graduates," "intern," and "junior doctor." Information was summarized using a textual description template that included information on study setting, participants, methodologies, limitations, and key result areas (including measures/themes and study conclusions). Consensus discussions between authors led to the naming and understanding of the key themes.

RESULTS

Seventy studies were included in the review. Study participants included final-year medical students (n = 20), junior doctors early in internship (n = 24), and junior doctors late in internship or postgraduate year 2 and above (n = 23). Most studies explored work readiness through the retrospective self-report of the students and/or junior doctor participants. Quantitative research methods elaborated on key skills-based competencies, whereas qualitative research methods provided insight into key contextual and individual characteristics that contributed to preparedness.

CONCLUSIONS

Different research methods provided insight into competencies, as well as individual and contextual aspects, associated with preparedness for practice. The transition from university to clinical practice is significant and requires personal capability and confidence, as well as a supportive training context. Enabling students to engage authentically in clinical environments enhanced preparedness by promoting understanding of role and responsibility. Individual resilience is important, but contextual factors, including provision of adequate support and feedback, can enhance or subtract from feeling prepared. We propose a novel conceptual framework for better understanding work readiness.

Virtual Resident Mentorship Groups for Fourth Year Medical Students Applying into Otolaryngology-Head and Neck Surgery

OBJECTIVE

To create a longitudinal near-peer mentorship program for medical students applying to otolaryngology.

METHODS

A program for longitudinal near-peer mentorship was designed based on a needs analysis of senior medical students. Program objectives were to (1) provide didactic education on common otolaryngology consults, (2) facilitate resident-student networking, and (3) enable applicants to meet other students. Senior otolaryngology residents were matched with medical students from across the United States applying to otolaryngology for a series of online small group meetings. Sessions included resident-designed didactics covering high-yield clinical scenarios and a mentorship component focused on transition to residency topics. Program evaluation included anonymized pre- and post-tests for each didactic session and an anonymous post-program participant survey.

RESULTS

There were 40 student participants from across the United States, with an average attendance of 73% of sessions per participant. Performance on didactic testing improved for 2 of the 3 sessions. Participants stated they would be very likely to recommend each session to another student in the future (4.96/5.00, obs = 155). Participants stated the most valuable part of the program was interacting with residents (82% of responses), transition to residency advice (28%), and learning about otolaryngology consults (28%). Suggestions for improvement included expanding content, increasing the number of sessions, and involving additional faculty and residents.

CONCLUSION

A longitudinal virtual experience can be valuable for near-peer mentorship for medical students applying to otolaryngology.

Medical Students' Views on Implementing the Core EPAs: Recommendations From Student Leaders at the Core EPAs Pilot Institutions

In 2014, the Association of American Medical Colleges recruited 10 institutions across the United States to pilot the 13 Core Entrustable Professional Activities for Entering Residency (Core EPAs). The goal was to establish a competency-based framework to prepare graduating medical students for the transition to residency. Within the Core EPAs pilot, medical students play an influential role in the development and implementation of EPA-related curricula. Student engagement was a priority for the Core EPAs institutions given students' roles as the end users of the curriculum, thus they may offer valuable insight into its design and implementation. Here, the authors provide the perspective of medical students who serve as leaders in the Core EPAs pilot at their respective institutions. They describe student leadership models across the pilot institutions as well as 6 key challenges to implementation of the Core EPAs: (1) How and when should the Core EPAs be introduced? (2) Who is responsible for driving the assessment process? (3) What feedback mechanisms are required? (4) What systems are required for advising, mentoring, or coaching students? (5) Should EPA performance contribute to students' grades? and (6) Should entrustment decisions be tied to graduation requirements? Using a polarity management framework to address each challenge, the authors describe inherent tensions, approaches used by the Core EPAs pilot institutions, and student-centered recommendations for resolving each tension. By sharing the experiences and perspectives of students engaged in the Core EPAs pilot, the authors hope to inform implementation of EPA-oriented assessment practices and feedback across institutions in the United States.

The Transition From Medical Student to Resident: A Qualitative Study of New Residents' Perspectives

PURPOSE

To understand the learner's perspective on the transition from medical school to residency and to develop a conceptual model for how learners experience the transition from student to resident.

METHOD

This prospective qualitative study explored the experience of first-year residents using semistructured, one-on-one telephone interviews. Ten first-year residents who participated in the Transition to Residency elective as fourth-year students at the New York University Grossman School of Medicine in April 2018 participated from December 2018 to April 2019. Using a 3-phase coding process and grounded theory methodology, the authors identified categories, which they organized into broader themes across interview transcripts and used to develop a conceptual model.

RESULTS

From the perspective of new residents, developing professional identity is the core construct of the transition experience. The residents focused on individual aspects of the experience-professional identity, self-awareness, professional growth, approach to learning, and personal balance-and external aspects-context of learning, professional relationships, and challenges in the context of their new role. Across these 8 categories, 5 broader themes emerged to describe an abrupt change in educational environment, an immersive experience of learning as a resident, ambivalence and tensions around the new role, navigation of professional relationships, and balance and integration of working in medicine with personal lives and goals. A conceptual model illustrates this phenomenon as a cell where professional identity and growth (the nucleus) is surrounded by interactions with patients and other members of the medical team (in the cytoplasm) that create a substrate for learning and development.

CONCLUSIONS

This study suggests that being immersed in the residency experience is how medical students transition to resident physicians. Educational interventions that allow learners to acclimate to the experience of being a doctor through gradual exposure to authentic interactions have the potential to bridge the abrupt transition.

An international study of trainee-trained transitions: Introducing the transition-to-trained-doctor (T3D) model

Background: Throughout their careers, doctors and other healthcare professionals experience numerous transitions. When supporting transitions, opportunities for development and learning should be maximized, while stressors having negative impacts on well-being should be minimized. Building on our international data, this study aimed to develop a conceptual model of the trainee-trained transition (i.e. the significant transitions experienced by doctors as they complete postgraduate training moving from trainee/resident status to medical specialist roles).Methods: Employing Multiple and Multidimensional Transitions (MMT) theory and current conceptualizations of clinical context, this study undertook secondary analysis of 55 interviews with doctors from three countries (Netherlands, Cananda and the UK) undergoing trainee-trained transitions.Results: Through this analysis, the Transition-To-Trained-Doctor (T3D) conceptual model has been developed. This model takes into consideration the multiple contexts and multiple domains in which transitions take place.Discussion: This model is significant in that it has several uses and is applicable across countries: to remind doctors, managers and medical educators of the complexity of transitions; to frame and facilitate supportive conversations; and as a basis to teach about transitions.

Social Identification with the Medical Profession in the Transition from Student to Practitioner

Phenomenon: This study explores professional identity formation during a final year of medical school designed to ease the transition from student to practitioner. Although still part of the undergraduate curriculum, this "transitional year" gives trainees more clinical responsibilities than in earlier rotations. Trainees are no longer regarded as regular clerks but work in a unique position as "semi-physicians," performing similar tasks as a junior resident during extended rotations. Approach: We analyzed transcripts from interviews with 21 transitional-year medical trainees at University Medical Center Utrecht about workplace experiences that affect the development of professional identity. We used Social Identity Approach as a lens for analysis. This is a theoretical approach from social psychology that explores how group memberships constitute an important component of individual self-concepts in a process called 'social identification.' The transcripts were analyzed using thematic analysis, with a focus on how three dimensions of social identification with the professional group emerge in the context of a transitional year: cognitive centrality (the prominence of the group for self-definition), in-group affect (positivity of feelings associated with group membership) and in-group ties (perception of fit and ties with group members). Findings: Students were very aware of being a practitioner versus a student in the position of semi-physician and performing tasks successfully (i.e., cognitive centrality). Students experienced more continuity in patient care in transitional-year rotations than in previous clerkships and felt increased clinical responsibility. As a semi-physician they felt they could make a significant contribution to patient care. Students experienced a sense of pride and purpose when being more central to their patients' care (i.e., in-group affect). Finally, in extended rotations, the trainees became integrated into daily social routines with colleagues, and they had close contact with their supervisors who could confirm their fit with the group, giving them a sense of belonging (i.e., in-group ties). Insights: Using the three-dimension model of social identification revealed how students come to identify with the social group of practitioners in the context of a transitional year with extended rotations, increased clinical responsibilities, and being in the position of a "semi-physician." These findings shed light on the identity transition from student to practitioner within such a curricular structure.

A Responsible Educational Handover: Improving Communication to Improve Learning

An important tenet of competency-based medical education is that the educational continuum should be seamless. The transition from undergraduate medical education (UME) to graduate medical education (GME) is far from seamless, however. Current practices around this transition drive students to focus on appearing to be competitively prepared for residency. A communication at the completion of UME-an educational handover-would encourage students to focus on actually preparing for the care of patients. In April 2018, the American Medical Association's Accelerating Change in Medical Education consortium meeting included a debate and discussion on providing learner performance measures as part of a responsible educational handover from UME to GME. In this Perspective, the authors describe the resulting 5 recommendations for developing such a handover: (1) The purpose of the educational handover should be to provide medical school performance data to guide continued improvement in learner ability and performance, (2) the process used to create an educational handover should be philosophically and practically aligned with the learner's continuous quality improvement, (3) the educational handover should be learner driven with a focus on individualized learning plans that are coproduced by the learner and a coach or advisor, (4) the transfer of information within an educational handover should be done in a standardized format, and (5) together, medical schools and residency programs must invest in adequate infrastructure to support learner improvement. These recommendations are shared to encourage implementation of the educational handover and to generate a potential research agenda that can inform policy and best practices.

Moving Toward Summative Competency Assessment to Individualize the Postclerkship Phase

In the move toward competency-based medical education, leaders have called for standardization of learning outcomes and individualization of the learning process. Significant progress has been made in establishing defined expectations for the knowledge, skills, attitudes, and behaviors required for successful transition to residency training, but individualization of educational processes to assist learners in reaching these competencies has been predominantly conceptual to date. The traditional time-based structure of medical education has posed a challenge to individualization within the curriculum and has led to more attention on innovations that facilitate transition from medical school to residency. However, a shift of focus to the clerkship-to-postclerkship transition point in the undergraduate curriculum provides an opportunity to determine how longitudinal competency-based assessments can be used to facilitate intentional and individualized structuring of the long-debated fourth year.This Perspective demonstrates how 2 institutions-the University of Virginia School of Medicine and the University of Michigan Medical School-are using competency assessments and applying standardized outcomes in decisions about individualization of the postclerkship learning process. One institution assesses Core Entrustable Professional Activities for Entering Residency, whereas the other has incorporated Accreditation Council for Graduate Medical Education core competencies and student career interests to determine degrees of flexibility in the postclerkship phase. Individualization in addition to continued assessment of performance presents an opportunity for intentional use of curriculum time to develop each student to be competently prepared for the transition to residency.

A One-Year Institutional View of Resident Physician Burnout

OBJECTIVES

This prospective study explores the prevalence, associated characteristics, and trajectory of burnout over one academic year in a multidisciplinary sample of resident physicians using a relatively new burnout survey instrument.

METHODS

All residents from a U.S. academic health center (n = 633) were invited to complete the Copenhagen Burnout Inventory (CBI) three times, with 4-month time lags between invitations. A total of 281 (44%) provided complete CBI survey responses at least once, and 43 (7%) did at all three times. Descriptive statistics, cross-sectional analyses, correlations, and multivariable linear regression analyses were computed, as well as repeated measures ANOVAs and paired t tests, as appropriate, for each CBI domain (personal, work, patient-related burnout).

RESULTS

About half had CBI scores indicating moderate-to-high levels of personal burnout (49-52%) and work-related burnout (45-49%), whereas patient-related burnout was less common (14-24%). However, patient-related burnout increased significantly from the beginning to the end of the year. Regression analyses indicated patient-related burnout was significantly higher for postgraduate year 1-2 residents compared to PGY 4+ residents, but was not significantly different by gender. Personal and work burnout scores were significantly higher for females. Persistently high burnout was observed in only 6% of respondents.

CONCLUSIONS

In this study of resident physicians using the CBI, burnout was prevalent and higher levels of burnout were observed for females on the personal and work burnout domains, while junior residents had higher patient-related burnout. Persistently, high burnout was rare. The CBI demonstrated high reliability, was practical to administer, and produced similar results with existing burnout research.

Exploring group boundaries and conflicts: a social identity theory perspective

CONTEXT

In the clinical environment, health care professionals self-categorise into different groups towards which they develop positive attitudes, whereas they view other groups less favourably. Social identity theory purports that these attitudes influence group processes and may foster conflicts that impede collaborative practice, although this relationship is poorly understood. This study used concepts from social identity theory to examine the interplay between group processes and conflicts, as well as the consequences of these conflicts, with the goal of identifying educational strategies to favour teamwork.

METHODS

Semi-structured interviews with 82 randomly selected physicians and nursing professionals working at a Swiss academic medical centre explored participants' experiences of conflicts. Data analysis was informed by social identity theory and focused on interviews where group processes were highlighted by participants. The analysis sought to uncover how group processes were intertwined with conflicts and how they affected health care professionals.

RESULTS

A total of 42 participants out of the initial pool of 82 interviews shared 52 stories of conflicts involving group processes. Most of these stories were shared by physicians and involved groups of physicians at different hierarchical levels. Conflicts and group processes were linked in two ways: (i) through processes of group membership when individuals struggled to join a relevant group, and (ii) through intergroup boundaries, such as when participants perceived that power differentials disadvantaged their own groups. Conflicts could lead to difficult experiences for clinicians who questioned their abilities, became disillusioned with their professional ideals and developed negative perceptions of other groups.

CONCLUSIONS

This study suggests that conflicts involving group processes may lead to stronger intergroup boundaries, challenging current educational efforts to favour teamwork in health care. Taking steps to create more inclusive groups and to encourage perspective taking may help manage intergroup conflict.

Why do trainees leave hospital-based specialty training? A nationwide survey study investigating factors involved in attrition and subsequent career choices in the Netherlands

OBJECTIVE

To gain insight into factors involved in attrition from hospital-based medical specialty training and future career plans of trainees who prematurely left their specialty training programme.

DESIGN

Nationwide online survey study.

SETTING

Postgraduate education of all hospital-based specialties in the Netherlands.

PARTICIPANTS

174 trainees who prematurely left hospital-based medical specialty training between January 2014 and September 2017.

MAIN OUTCOME MEASURES

Factors involved in trainees' decisions to leave specialty training and their subsequent career plans.

RESULTS

The response rate was 38%. Of the responders, 25% left their programme in the first training year, 50% in year 2-3 and 25% in year 4-6. The most frequently reported factors involved in attrition were: work-life balance, job content, workload and specialty culture. Of the leaving trainees, 66% switched to another specialty training programme, of whom two-thirds chose a non-hospital-based training programme. Twelve per cent continued their career in a non-clinical role and the remainder had no specific plans yet.

CONCLUSIONS

This study provides insight in factors involved in attrition and in future career paths. Based on our findings, possible interventions to reduce attrition are: (1) enable candidates to develop a realistic view on job characteristics and demands, prior to application; (2) provide individual guidance during specialty training, with emphasis on work-life balance and fit with specialty.

Beyond the struggles: a scoping review on the transition to undergraduate clinical training

CONTEXT

The transition to clinical training within medical school is often seen as a struggle and students remain in distress despite numerous efforts to minimise threats. Efforts to change this may be misdirected if they are based on narrow conceptualisations of transitions. The authors conducted a scoping review to explore existing conceptual perspectives regarding the transition within medical school from pre-clinical training to clinical training to suggest a research agenda and practical implications.

METHODS

Between October 2017 and February 2018 the authors searched PubMed, MEDLINE, ERIC, PsycINFO, Web of Science and CINAHL for English language literature with no date limits and retrieved 1582 articles; 46 were included in this review. Two reviewers independently screened articles and extracted data. Data were then charted, analysed and discussed with the research team.

RESULTS

The transition to clinical training was often described negatively as 'difficult', 'a problem' and 'a struggle'. Our analysis found that researchers in medical education conducted studies on the transition to clinical training from three conceptual perspectives: educational; social, and developmental. Most research approached the transition to clinical training as a problem to be addressed from an educational perspective through transition to clerkship courses and curriculum innovations. Some research was conducted from a social perspective, focusing on building relationships. Regarding development, authors found a few articles highlighting opportunities for personal and professional development by nurturing transferrable learning strategies and reflection.

CONCLUSIONS

This review provides an empirical base on which future research can be built to better understand and support medical students' ability to navigate change. Finding new perspectives to approach the transition to clinical training could allow researchers to look beyond preparing students for struggles.

Assessing Entrustable Professional Activities Using an Orientation OSCE: Identifying the Gaps

BACKGROUND

A residency program's intern cohort is comprised of individuals from different medical schools that place varying levels of emphasis on Core Entrustable Professional Activities for Entering Residency (CEPAERs). Program directors have expressed concerns about the preparedness of medical school graduates. Though guiding principles for implementation of the CEPAERs have been published, studies using this framework to assess interns' baseline skills during orientation are limited.

OBJECTIVE

A CEPAER-based objective structured clinical examination (OSCE) was implemented with the aims to (1) assess each intern's baseline clinical skills and provide formative feedback; (2) determine an intern's readiness for resident responsibilities; (3) inform individualized education plans; and (4) address identified gaps through curricular change.

METHODS

During orientation, all 33 interns from internal medicine (categorical, preliminary, and medicine-psychiatry) participated in the OSCE. Six 20-minute stations evaluated 8 EPAs. Faculty completed a global assessment, and standardized patients completed a communications checklist and global assessment. All interns completed a self-assessment of baseline skills and a post-OSCE survey.

RESULTS

Stations assessing handoffs, informed consent, and subjective, objective, assessment, and plan (SOAP) note were the lowest-performing stations. Interns performed lower in skills for which they did not report previous training. Formal instruction was incorporated into didactic sessions for the lowest-performing stations. The majority of interns indicated that the assessment was useful, and immediate feedback was beneficial.

CONCLUSIONS

This OSCE during orientation offers just-in-time baseline information regarding interns' critical skills and may lead to individualized feedback as well as continuous curricular improvement.

Working in the dead of night: exploring the transition to after-hours duty

CONTEXT

Transitions, although often difficult, represent integral components of medical training. New postgraduate trainees (first-year residents) find themselves in an especially challenging transition as they are expected to fulfil both learning and service expectations concurrently. Workplace learning theory has been suggested as a lens through which to understand this unique educational, yet service-oriented, role. This tension may be further amplified overnight when residents are on-call with little to no support.

OBJECTIVES

The aims of this study were to explore the transition from medical student to resident with respect to the on-call experience, and to provide theory-based suggestions to enhance learning during this unique transition.

METHODS

We conducted an interpretivist qualitative study by interviewing eight medical students and 10 first-year residents from six different specialty training programmes across four academic sites. Each semi-structured interview was transcribed verbatim and anonymised. Resident interview transcripts were initially coded for major themes, after which medical student interview transcripts were coded for consistencies and discrepancies.

RESULTS

Four interrelated themes were identified in students' and residents' descriptions of on-call experiences: (i) shift in responsibility; (ii) supervisory support; (iii) contextual conditions, and (iv) clarity of expectations. Generally, students were not able to anticipate the challenges they would face as residents on-call, and residents perceived the transition as sudden with little emphasis placed on learning.

CONCLUSIONS

First-year residents face multiple challenges during on-call, which may prevent optimal learning in this setting. These challenges are amplified by the large gap between the respective roles of medical students and residents. We identified promoters of and barriers to effective learning in this environment and, by using workplace learning theory, provide recommendations for how we might be able to enhance medical students' preparation for and first-year residents' learning during experiences of being on-call.