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

Outcomes of Residency Education: Insights Into the Professional Formation of the Physical Therapist Resident

INTRODUCTION

The definition of excellence in physical therapy (PT) education is evolving, yet the role of postprofessional residency education remains uncertain. Arguments in favor of required residency have emerged through the re-visioning of PT education across the continuum. Yet, little evidence exists whether residency education further develops clinical skills, clinical knowledge, and clinical reasoning abilities.

REVIEW OF LITERATURE

Previous studies have explored the development of the novice physical therapist in the first 2 years of practice; however, there is little evidence about the outcomes of PT residency education. Thus, this study looked to explore the development of learners through their residency education and to identify the critical elements of the teaching and learning environment in residency education.

SUBJECTS

Eleven PT residency programs and 13 residents participated in a qualitative study to explore the learner development through residency. Each residency program consisted of a residency program director, one or more mentors identified by the residency program director, and at least one physical therapist resident. Semistructured interviews were conducted with program participants, and journal entries were collected from residents.

METHODS

Using a purposeful sample of convenience, an exploratory, multiple-site/specialty area qualitative case study design was conducted.

RESULTS

Three emerging themes were identified including growth of self, becoming a member of the community of practice, and facilitation of learning through mentoring. Through the transformative journey of residency education, there are critical elements of the learning environment supporting deep learning within the community of practice. These elements include the provision of opportunities and adequate time and space for learning to occur.

DISCUSSION AND CONCLUSION

The intentional design of the community of practice through residency education facilitates the development of the novice clinician to experienced clinician in an accelerated period of time. In addition, residency graduates develop characteristics similar to adaptive learners through planned teaching and learning opportunities. Finally, the structure of residency education mattered to the resident participants such that the learning environment enhanced peer learning and the development of professional relationships.

Beyond the Recruitment Pipeline: A Call to Action for Centering the Success of Under-represented Minority Trainees in Obstetrics and Gynecology

Just like all aspects of the American experience, racism has had a significant presence in Obstetrics and Gynecology (OBGYN). Black physicians in OBGYN face unique challenges in training programs, having to learn a specialty while combating racial macroaggression and microaggressions constantly and, often, in isolation. We present the stories of black OBGYNs who have sustained such an experience while also offering equitable and actionable solutions to improve clinical training environments.

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.

Consensus-Derived Recommended Skills for Transition to Residency Courses

PURPOSE

Transition to residency (TTR) courses facilitate the medical student-residency transition and are an integral part of senior medical student training. The authors established a common set of skills for TTR courses, and an expected level of entrustment students should demonstrate in each skill on TTR course completion.

METHOD

A modified Delphi approach was used with 3 survey iterations between 2020 and 2022 to establish skills to be included in a TTR course. Nine TTR experts suggested general candidate skills and conducted a literature search to ensure no vital skills were missed. A stakeholder panel was solicited from email lists of TTR educators, residency program directors, and residents at the panelists' institutions. Consensus was defined as more than 75% of participants selecting a positive inclusion response. An entrustment questionnaire asked panelists to assign a level of expected entrustment to each skill, with 1 indicating observation only and 6 indicating perform independently.

RESULTS

The stakeholder panel initially consisted of 118 respondents with representation across educational contexts and clinical specialties. Response rates were 54% in iteration 2, 42% in iteration 3, and 33% on the entrustment questionnaire. After 3 iterations, 54 skills met consensus and were consolidated into 37 final skills categorized into 18 clinical skills (e.g., assessment and management of inpatient concerns), 14 communication skills (e.g., delivering serious news or having difficult conversations), 4 personal and professional skills (e.g., prioritization of clinical tasks), and 1 procedural skill (mask ventilation). Median entrustment levels were reported for all skills, with 19 skills having a level of expected entrustment of 4 (perform independently and have all findings double-checked).

CONCLUSIONS

These consensus skills can serve as the foundation of a standardized national TTR curriculum framework. Entrustment guidance may help educational leaders optimize training and allocation of resources for TTR curriculum development and implementation.

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.

Why are medical students so motivated to learn ultrasound skills? A qualitative study

BACKGROUND

The introduction of ultrasound (US) courses into medical undergraduate courses is usually met with a particularly high level of student motivation. The reasons for this are unclear. The aim of this study was to investigate the factors that contribute to undergraduate medical students' motivation to learn US skills. Understanding what motivates students to learn US will inform the efforts of faculty to foster students' motivation to learn.

METHODS

We carried out in-depth semi-structured one-to-one interviews with medical students participating in an optional US course at two Swiss universities. The interview guide consisted of 10 main questions. The content was informed by experts in the field of medical education and US, as well as by a literature review of motivation theories for learning, in particular by self-determination theory (SDT). SDT was used to guide the development of the interview guide and to reflect on the resulting themes in the discussion section. The interview guide was piloted with two medical students. The interviews lasted an average of 45 min and were audio recorded and transcribed. Thematic analysis was used to analyse the data.

RESULTS

Fourteen undergraduate medical students in their preclinical (year 3) and clinical studies (years 4 and 5) elaborated on a wide range of reasons for their high motivation to learn US. They were motivated for US training because of the positive nimbus of the US modality, emphasising the advantages of visualisation. Students acknowledged the potential professional benefits of learning US and described it as a fun, exciting group activity.

CONCLUSIONS

The four themes we found in our analysis can all be related to the three universal needs described in SDT. The strong focus on the visual aspect and the positive nimbus of the modality goes beyond that and reflects the visuo-centric Zeitgeist, which claims the superiority of visual information over other data. Educators should be aware that motivation to learn is affected by the Zeitgeist and ensuing preconceptions, such as the perception of the positive nimbus surrounding a topic. Other key elements that can be implemented to motivate students are just-in-time feedback, enabling group experiences and creating awareness of the clinical relevance of learning content.

Interns' Perceived Level of Proficiency After General Surgery Rotation: A Cross-Sectional Study From Saudi Arabia

BACKGROUND

The role of interns during general surgical rotation is crucial in shaping their future careers as surgeons. Surgical rotation offers a unique opportunity to gain valuable hands-on experience in fast-paced and challenging environments. However, interns often face significant challenges in obtaining the necessary practical training to develop proficiency in surgical techniques. This article aims to analyze some aspects of the accumulated competency of interns during their general surgery rotation, focusing on the range of skills and knowledge gained, in addition to the challenges faced.

SUBJECTS AND METHODS

We conducted a cross-sectional study using an anonymous web-based self-assessment questionnaire. The target population of the study included all Jazan University medical interns enrolled in the academic year 2022-2023.

RESULTS

Most participants showed low-to-average levels of proficiency in monitoring clinical evolution and treatment plans, ranging from fundamental awareness (n = 17, 17.5%) to working knowledge (n = 51, 52.6%), with only three participants (3.1%) reporting an expert level of proficiency. The same pattern was observed in the documentation of patient records (range: 7.2%, n = 7 for fundamental awareness to 42.3%, n = 41 for working knowledge). However, a significant proportion saw themselves as either proficient (n = 23, 23.7%) or experts (n = 15, 15.5%) in this aspect. Regarding bedside procedures, such as venipuncture, proctoscopy, nasogastric tube insertion, and urethral catheterization, the participants showed different proficiency levels, with the lowest in proctoscopy, where 66 (68.0%) of the participants reported only fundamental awareness. The results also revealed low perceived proficiency in performing surgical skin incisions, wound suturing, knot tying, application of surgical skin clips, and abscess drainage, with the lowest proficiency observed in the excision of superficial lumps as more than half of the participants reported only fundamental awareness (n = 51, 52.6%).

CONCLUSION

The results of this study indicate that documentation and monitoring of patient progress are the competencies mastered most by the majority of interns during their rotations in general surgery. However, the interns' overall level of proficiency in bedside procedures and basic surgical skills acquired during their rotation was low to average. Additionally, interns were dissatisfied with their training and the opportunities provided for them to actively engage in performing procedures in the operating room. This low proficiency is unrelated to pre-internship academic achievement, sex, or interest in future surgical careers. This suggests that efforts are needed to develop strategies to enhance interns' satisfaction and engagement, ultimately improving their overall experience during internships.

Finding the right combination for self-directed learning: A focus group study of residents' choice and use of digital resources to support their learning

BACKGROUND

There has been a shift in postgraduate medical education towards digital educational resources-podcasts, videos, social media and other formats consumed asynchronously and apart from formal curricula. It is unclear what drives residents to select and use these resources. Understanding how and why residents choose digital resources can aid programme directors, faculty and residents in optimising residents' informal learning time.

METHOD

This focus group study was conducted with residents at two US internal medicine residency programmes. The authors used the framework approach to content analysis using self-determination theory as guide for deductive coding and iteratively assessing connections among codes and identifying themes. Trustworthiness was addressed through use of analytic memos, reflexive practice and member checking.

RESULTS

The authors conducted eight virtual focus groups (n = 23) from 5/27/20 to 6/11/20. Residents described that a feeling of 'should know' drove initial choices towards self-directed learning outside of work. Regular use of a resource was influenced by how the resource fit into a resident's lifestyle, the personal cognitive energy and the perceived 'activation energy' of using a particular resource. Familiarity, increased confidence and in-person social networks gained from digital resources served to reinforce and further guide resource choice.

CONCLUSIONS

The selection of digital resources for self-directed learning is driven by multiple factors, suggesting an interdependent relationship between the learning environment and a residents' cognitive capacity. Understanding these interconnections can help residents and clinical educators explicitly choose resources that fit their lifestyle and learning needs.

Transition to Residency Courses: Recommendations for Creation and Implementation

Transition to Residency (TTR) courses help ease the critical transition from medical school to residency, yet there is little guidance for developing and running these courses. In this perspective, the authors use their expertise as well as a review of the literature to provide guidance and review possible solutions to challenges unique to these courses. TTR courses should be specialty-specific, allow for flexibility, and utilize active learning techniques. A needs assessment can help guide course content, which should focus on what is necessary to be ready for day one of residency. The use of residents in course planning and delivery can help create a sense of community and ensure that content is practical. While course assessments are largely formative, instructors should anticipate the need for remediation, especially for skills likely to be performed with limited supervision during residency. Additionally, TTR courses should incorporate learner self-assessment and goal setting; this may be valuable information to share with learners' future residency programs. Lastly, TTR courses should undergo continuous quality improvement based on course evaluations and surveys. These recommendations are essential for effective TTR course implementation and improvement.

Perceived Preparedness of Internal Medicine Interns for Residency and the Value of Transition to Residency Courses

The popularity of Transition to Residency (TTR) courses has been increasing in U.S. medical schools. Yet there is limited data on interns' perceived preparation for residency and the value of nonsurgical TTR courses and their common components. Research has shown that TTR courses increase medical knowledge, clinical skills, and an increase in confidence in participants, but still, incoming residents do not feel prepared for the start of residency. Currently, there are only a few single institution studies researching interns' perceived value of TTR courses. This quantitative study surveyed internal medicine interns at five residency programs to find their preparation for residency, their preparedness in TTR competencies, and the perceived value of common TTR components. Data show that IM interns still feel unprepared for residency. The data also indicate that individuals who engage in TTR courses feel more prepared in TTR competencies compared to those who do not participate in TTR courses. Finally, internal medicine interns found the common TTR components valuable.

Ready Day One: What Residents and Program Directors Think is Needed for a Successful Transition to Residency

OBJECTIVE

To evaluate perceived gaps in preparedness, current on-boarding practices, and need for specialty wide resources in the transition to residency training in obstetrics and gynecology (OB/GYN) DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional survey of current U.S. OB/GYN residents and program directors (PDs) at the time of the resident in-training exam was conducted in 2022. Both groups provide demographic information and identified specific knowledge, skills, and abilities in need of more preparation at the start of residency. PDs were queried on perceptions of readiness for their current first year class, educational on-boarding practices, and their preference for standardized curricular materials and assessment tools. Chi-squared and Kruskal-Wallis tests were used to compare perceptions of skills deficits between PDs and residents, and the relationship of preparedness to program type and resident year in training.

RESULTS

Response rates for residents and program directors were 64.9% and 72.6% respectively. A majority (115/200, 57.5%) of program directors agreed or strongly agreed with the statement, "In general, I feel that my new interns are well prepared for residency when they arrive at my program." Both groups agreed that basic suturing and ultrasound skills were deficits. Residents identified a need for better preparation in management of inpatient issues while PDs identified time management skills as lacking. There was considerable heterogeneity of program on-boarding practices across the specialty. Most PDs agreed or strongly agreed that a standardized curriculum (80.5%, 161/200) and assessment tools (75.3%, 150/199) would be helpful.

CONCLUSION

OBGYN PDs feel that not all residents arrive prepared for residency and overwhelmingly support the development of standardized transition curricular and assessment tools, similar to the curriculum developed in general surgery. Based on input from PDs and residents, early curricular efforts should focus on basic surgical, ultrasound, and time management skills and on management of inpatient issues.

A Qualitative Analysis of Experiences of Medical Students Serving as Abortion Doulas

INTRODUCTION

Innovative strategies are needed in clinical education to teach empathetic behavior and communication skills. This study aimed to investigate preclinical medical students' experiences volunteering as abortion doulas and to understand the impact of their participation on their professional training.

METHODS

In this qualitative study, the authors conducted semistructured interviews with medical students who had volunteered as abortion doulas in March to July 2016. The interviews described motivations for participating, experiences volunteering as a doula, approach to caring for patients, and acquisition of communication skills and knowledge of abortion. The authors analyzed interview transcripts using a conventional content analysis approach, and themes were identified.

RESULTS

The authors performed 22 interviews. For most participants, this was their first exposure to an abortion procedure or patient care in any capacity. Participants identified acquisition of skills including patient advocacy, communication, and empathy that they were later able to apply throughout their clinical clerkships. This opportunity improved well-being and solidified their decision to apply for residencies in reproductive health fields.

DISCUSSION

After volunteering as abortion doulas, medical students were able to develop communication skills, empathy, and patient advocacy applicable to other areas of patient care. Preclinical students, potentially in other health care professions training, participating in patient care as doulas have the potential to further personal development, professionalism, and activism.

Reluctant heroes: New doctors negotiating their identities dialogically on social media

BACKGROUND

Ensuring that students transition smoothly into the identity of a doctor is a perpetual challenge for medical curricula. Developing professional identity, according to cultural-historical activity theory, requires negotiation of dialectic tensions between individual agency and the structuring influence of institutions. We posed the research question: How do medical interns, other clinicians and institutions dialogically construct their interacting identities?

METHODS

Our qualitative methodology was rooted in dialogism, Bakhtin's cultural-historical theory that accounts for how language mediates learning and identity. Reasoning that the COVID pandemic would accentuate and expose pre-existing tensions, we monitored feeds into the Twitter microblogging platform during medical students' accelerated entry to practice; identified relevant posts from graduating students, other clinicians and institutional representatives; and kept an audit trail of chains of dialogue. Sullivan's dialogic methodology and Gee's heuristics guided a reflexive, linguistic analysis.

RESULTS

There was a gradient of power and affect. Institutional representatives used metaphors of heroism to celebrate 'their graduates', implicitly according a heroic identity to themselves as well. Interns, meanwhile, identified themselves as incapable, vulnerable and fearful because the institutions from which they had graduated had not taught them to practise. Senior doctors' posts were ambivalent: Some identified with institutions, maintaining hierarchical distance between themselves and interns; others, along with residents, acknowledged interns' distress, expressing empathy, support and encouragement, which constructed an identity of collegial solidarity.

CONCLUSIONS

The dialogue exposed hierarchical distance between institutions and the graduates they educated, which constructed mutually contradictory identities. Powerful institutions strengthened their identities by projecting positive affects onto interns who, by contrast, had fragile identities and sometimes strongly negative affects. We speculate that this polarisation may be contributing to the poor morale of doctors in training and propose that, to maintain the vitality of medical education, institutions should seek to reconcile their projected identities with the lived identities of graduates.

The Neonatal-Perinatal Medicine fellowship application webinar series: a novel approach to helping applicants succeed

BACKGROUND

In 2022, 13,586 candidates applied to subspecialty fellowships. Formal resources to inform candidates on subspecialty-specific fellowship application are limited. Candidates rely on residency application experience, informal advice, and online research for navigating the application process. Thus, a need exists for formal subspecialty-specific fellowship application guidance. The American Academy of Pediatrics Organization of Neonatal-Perinatal Medicine Training Program Directors (ONTPD) and Trainees and Early Career Neonatologists (TECaN) created a webinar-based curriculum to help educate trainees about the application process and recruit diverse fellowship applicants.

METHODS

In 2022, ONTPD and TECaN co-hosted and implemented a four-part national webinar series focused on different aspects of the Neonatal-Perinatal Medicine (NPM) fellowship application and interview processes. Webinars were advertised through list-servs and social media, conducted in two time zones, and recorded for asynchronous viewing. Registration, demographic data, and questions for webinar panelists were collected via electronic survey. Program evaluation data was collected after each webinar and following the fellowship match.

RESULTS

In the 2022 appointment year, 310 candidates participated in the NPM fellowship match and 250 individuals registered for the webinar series. A quarter (26%) of registrants identified as underrepresented in medicine. Most registrants reported minimal or no knowledge of the fellowship application (64%, 158/248) and interview (81%, 201/248) processes. The majority of registrants (70%, 173/248) were planning on applying to fellowship in 2022, and 91% of post-webinar respondents (43/47) felt the webinars were moderately or extremely helpful, a finding that was sustained beyond the match (37/42). Almost all respondents rated the quality of the webinars as good or higher and were likely or very likely to recommend them to peers (39/42). There was considerable variability amongst respondents in the number of fellowship programs applied to, interviewed at, and ranked, and factors influencing rank list.

CONCLUSION

We describe a virtual curriculum to prepare trainees for the NPM fellowship application and interview process. This webinar series provides needed education to fellowship candidates, bridges the gap between candidate knowledge and program director expectations, is generalizable to other specialties, and can be replicated with minimal resources.

Minimum standard assessment of informed consent for internal medicine transition to residency program: A cohort study

Background and Aims

Interns must be proficient in obtaining informed consent (IC), which is the Association of American Medical College's 11th of 13 Entrustable Professional Activities (EPAs). Medical students have limited opportunity to practice IC during clerkships, resulting in inconsistent proficiency. We aimed to create a tool to assess whether our transition to residency (TTR) workshop enables fourth-year medical students to meet a minimum standard of obtaining IC.

Methods

Sixty fourth-year medical students were enrolled in the internal medicine virtual TTR course during AY2021. The curriculum prioritizes deliberate practice activities. Pre- and postworkshop assignments involved students typing verbatim what they would say during IC encounters. We modified an IC abstraction tool created by Spatz et al. to assess a minimum standard for students' IC assignments. Our final 7-item tool consisted of the following domains: "What," "Why," "How," "Benefits," "Quantitative Risks," "Qualitative Risks," and "Alternatives," weighing 1 point each. A minimum standard was obtained with a score of 6 or more points by appropriately discussing at least one domain involving risk and all other domains.

Results

Students scored highly on the prework domains pertaining to "What," "Why," and "How" of the procedure with no significant difference on postwork. Significant improvement was achieved on postwork domains covering "Benefits" (p = 0.039) and "Alternatives" (p = 0.031). For domains involving "Qualitative" and "Quantitative Risks," there were no statistically significant improvements from pre- to postwork scores. Fifteen and 22 students met the minimum standard for IC on pre- and postwork, respectively.

Conclusion

Our students demonstrated a good a priori understanding of the "What," "Why," and "How" domains. After the workshop, they more reliably discussed "Benefits" and "Alternatives." Our abstraction tool helped assess the strengths and weaknesses in our students' IC skillset and helped recognize areas of our curriculum that will benefit from improvements to bring students to meet the minimum standard.

How is transition to medical practice shaped by a novel transitional role? A mixed-methods study

OBJECTIVES

This study considered a novel 'interim' transitional role for new doctors (termed 'FiY1', interim Foundation Year 1), bridging medical school and Foundation Programme (FP). Research questions considered effects on doctors' well-being and perceived preparedness, and influences on their experience of transition. While FiY1 was introduced in response to the COVID-19 pandemic, findings have wider and ongoing relevance.

DESIGN

A sequential mixed-methods study involved two questionnaire phases, followed by semi-structured interviews. In phase 1, questionnaires were distributed to doctors in FiY1 posts, and in phase 2, to all new FP doctors, including those who had not undertaken FiY1.

SETTING AND PARTICIPANTS

Participants were newly qualified doctors from UK medical schools, working in UK hospitals in 2020. 77% (n=668) of all participants across all phases had undertaken FiY1 before starting FP in August. The remainder started FP in August with varying experience beforehand.

OUTCOME MEASURES

Questionnaires measured preparedness for practice, stress, anxiety, depression, burnout, identity, and tolerance of ambiguity. Interviews explored participants' experiences in more depth.

RESULTS

Analysis of questionnaires (phase 1 n=441 FiY1s, phase 2 n=477 FiY1s, 196 non-FiY1s) indicated that FiY1s felt more prepared than non-FiY1 colleagues for starting FP in August (β=2.71, 95% CI=2.21 to 3.22, p<0.0001), which persisted to October (β=1.85, CI=1.28 to 2.41, p<0.0001). Likelihood of feeling prepared increased with FiY1 duration (OR=1.02, CI=1.00 to 1.03, p=0.0097). Despite challenges to well-being during FiY1, no later detriment was apparent. Thematic analysis of interview data (n=22) identified different ways, structural and interpersonal, in which the FiY1 role enhanced doctors' emerging independence supported by systems and colleagues, providing 'supported autonomy'.

CONCLUSIONS

An explicitly transitional role can benefit doctors as they move from medical school to independent practice. We suggest that the features of supported autonomy are those of institutionalised liminality-a structured role 'betwixt and between' education and practice-and this lens may provide a guide to optimising the design of such posts.

Experience-based learning during the final year - quantitative content analyses of students' self-reports

PURPOSE

The final year offers students the opportunity to explore their future role as a physician in different environments. Learning success depends in large part on how students experience these assignments. The aim of this study is to analyze students' self-reported experiences to derive factors that promote experience-based learning in the transition phase during the final year of medical school in order to optimally prepare students for professional practice.

METHOD

Data were collected from 2013 to 2019 via written survey after each assignment in the final year. Students were asked to report their pleasant and unpleasant experiences in free-text fields. The text material was analyzed using quantitative content analysis.

RESULTS

The authors included 1762 questionnaires for analysis. They formed 12 main categories from the text material, equally covering pleasant and unpleasant experiences. Supervisors and teamwork played a central role in both questions, responsibility and working areas frequently led to positive experiences, and working conditions to negative ones.

CONCLUSION

This study confirms the great importance of supervision. Above all, successful collaboration serves as a door opener into a feeling of security which students need to take on responsibility. The authors adapted Dornan's model of experience-based learning to the transition phase to help medical schools establish tailored conditions for students' successful entry into professional practice.

SMARTer Goalsetting: A Pilot Innovation for Coaches During the Transition to Residency

PROBLEM

Ability to set goals and work with coaches can support individualized, self-directed learning. Understanding the focus and quality of graduating medical student and first-year resident goals and the influence of coaching on goal-setting can inform efforts to support learners through the transition from medical school to residency.

APPROACH

This observational study examined goal-setting among graduating medical students and first-year residents from April 2021 to March 2022. The medical students set goals while participating in a Transition to Residency elective. The residents in internal medicine, obstetrics and gynecology, emergency medicine, orthopedics, and pathology set goals through meeting 1:1 with coaches. Raters assessed goals using a 3-point rubric on domains of specific, measurable, attainable, relevant, and timely (i.e., SMART goal framework) and analyzed descriptive statistics, Mann-Whitney U tests, and linear regressions.

OUTCOMES

Among 48 medical students, 30 (62.5%) set 108 goals for early residency. Among 134 residents, 62 (46.3%) entered goals. Residents met with coaches 2.8 times on average (range 0-8 meetings, median = 3). Goal quality was higher in residents than medical students (average score for S: 2.71 vs 2.06, P < .001; M: 2.38 vs 1.66, P < .001; A: 2.92 vs 2.64, P < .001; R: 2.94 vs 2.86, P = .002; T: 1.71 vs 1.31, P < .001). The number of coaching meetings was associated with more specific, measurable goals (specific: F [1, 1.02] = 6.56, P = .01, R2 = .10; measurable: F [1, 1.49] = 4.74, P = .03, R2 = .07).

NEXT STEPS

Learners set realistic, attainable goals through the transition to residency, but the goals could be more specific, measurable, and timely. The residents set SMARTer goals, with coaching improving goal quality. Understanding how best to scaffold coaching and support goal-setting through this transition may improve trainees' self-directed learning and well-being.

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.

Endured and prevailed: a phenomenological study of doctors' first year of clinical practice

CONTEXT

The challenging nature of the transition from medical student to doctor is highlighted by the associated negative consequences to new doctors' mental health and wellbeing. Enhanced understanding of the lived experience of recent medical graduates as they move through the stages of transition over the first year of practice can inform interventions to ease the difficulties encountered.

METHODS

Using interpretative phenomenological analysis (IPA), a novel approach to this topic, we explored the lived experience of transition from student to doctor over the first year of practice after graduation. Twelve new graduates were purposively recruited. We conducted semi-structured interviews at the end of their first year of practice with respect to their experience over the first year.

RESULTS

The experience of transition was characterised by overlapping temporal stages. Participants' initial adjustment period was characterised by shock, coping and stabilisation. A phase of development followed, with growth in confidence and a focus on self-care. Adversity was experienced in the form of interprofessional tensions, overwork, isolation and mistreatment. Finally, a period of reflection and rationalisation marked the end of the first year.

DISCUSSION

Following initial anxiety regarding competence and performance, participants' experience of transition was predominantly influenced by cultural, relational and contextual aspects of clinical practice. Solutions to ease this challenging time include stage-specific transitional interventions, curricular change at both undergraduate and postgraduate levels and a re-evaluation of the clinical learning environment to mitigate the difficulties endured.

Sailing the boat together: Co-creation of a model for learning during transition

PURPOSE

Medical students' transition to postgraduate training, given the complexity of new roles and responsibilities, requires the engagement of all involved stakeholders. This study aims to co-create a transition curriculum and determine the value of involving the key stakeholders throughout such transition in its design process.

METHODS

We conducted a mixed-methods study involving faculty/leaders (undergraduate/postgraduate), final-year medical students, and chief residents. It commenced with eight co-creation sessions (CCS), qualitative results of which were used to draft a quantitative survey sent to non-participants, followed by two consensus-building CCS with the original participants. We applied thematic analysis for transcripts of all CCS, and mean scores with standard deviations for survey analysis.

RESULTS

We identified five themes: adaptation, authenticity, autonomy, connectedness, and continuity, embedded in the foundation of a supportive environment, to constitute a Model of Learning during Transition (MOLT). Inclusion of various stakeholders and optimizing their representation brought rich perspectives to the design process. This was reinforced through active students' participation enabling a final consensus.

CONCLUSIONS

Bringing perspectives of key stakeholders in the transition spectrum enriches transition curricula. The proposed MOLT can provide a guide for curriculum designers to optimize the final year of undergraduate medical training in preparing students for postgraduate training with essential competencies to be trained.

From doing to leading: PGY-1 to PGY-2 transition

BACKGROUND

Clinical trainees experience several professional transitions throughout their career, which can be exciting, anxiety-provoking or both. The first to second post-graduate year (PGY) transition for residents (junior doctors) in North America involves assuming new roles such as team leader, clinical supervisor, and teacher, often with minimal preparation. We explored resident experiences and emotions during this transition, and obtained their strategies for navigating this transition, through the lens of Bridges' transition model. This model has three stages: (1) ending, losing and letting go, (2) the neutral zone and (3) the new beginning.

METHODS

We conducted one in-person focus group and subsequent one-on-one virtual semistructured interviews (due to COVID-19) of PGY-2 and PGY-3 residents who had previously undergone the transition. These sessions were recorded and transcribed, and thematic analysis was performed.

FINDINGS

Four residents participated in the focus group, and 14 participated in one-on-one interviews. We identified five key themes: (1) not just a cog in the wheel, (2) contributing to growth of near-peers, (3) being flexible and adaptive, (4) emulating resident role models and (5) relationships with attendings. Residents suggested a transitions-focused retreat, simulation training to lead clinical emergencies, supervised opportunities for PGY-1s to act as PGY-2s coached by senior residents, and pairing PGY-1s with senior residents to help prepare for the transition.

CONCLUSION

Professional transitions are both anxiety-provoking and exciting. Clinical trainees need preparation to successfully navigate multiple transitions. The Bridges' transition model could be useful in conceptualising transitions and planning curricula.

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.

Improving the Medical School to Residency Transition: Narrative Experiences From First-Year Residents

OBJECTIVES

We sought to identify first-year obstetrics and gynecology residents' perceptions of both support needed at the medical school to residency transition and readiness to address structural racism and bias at the start of residency training.

STUDY DESIGN

Residents were recruited by email and social media for 1:1 interviews from March to June 2021. All interviews were completed by a first-year resident or fourth-year medical student using an interview guide created by the authorship team. Recorded interviews were anonymously transcribed and independently reviewed for themes by two authors.

SETTING

Virtual interviews on the Zoom platform.

PARTICIPANTS

First-year obstetrics and gynecology residents.

RESULTS

Interviews were performed with 26 residents, and six themes for support emerged from their narratives: 1) Establishing a residency program community; 2) Relocation resources; 3) Residency preparation content in medical school and residency; 4) Preparedness to address racism and bias; 5) Connecting with peers with similar lived experiences across institutions; and 6) More proactive intentional touchpoints from program leadership early in residency.

CONCLUSIONS

Resident narratives described multiple crucial opportunities to improve learners' transition to residency. These findings can help define a roadmap of resources and support that residency programs can provide for learners from Match Day through the first few months of residency.

The Best Laid Plans? A Qualitative Investigation of How Resident Physicians Plan Their Learning

PURPOSE

Adaptive expertise (AE) has been identified as a critical trait to cultivate in future physicians. The 4-phase master adaptive learner (MAL) conceptual model describes the learning skills and behaviors necessary to develop AE. Though prior work has elucidated skills and behaviors used by MALs in the initial planning phase of learning, most resident learners are not thought to be MALs. In this study, the authors investigated how these majority "typical" learners develop AE by exploring the strategies they used in the planning phase of learning.

METHOD

Participants were resident physicians at graduate medical education (GME) training programs located at 4 academic medical centers in the United States. Participants participated in semistructured individual interviews in 2021, and interview transcripts were analyzed using constant comparative analysis of grounded theory.

RESULTS

Fourteen subjects representing 8 specialties were interviewed, generating 152 pages of transcripts for analysis. Three themes were identified: "Typical" learners were challenged by the transition from structured undergraduate medical education learning to less-structured GME learning, lacked necessary skills to easily navigate this transition, and relied on trial and error to develop their learning skills.

CONCLUSIONS

Participants used trial and error to find learning strategies to help them manage the systemic challenges encountered when transitioning from medical school to residency. The success (or failure) of these efforts was tied to learners' efficacy with the self-regulated learning concepts of agency, metacognitive goal setting, and motivation. A conceptual model is provided to describe the impact of these factors on residents' ability to be adaptive learners, and actionable recommendations are provided to help educators' efforts to foster adaptive learning skills and behaviors. These findings also provided valuable evidence of validity of the MAL model that has thus far been lacking.

Collaborators as a key to survival: an ethnographic study on newly graduated doctors' collaboration with colleagues

BACKGROUND

Newly graduated doctors find their first months of practice challenging and overwhelming. As the newly graduated doctors need help to survive this period, collaborators such as peers, senior doctors, registered nurses and other junior doctors are crucial. However, little is known about what characterise these collaborations, and how much is at stake when newly graduated doctors are striving to establish and maintain them. This study aims to describe and explore the collaborations in depth from the newly graduated doctors' point of view.

METHODS

We conducted 135 h of participant observations among newly graduated doctors (n = 11), where the doctors were observed throughout their working hours at various times of the day and the week. Furthermore, six semi-structured interviews (four group interviews and two individual) were carried out. The data was analysed thematically.

RESULTS

Newly graduated doctors consulted different collaborators (peers, senior doctors, registered nurses, and other junior doctors) dependent on the challenge at hand, and they used different strategies to get help and secure good relationships with their collaborators: 1) displaying competence; 2) appearing humble; and 3) playing the game. Their use of different strategies shows how they are committed to engage in these collaborations, and how much is at stake.

CONCLUSIONS

Newly graduated doctors rely on building relationships with different collaborators in order to survive their first months of practice. We argue that the collaboration with peer NGDs and registered nurses has not received the attention it deserves when working with the transition from medical school. We highlight how it is important to focus on these and other collaborators and discuss different work-agendas, mutual expectations, and interdependence. This could be addressed in the introduction period and be one way to ensure a better learning environment and a respectful interprofessional culture.

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.

Anesthesiology Residency and Relationship Health: A Psychological Approach

This article explores an often-untouched subject in anesthesiology residency: relationships. The authors examine the importance of fostering all types of relationships (eg, personal, professional, self) and the impact of the training process on relationships and total well-being. Common issues in relationships during anesthesiology residency are shared through real-life anecdotes from physicians who are currently in or have completed their residencies. Psychological principles including optimism bias, cognitive dissonance, social comparison, and self-efficacy are explored as contributing to dysfunction in relationships. Strategies are offered for each psychological domain as a resource for faculty and program leadership to improve the residency experience in anesthesiology.

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.

Junior doctors' experiences with interprofessional collaboration: Wandering the landscape

CONTEXT

The transition from medical student to junior doctor is challenging. Junior doctors need to become part of the physician community of practice (CoP), while dealing with new responsibilities, tasks and expectations. At the same time, they need to learn how to navigate the frontiers and intersections with the other communities of practice that form the Landscape of Practice (LoP). This study aims to understand how junior doctors experience interprofessional collaboration (IPC) and what elements shape these experiences considering their transition to clinical practice.

METHODS

In this multicentre qualitative study, 13 junior doctors individually drew two rich pictures of IPC experiences, one positive and one negative. A rich picture is a visual representation, a drawing of a particular situation intended to capture the complex and non-verbal elements of an experience. We used semi-structured interviews to deepen the understanding of junior doctors' depicted IPC experiences. We analysed both visual materials and interview transcripts iteratively, for which we adopted an inductive constructivist thematic analysis.

RESULTS

While transitioning into a doctor, junior doctors become foremost members of the physician CoP and shape their professional identity based on perceived values in their physician community. Interprofessional learning occurs implicitly, without input from the interprofessional team. As a result, junior doctors struggle to bridge the gap between themselves and the interprofessional team, preventing IPC learning from developing into an integrative process. This professional isolation leaves junior doctors wandering the landscape of practice without understanding roles, attitudes and expectations of others.

CONCLUSIONS

Learning IPC needs to become a collective endeavour and an explicit learning goal, based on multisource feedback to take advantage of the expertise already present in the LoP. Furthermore, junior doctors need a safe environment to embrace and reflect on the emotions aroused by interprofessional interactions, under the guidance of experienced facilitators.

Creating a better learning environment: a qualitative study uncovering the experiences of Master Adaptive Learners in residency

BACKGROUND

Adaptive expertise is an important physician skill, and the Master Adaptive Learner (MAL) conceptual model describes learner skills and behaviors integral to the acquisition of adaptive expertise. The learning environment is postulated to significantly impact how MALs learn, but it is unclear how these successful learners experience and interact with it. This study sought to understand the authentic experience of MALs within the learning environment and translate those experiences into practical recommendations to improve the learning environment for all trainees.

METHODS

Following a constructivist paradigm, we conducted a thematic analysis of transcripts from focus groups composed of MALs to identify commonalities in experiences and practices of successful postgraduate trainees in the learning environment. Saturation was achieved after seven focus groups, consisting of thirty-eight participants representing fourteen specialties from four institutions. Researchers coded transcripts using constant comparison analysis, which served as the foundation for our thematic analysis.

RESULTS

We identified eight themes and situated them within a 4-component model of the learning environment. Four themes were identified within the personal component: (1) patients drive learning; (2) learning has no endpoint; (3) management of emotions is crucial for learning; (4) successful learning requires a structured approach. Two themes were identified in the social component: (5) positive social relationships are leveraged to maximize learning; (6) teaching facilitates personal learning. Two themes were identified in the organizational component: (7) transitions challenge learners to adapt; (8) the learning environment dictates goal setting strategy. No major themes were identified in the physical/virtual component, although participants frequently used technology when learning.

CONCLUSIONS

Master Adaptive Learners experience similar facilitators of, and barriers to, success in the learning environment. Overall, our data show that acquisition of many successful strategies and skills that support learning are relegated to the hidden curriculum of residency training. Educators could support a more effective learning environment for all trainees by: (1) highlighting patients as the focal point of learning, (2) building a professional 'learner' identity, (3) teaching learning skills, and (4) creating opportunities for collaborative learning.

Networking practices and gender inequities in academic medicine: Women's and men's perspectives

BACKGROUND

Studies of gender inequities in academic medicine suggest the negative impact of men's networking practices, but little is known about how they shape faculty experiences.

METHODS

In this qualitative study, in-depth, semi-structured interviews were conducted with 52 women and 52 men academic medicine faculty members at 16 institutions across the US in 2019. Interviews explored participants' experiences and perceptions of gender inequities in academic medicine, including perceptions of men's networking practices. Interviews were recorded and transcribed verbatim, and transcripts were analyzed using a mixture of deductively and inductively generated codes.

FINDINGS

Qualitative analysis of interview transcripts identified different dominant themes: (1) Women were often excluded from networking activities dominated by men, (2) Both women and men referred to men's networking practices in academic medicine, and believed they conferred benefits to members and excluded non-members from such benefits, (3) Participation in such networking activities yielded professional advantages, (4) Women made efforts to counteract their exclusion yet identified limits of those efforts.

INTERPRETATION

The data suggests that gender inequities in academic medicine might be associated with professional interactions that occur outside of the scope of professional work practices and in formal work sites. Additional research is needed to better understand practices such as informal networking activities and their impact in order to promote gender equity.

Reframing professional identity through navigating tensions during residency: A qualitative study

INTRODUCTION

Professional identity formation (PIF) is the internalization of characteristics, values, and norms of the medical profession. An individual's identity formation has both psychological and sociological influences. Social psychology may be useful to explore the interactions between the psychological and sociological aspects of PIF. In this study, we explored how resident physicians navigated tensions between professional ideals and the reality of medical practice to characterize PIF during residency training.

METHODS

Using constructivist grounded theory, the authors conducted 23 semi-structured interviews with internal medicine residents. Interview transcripts were processed through open coding and analytic memo writing. During data gathering and analysis, the authors utilized Social Cognitive Theory, specifically the bidirectional influence between person, behavior, and context, to analyze relationships among themes. Theoretical insights were refined through group discussion and constant comparison with newly collected data.

RESULTS

Residents described tensions experienced during residency between pre-existing ideals of "a good doctor" and the realities of medical practice, often challenging residents to reframe their ideals. The authors provide evidence for the presence of dynamic, bidirectional influences between identity (person), behavior, and environment (context), and demonstrate how PIF is informed by a complex interplay between these elements. The authors present two examples to demonstrate how residents reframed their ideals during residency training.

DISCUSSION

The complex bidirectional influences between person, behavior, and context, informed by SCT, helps illuminate the process of PIF in residency training. This study highlights the effects of the context of residency training on the development of residents' professional identities.

Frequency of medical students' language expressing implicit uncertainty in simulated handovers

OBJECTIVES

The aim of this study was to investigate the number and type of implicit expressions of uncertainty by medical students during simulated patient handovers.

METHODS

Eighty-seven volunteer medical students, a convenience sample collected on a first-come, first-served basis, participated in simulated handovers. They each worked with three simulated patients who presented with different chief complaints and personal conditions. The handovers were video recorded and transcribed. A framework of implicit expressions of uncertainty was used to identify and count modifiers that attenuate or strengthen medical information using MAXQDA lexical search. We analysed the findings with respect to the patients' contexts.

RESULTS

Implicit uncertainty expressions which attenuate or strengthen information occurred in almost equal frequency, 1879 (55%) versus 1505 (45%). Attenuators were found most frequently in the category 'Questionable', 1041 (55.4%), strengtheners in the category 'Focused', 1031 (68.5%). Most attenuators and strengtheners were found in the handover of two patients with challenging personal conditions ('angry man', 434 (23.1%) versus 323 (21.5%); 'unfocused woman', 354 (19.4%) versus 322 (21.4%)) and one patient with abnormal laboratory findings ('elevated creatinine', 379 (20.2%) versus 285 (18.9%)).

CONCLUSIONS

Medical students use a variety of implicit expressions of uncertainty in simulated handovers. These findings provide an opportunity for medical educators to design communication courses that raise students' awareness for content-dependent implicit expressions of uncertainty and provide strategies to communicate uncertainty explicitly.

Mentoring Relationships and Gender Inequities in Academic Medicine: Findings From a Multi-Institutional Qualitative Study

PURPOSE

This study examined how mentoring relationships may reinforce or mitigate gender inequities in academic medicine.

METHOD

In-depth, semistructured interviews with medical school faculty members (52 women and 52 men) were conducted at 16 institutions across the United States in 2019. Institutions were recruited using a purposive sampling strategy to seek diversity in geography, ownership (private or public), and prestige. Within institutions, purposive sampling was used to recruit equal numbers of women and men and to seek diversity in degree type (MD, PhD), age, and career stage. A coding scheme was developed through iterative analysis of the interview transcripts. All interview transcripts were then coded with the goal of identifying intersections between mentorship and experiences of and responses to gender inequities.

RESULTS

Four key themes at the intersection of mentoring relationships and gender inequities were identified. (1) Both women and men became aware of gender inequities in academic medicine through relationships with women mentors and mentees. (2) Both women and men mentors recognized the challenges their female mentees faced and made deliberate efforts to help them navigate an inequitable environment. (3) Both women and men mentors modeled work-family balance and created family friendly environments for their mentees. (4) Some women, but no men, reported being sexually harassed by mentors.

CONCLUSIONS

This study shows that mentoring relationships may be a context in which gender inequities are acknowledged and mitigated. It also shows that mentoring relationships may be a context in which gender inequities, such as sexual harassment, may occur. Sexual harassment in academic medicine has been widely documented, and gender inequity in academic medicine has proved persistent. While mentoring relationships may have the potential to identify and mitigate gender inequities, this study suggests that this potential remains largely unrealized.

Transition to clinical practice during the COVID-19 pandemic: a qualitative study of young doctors' experiences in Brazil and Ireland

OBJECTIVES

To explore and compare the perspectives of junior doctors in Brazil and Ireland regarding transition and professional socialisation during the COVID-19 pandemic, with the purpose of identifying better ways to support doctors as they assume their new professional role.

DESIGN

27 semistructured interviews. Transcripts were analysed using qualitative thematic analysis. Cruess' framework of professional socialisation in medicine supported the interpretation of these data.

SETTING

Public health hospitals across four Brazilian states (Santa Catarina, São Paulo, Ceará, Paraíba) and County Cork in the South of Ireland.

PARTICIPANTS

Twenty-seven male and female medical junior doctors who had graduated between November 2019 and April 2020.

RESULTS

Fourteen Brazilian and 13 Irish junior doctors were interviewed for this study. Entry to clinical practice during the pandemic had a significant impact on factors influencing the professional socialisation of junior doctors. This impact was reflected across the following six thematic areas: lack of preparedness; disrupted trajectory of role adaptation; fewer opportunities for experiential learning; solidarity and isolation; altered interactions with patients; challenges to health and well-being.

CONCLUSIONS

Transition to clinical practice is an important stage in junior doctors' professional socialisation and identity formation. The COVID-19 pandemic created the opportunity for medical graduates to enter the workforce earlier than usual. Entering the workforce during this period created a lack of confidence among junior doctors concerning the boundaries of their new role and responsibilities, while simultaneously disrupting their social integration. Priorities to mitigate the impact of COVID-19 and future pandemics on this transition are presented.

Women's Experiences of Promotion and Tenure in Academic Medicine and Potential Implications for Gender Disparities in Career Advancement: A Qualitative Analysis

IMPORTANCE

Gender disparities in career advancement in academic medicine have persisted despite gender parity in medical school matriculation. Although numerous explanations for this gap exist, little is known about women's experiences of promotion and tenure in academic medicine.

OBJECTIVE

To examine women's experiences of promotion and tenure in academic medicine to uncover mechanisms associated with the gender disparity in career advancement.

DESIGN, SETTING, AND PARTICIPANTS

In this qualitative study, 52 in-depth, semistructured interviews with women academic medicine faculty members were conducted in 2019. The 52 participants were drawn from 16 medical schools across the US. Institutions were selected using a purposive sampling strategy to seek diversity of geography and ownership (private or public). Within institutions, purposive and snowball sampling were used to seek diversity with respect to respondents' degree type (MD, PhD, and MD and PhD), age, and career stage. Interview transcripts were analyzed using qualitative thematic analysis. Data analysis was performed from March to December 2020.

MAIN OUTCOMES AND MEASURES

Themes and subthemes in participants' experiences of promotion and tenure.

RESULTS

The 52 women in this study ranged in age from 34 to 82 years (mean [SD] age, 54.0 [10.7] years). Eighteen respondents (34.6%) held an MD, 4 (7.7%) held both an MD and PhD, and 30 (57.7%) held a PhD. Fourteen respondents (26.9%) were assistant professors at the time of the study, 8 (15.4%) were associate professors, and 30 (57.7%) were full professors. Four main themes within participants' experiences of promotion and tenure that pertain to gender inequities were identified: ambiguous or inconsistent criteria for promotion or tenure; lack of standard processes for reviewing applications and making decisions; vulnerability to malicious behavior of senior faculty, department chairs, and division chiefs; and women seeing men have different experiences of advancement.

CONCLUSIONS AND RELEVANCE

The respondents' experiences of promotion and tenure suggest that promotion and tenure processes may be characterized by inconsistency and a lack of oversight, which have the potential to contribute to well-documented patterns of gender disparities in career advancement in academic medicine.

Post-Clerkship Curricular Reform: Specialty-Specific Tracks and Entrustable Professional Activities to Guide the Transition to Residency

The development of core entrustable professional activities (EPA) for entering residency and Accreditation Council for Graduate Medical Education's milestones have spurred thinking about the fourth year of medical school as a transition to residency. In this monograph, we lay out our specialty focused post-clerkship curriculum and report learner and residency director perceptions over the first three years of implementation. Ongoing curricular monitoring has reinforced core principles but has also informed actionable quality improvement efforts. EPA-focused learning experiences, integration of specialty-specific milestones, addition of the feedforward process, and accessible mentorships have been key curricular elements to guide the transition to residency.