Understanding the transition from resident to attending physician: a transdisciplinary, qualitative study

Novice Experts: Exploring Fellows' Perspectives on the Transition from Residency to Fellowship

Introduction

Advanced training experiences are required in certain countries for subspecialization. In the United States, a decline in Milestones and in levels of supervision for Entrustable Professional Activities for incoming subspecialty fellows has been described and attributed to changes in context that fellows experience. We aimed to explore this transition to advanced training, and specifically to describe which contextual factors are salient to fellows at the residency to fellowship transition and the supports available for a smooth transition to fellowship.

Methods

Using contextual competence as a sensitizing concept, ten semi-structured interviews with first- and second-year pediatric subspecialty fellows from three subspecialties were performed at a large academic medical center in 2023, using thematic analysis informed by elements of constructivist grounded theory.

Results

Contextual factors that impacted the transition included changes in systems, necessary knowledge, and roles and responsibilities. At times, participants describe a tension between feeling like novices while simultaneously feeling like they should have more expertise than they had. Supports in navigating this tension, and in navigating the transition more generally, included formal orientations, fellow behaviors and perspective, and input from others.

Conclusions

The transition to advanced training is characterized, at times, by experiencing tension between feeling like a novice while feeling like one should have expertise, with fellows' own behaviors and the support of those around them being essential to fellows' smooth transition. While fellowship programs offer orientations, systems-level solutions for supporting fellows' navigation of the transition are underexplored.

Ready or Not, Here We Come: A Qualitative Study of the Transition From Graduate Medical Education to Independent Practice

Background The transition from graduate medical education (GME) into independent practice is challenging for new attendings despite achieving "readiness for practice," by Accreditation Council for Graduate Medical Education (ACGME) Milestones. Most medical literature on this transition is specialty-specific and rarely involves assessment of new-to-practice attendings (NTPAs). Objective Lack of attending readiness results in compromised patient care. To inform GME leaders and managers, we sought to identify areas of struggle for NTPAs across specialties. With this information, we hope to spur national GME curriculum evolution, better support our NTPAs, and ultimately provide better patient care. Methods Qualitative freelisting was used in 2021 to explore how NTPAs, educational program leaders, and managers perceive the transition struggles. Response lists were collected electronically, then cleaned and categorized by the research team using iterative inductive combination of similar concepts. Salience index scores (Smith's S) were calculated and plotted graphically to identify inflection points for each group, above which domains were deemed salient. Results One hundred eighty-six participants completed surveys, yielding 518 individual responses and a response rate of 34%. Of the ACGME competencies, systems-based practice domains were most frequently salient, including "workload" and "billing." "Confidence," "supervision," "work-life balance," "decision-making," and "time management" were salient struggles in all groups. Each group had domains only achieving salience for them. Professional development domains including "confidence," "imposter syndrome," and "culture" achieved salience in different groups. Conclusions This study identifies domains of struggle for NTPAs, which fall outside ACGME competency frameworks including workload, new environments, and professional development. Domains identified by NTPAs, program leaders, and managers were not identical.

Ready, or not? A qualitative study of emergency medicine senior residents' perspectives on preparing for practice

Objectives

The transition from residency to unsupervised practice challenges doctors to adapt to new environments and responsibilities. Past work has focused on how physicians acclimate to their new roles, raising questions about how residents might think proactively about transitions while still in training. This study explores senior emergency medicine (EM) residents' perspectives on preparedness for unsupervised practice and how they draw from training experiences to assess their evolving sense of preparedness.

Methods

The authors used a constructivist grounded theory approach, inviting all fourth-year EM residents from two residency programs to participate in semistructured interviews. Participants were asked to reflect on their preparedness for entering unsupervised practice and to imagine scenarios for which they felt unprepared. Two authors coded line by line using constant comparison, organizing data into codes and categories. The research team met to discuss relationships between codes, developing themes to theorize about the phenomenon of interest.

Results

Sixteen residents were interviewed. The authors identified two overarching categories of themes. First, participants described individualized conceptualizations of preparedness, constructed from past workplace experiences and those they anticipated they would have in unsupervised practice. These conceptualizations emphasized drawing confidence from experience and developing adaptability to manage the uncertainties of medical practice. The second overarching category involved participants' efforts to gauge their own preparedness. To do so, they used interactions with others to assess their readiness to manage specific problems and made holistic appraisals across multiple experiences to assess their overall preparedness for unsupervised practice.

Conclusions

Trainees draw from past experiences to forecast their abilities to manage the inevitable uncertainties of unsupervised practice. These conceptualizations of preparedness reflect a capability approach to training, with informed confidence and dynamic self-appraisal. These findings suggest potential learning goals of senior trainees and considerations for medical educators to consider when fostering trainees' capabilities for unsupervised practice.

Mentorship in academic musculoskeletal radiology: perspectives from a junior faculty member

The first years of an academic musculoskeletal (MSK) faculty position are a time of transition for the junior faculty member, who must rapidly adjust to new clinical, academic, operational, and professional responsibilities. Mentoring has a critical role in helping the faculty member to thrive in these early years. Establishing clear communication, trust, and expectations can set the foundation for an effective mentoring relationship. Junior faculty members ideally would have multiple mentors with different areas of expertise, including mentors of all roles in MSK radiology but also in other radiology divisions and other departments. Private practice MSK radiologists can also benefit from mentorship. Barriers to mentoring in MSK radiology include overall smaller division sizes, a newer and smaller field on a national level, and the increase in clinical volume and remote work that results in less face-to-face interaction. Despite the challenges, both junior MSK faculty members and their mentors can benefit greatly from strong mentoring connections.

Evaluating the Role of Mentorship in Career Advancement: A Survey of Women in Academic Hand Surgery

PURPOSE

Despite the increasing percentage of women within the American Society for Surgery of the Hand, women remain underrepresented within leadership in academic hand surgery. Although this disparity in leadership representation may be improving, we aimed to investigate the role mentorship plays in advancing women in academic hand surgery.

METHODS

This is a survey-based, mixed-methods study. A written survey assessing themes in personal and professional experiences with mentorship was sent to hand fellowship-trained women. Inclusion criteria were the completion of a hand fellowship and current affiliation with an academic institution. An evolved grounded theory framework was used to evaluate the responses. Themes were identified based on common responses.

RESULTS

Of 186 eligible participants, 144 (85.2%) received the survey. The response rate was 48.6%. Respondents indicated that residency was the stage at which mentorship was most impactful (n = 25, 37%), and half of the respondents identified their desire to work in academic hand surgery during residency (n = 35, 50%). Obstacles to finding a mentor included lack of availability (n = 46, 67.7%), hesitance in searching for a mentor (n = 16, 23.5%), and searching for a mentor within an environment that was not conducive to success for trainees (n = 7, 10.3%). Most (84%) cited instances were the ones having the advice of a woman mentor was more impactful than that of a mentor who is a man. The reported need for same-sex mentorship fell into three categories: (1) insight into shared experiences, (2) assistance with conflict/bias management, and (3) support during career navigation.

CONCLUSIONS

The findings of this study demonstrate the need for high-quality mentorship during the residency with a specific emphasis on same-sex mentorship.

CLINICAL RELEVANCE

Our findings provide clear objectives related to improving access to and quality of mentorship. This foundational understanding will enrich mentor-mentee relationships, allowing for greater personal and professional success and satisfaction for both parties.

Understanding learners' experiences across three major transitions in undergraduate medical education

BACKGROUND

Medical students in the United States undergo three significant transitions as they progress from pre-clinical to clinical rotations, to acting interns, and ultimately to first-year resident. However, there is limited understanding of whether the factors and strategies that impact these transitions remain consistent or are unique to each individual transition.

METHODS

Qualitative data was collected from three Nominal Group Technique (NGT) sessions held separately for third-year students (M3), fourth-year students (M4), and first-year residents (PGY-1). The participants were asked to share their perceptions on their most recent medical school transition. These responses were independently coded into thematic categories.

RESULTS

The NGT session with M3 students (n = 9) identified 67 transition factors and 64 coping strategies. The M4 (n = 8) session identified 33 transition factors and 72 strategies to manage their transition. The PGY-1 (n = 5) session identified 28 factors and 25 strategies. The coping strategies for each session were categorized into seven themes and the transition factors were assigned to ten thematic categories.

CONCLUSION

Just as each transition is unique, so too are the number and variety of factors and strategies to manage each transition. Despite these differences, the themes of "Professional socialization" and "Prioritization, efficiency, and delegation" emerged as impactful in all three transitions.

"Everything new is happening all at once": a qualitative study of early career obstetrician and gynaecologists' preparedness for independent practice

Background

The transition from residency training into practice is associated with increasing risks of litigation, burnout, and stress. Yet, we know very little about how best to prepare graduates for the full scope of independent practice, beyond ensuring clinical competence. Thus, we explored the transition to independent practice (TTP) experiences of recent Obstetrics and Gynaecology graduates to understand potential gaps in their perceived readiness for practice.

Methods

Using constructivist grounded theory, we conducted semi-structured interviews with 20 Obstetricians/Gynaecologists who graduated from nine Canadian residency programs within the last five years. Iterative data collection and analysis led to the development of key themes.

Results

Five key themes encompassed different practice gaps experienced by participants throughout their transition. These practice gaps fit into five competency domains: providing clinical care, such as managing unfamiliar low-risk ambulatory presentations; navigating logistics, such as triaging referrals; managing administration, such as hiring or firing support staff; reclaiming personhood, such as boundary-setting between work and home; and bearing ultimate responsibility, such as navigating patient complaints. Mitigating factors were found to widen or narrow the extent to which new graduates experienced a practice gap. There was a shared sense among participants that some practice gaps were impossible to resolve during training.

Conclusions

Existing practice gaps are multi-dimensional and perhaps not realistically addressed during residency. Instead, TTP mentorship and training opportunities must extend beyond residency to ensure that new graduates are equipped for the full breadth of independent practice.

What's up doc? Physicians' reflections on their sustainable employability throughout careers: a narrative inquiry

BACKGROUND

Physicians have complex and demanding jobs that may negatively affect their sustainable employability (SE) and quality of care. Despite its societal and occupational relevance, empirical research on physicians' SE is scarce. To further advance our understanding of physicians' SE, this study explores how physicians perceive their employment context to affect their SE, how physicians self-regulate with the intent to sustain their employability, and how self-regulations affect physicians' SE and their employment context.

METHODS

Twenty Dutch physicians from different specialisms were narratively interviewed between March and September 2021 by a researcher with a similar background (surgeon) to allow participants to speak in their own jargon. The interviews were analyzed collaboratively by the research team in accordance with theory-led thematic analysis.

RESULTS

According to the interviewees, group dynamics, whether positive or negative, and (mis)matches between personal professional standards and group norms on professionalism, affect their SE in the long run. Interviewees self-regulate with the intent to sustain their employability by (I) influencing work; (II) influencing themselves; and (III) influencing others. Interviewees also reflect on long-term, unintended, and dysfunctional consequences of their self-regulations.

CONCLUSIONS

We conclude that physicians' SE develops from the interplay between the employment context in which they function and their self-regulations intended to sustain employability. As self-regulations may unintentionally contribute to dysfunctional work practices in the employment context, there is a potential for a vicious cycle. Insights from this study can be used to understand and appraise how physicians self-regulate to face complex challenges at work and to prevent both dysfunctional work practices that incite self-regulation and dysfunctional consequences resulting from self-regulations.

French-speaking Swiss physician's perceptions and perspectives regarding their competencies and training need in leadership and management: a mixed-methods study

INTRODUCTION

Effective leadership and management (L&M) are essential to the success of health care organizations. Young medical leaders often find themselves ill-prepared to take on these new responsibilities, but rarely attend training in L&M skills. The aims of this study were to evaluate physician's self-perceived competencies and training needs for L&M, to identify available regional L&M training, and to highlight opportunities, challenges and threats regarding physicians' training in medical L&M in the French-speaking part of Switzerland.

METHODS

We conducted a mixed methods study in three steps: (1) a survey on perceived L&M competencies and training needs (5 dimensions) to all physicians of a Swiss University Hospital (N = 2247); (2) a mapping of the Swiss French speaking L&M training programs through analysis of hospital websites and interviews; and (3) semi-structured interviews with L&M program coordinators about the programs' strengths and weaknesses as well as the opportunities and challenges to include physicians in such training. We used analysis of variance to compare differences in perceived competences between physicians of different hierarchical status and used Cramer's V to measure the association's degree between physicians' training needs and prior training in L&M and hierarchical status. We analysed semi-structured interviews using thematic analysis.

RESULTS

Five-hundred thirty-two physicians responded (24%). Physicians perceived themselves as rather competent in most leadership dimensions. More experienced physicians reported a higher sense of competence in all dimensions of leadership (e.g. Working with others: F = 15.55, p < .001; Managing services: F = 46.89, p < .001). Three competencies did not vary according to the hierarchical status: emotional intelligence (F = 1.56, p = .20), time management (F = 0.47, p = .70) and communicating (F = 1.97, p = .12). There was a weak to moderate association between the responders' self-perceived needs for training and their hierarchal status for all competencies (Cramer's V ∈ [0.16;0.35]). Physicians expressed a strong desire to seek out training for all competencies, especially for knowing one's leadership style (82%), managing teams (83%), and managing conflict (85%). Although existing local L&M training programs covered most relevant topics, only a forth of responders had attended any type of training. L&M program coordinators identified several facilitators and barriers to physician attendance on institutional (matching reality and training), relational (managing collective intelligence), and individual levels (beliefs and self-perceived identity).

CONCLUSIONS

French-speaking Swiss hospital physicians clearly express training needs for L&M skills although they only rarely attend such training programs. Reasons for non-attendance to such programs should be explored in order to understand physicians' low participation rates in these trainings.

"You may think that the consultants are great, and they know everything, but they don't": exploring how new emergency medicine consultants experience uncertainty

BACKGROUND

Uncertainty is particularly obvious in emergency medicine (EM) due to the characteristics of the patient cohort, time constraints, and busy environment. Periods of transition are thought to add to uncertainty. Managing uncertainty is recognised as a key ability for medical practice, but is often not addressed explicitly. This study explored how new consultants in EM experience uncertainty, with the aim of making explicit what is often hidden and potentially informing support for doctors to manage the uncertainty they face.

METHODS

This was a qualitative study using interpretive phenomenological analysis (IPA). Five consultants working in the UK within one year of achieving a certificate of completion of training were interviewed online during 2021, these were transcribed and analysed using IPA.

RESULTS

Three superordinate themes were identified: 'transition and performance as a source of uncertainty', 'uncertainty and decision-making in the context of the emergency department' and 'sharing uncertainty and asking for help'. The transition created uncertainty related to their professional identity that was compounded by a lack of useful feedback. There was tension between perceived expectations of certainty and the recognition of uncertainty in practice. EM doctors were seen as experts in managing uncertainty, with responses to uncertainty including gathering information, sharing uncertainty and seeking help. Expressing uncertainty was viewed as necessary for good patient care but could be risky to credibility, with psychological safety and role modelling behaviour making it easier for the participants to express uncertainty.

CONCLUSION

This study highlights the need for new consultants to have psychologically safe, reflective spaces to think through uncertainties with others. This appears to reduce uncertainty, and also act as a source of feedback. The study adds to the existing calls to address uncertainty more explicitly in training, and challenge the expectations of certainty that exist within medicine.

Post-CSCST fellowships: beyond subspecialization

The transition from higher training to consultanthood is a crucial point in the medical training pathway. Despite comprehensive higher training programs, studies of new consultants have reported a disparity in their sense of preparation for non-clinical and clinical duties. Post- "Certificate of Satisfactory Completion of Specialist Training" (CSCST) fellowships have traditionally been undertaken as a means to access subspecialty clinical training which is otherwise unavailable in higher training programs. However, fellowships have a role beyond this subspecialization model, particularly in meeting the non-clinical training needs of new CSCST graduates.The design and goals of fellowship posts should be considered in this context, to align them with the reported needs of new consultants. Special consideration should be given to defining roles of independence for the fellow and to the nature of the mentorship relationship, distinguishing these posts from higher specialist training. Well-designed post-CSCST fellowships have an important role in facilitating the successful transition to consultanthood.

Ready for practice? National recommendations for emergency medicine transition to practice curriculum

BACKGROUND

Transition from residency to unsupervised practice represents a critical stage in learning and professional identity formation, yet there is a paucity of literature to inform residency curricula and emergency department transition programming for new faculty.

OBJECTIVE

The objective of this study was to develop consensus-based recommendations to optimize the transition to practice phase of emergency medicine training.

METHODS

A literature review and results of a survey of emergency medicine (EM) residency program directors informed focus groups of recent (within 5 years) EM graduates. Focus group transcripts were analyzed following conventional content analysis. Preliminary recommendations, based on identified themes, were drafted and presented at the 2022 Canadian Association of Emergency Physicians (CAEP) Academic Symposium on Education. Through a live presentation, symposium attendees representing the Canadian national EM community participated in a facilitated discussion of the recommendations. The authors incorporated this feedback to construct a final set of 14 recommendations, 8 targeted toward residency training programs and 6 specific to department leadership.

CONCLUSION

The Canadian EM community used a structured process to develop 14 best practice recommendations to enhance the transition to practice phase of residency training as well as the transition period in the career of junior attending physicians.

Are early career family physicians prepared for practice in Canada? A qualitative study

BACKGROUND

In Canada, the College of Family Physicians of Canada (CFPC) introduced Competency Based Medical Education to prepare and train family medicine residents to be competent to enter and adapt to the independent practice of comprehensive family medicine. Despite its implementation, the scope of practice is narrowing. This study aims to understand the degree to which early career Family Physicians (FPs) are prepared for independent practice.

METHOD

A qualitative design was used for this study. A survey and focus groups were conducted with early-career FPs who completed residency training in Canada. The survey and focus groups examined the degree of preparedness of early career FPs in relation to 37 core professional activities identified by the CFPC's Residency Training Profile. Descriptive statistics and qualitative content analysis were conducted.

RESULTS

Seventy-five participants from across Canada participated in the survey, and 59 participated in the focus groups. Early career FPs reported being well prepared to provide continuous and coordinated care for patients with common presentations and deliver various services to different populations. FPs were also well prepared to manage the electronic medical record, participate in team-based care, provide regular and after-hours coverage, and assume leadership and teaching roles. However, FPs reported being less prepared for virtual care, business management, providing culturally safe care, delivering specific services in emergency care hospitals, obstetrics, self-care, engaging with the local communities, and conducting research activities.

CONCLUSIONS

Early career FPs do not feel fully prepared for practice in all 37 core activities in the Residency Training Profile. As part of the introduction of the three-year program by the CFPC, the postgraduate family medicine training should consider providing more exposure to learning opportunities and developing curricula in the areas where FPs are unprepared for practice. These changes could facilitate the production of a FP workforce better prepared to manage the dynamic and complex challenges and dilemmas faced in independent practice.

Transition theory and the emotional journey to medical educator identity: A qualitative interview study

BACKGROUND

Medical academia is in crisis, with fewer people entering and growing concern at numbers leaving. While faculty development is often seen as part of the solution, there are significant issues with faculty not engaging with and resisting development opportunities. Lack of motivation may be linked to what might be called a 'weak' educator identity. We studied medical educators' experiences of career development to gain further insights into: how professional identity may develop; individuals' accompanying emotional responses to perceived identity change; and consideration of the accompanying temporal dimensions. Drawing on new materialist sociology, we explore medical educator identity formation in terms of an affective flow that places the individual within a constantly shifting assemblage of psychological, emotional and social relations.

METHOD

We interviewed 20 medical educators at various career stages, with differing strengths of medical educator self-identity. Using an adapted transition model as a basis for understanding the emotions experienced by those undergoing identity transitions, we explore the process that, for some medical educators, appears to lead to decreased motivation, ambiguous identity and disengagement, but for others results in renewed energy, a stronger and more stable professional identity and increased interest and engagement.

RESULTS

By more effectively illustrating the emotional impact of the transition process leading to a more stable educator identity, we show that some individuals, especially where the change was not sought or welcomed, express their uncertainty and distress through low mood, resistance and an attempt to minimise the significance of undertaking or increasing teaching duties.

DISCUSSION

Understanding the emotional and developmental phases of the transition to medical educator identity has several key implications for faculty development. Faculty development approaches should be alert to the individual educator's stage of transition since this will affect that individual's readiness to accept and respond to guidance, information and support. A renewed emphasis on early educational approaches that will support the transformational and reflective learning of the individual is needed, while traditional approaches emphasising skills and knowledge may be more useful in the later stages. Further testing of the transition model and its applicability to identity development in medical education is indicated.

Fitting In While Standing Out: Professional Identity Formation, Imposter Syndrome, and Burnout in Early-Career Faculty Physicians

PURPOSE

Professional identity formation (PIF) is a dynamic process by which an individual internalizes the core values and beliefs of a specific profession. Within medical education, PIF begins in medical school and continues throughout training and practice. Transitions affect PIF, with a critical transition occurring between medical training and unsupervised practice. This study aims to characterize PIF during the transition from resident to early-career faculty physician and explores the relationship between PIF and burnout during this transition.

METHOD

The authors conducted a qualitative study using constructivist grounded theory. They conducted semistructured interviews with early-career faculty physicians (defined as practicing for ≤ 5 years) from the Department of Medicine, Mayo Clinic. Deidentified interview transcripts were processed through open and axial coding. The authors organized themes and identified relationships between themes that were refined through discussion and constant comparison with newly collected data. During data analysis, the authors identified self-determination theory, with the concepts of autonomy, competence, and relatedness, as a framework to support the organization and analysis of the data.

RESULTS

Eleven early-career faculty physicians participated in the interviews. Their PIF was characterized by the dual desires to fit in and stand out. Striving for these desires was characterized by imposter syndrome, driving physicians to question their decision making and overall competence. Participants associated imposter syndrome and academic pressures with burnout. Autonomy support by the institution to pursue opportunities important for career development helped mitigate burnout and support PIF.

CONCLUSIONS

Early-career faculty physicians face identity challenges when transitioning from training to unsupervised practice, including striving to fit in and stand out. They link this tension to imposter syndrome, which they associated with burnout. Institutional awareness and support, including addressing structural and cultural contributors to imposter syndrome, are paramount as new faculty explore their identities and navigate new challenges.

Components and Outcomes in Under- and Postgraduate Medical Education to Prepare for the Delivery of Integrated Care for the Elderly: A Scoping Review

Introduction

The ageing society requires physicians who can deliver integrated care, but it is unclear how they should be prepared for doing so. This scoping review aims to create an overview of educational programmes that prepare (future) physicians to deliver integrated care while addressing components and outcomes of the interventions.

Method

We included papers from five databases that contained: (1) integrated care (2) education programme (3) medical students (4) elderly, or synonyms. We divided the WHO definition of integrated care into ten components for the concept of 'integrated care'. Data were collected with a charting template, and template analysis was used to formulate themes.

Results

We found 17 educational programmes in different learning settings. All programmes addressed several components of the WHO definition. The programmes primarily focused on care for individual patients (micro-level), and the outcomes suggested that experiencing the complexity of care is key.

Conclusion

This review revealed the limited evidence on educational programmes about integrated care for the elderly. Our findings suggest that educational programmes on integrated care should not be limited to the micro-level, and that students should obtain adaptive expertise by experiencing complexity. Future research should contain an explicit description and definition of integrated care.

Stress and conflict from tacit culture forges professional identity in newly graduated independent physicians

To transition successfully into independent practice, newly graduated independent physicians (new "attendings") undergo a process of professional identity formation (PIF) as a clinician within a new community of practice (CoP). PIF is crafted by socialization within a CoP including transfer of tacit knowledge. While certain tacit knowledge is critical for professional identity, we understand little how it shapes PIF. We set out to describe the tacit knowledge acquired by new attendings within a CoP and how it contributes to PIF. Informed by constructivist grounded theory, we interviewed 23 new attendings about the tacit knowledge they acquired in early practice. Data collection and analysis occurred iteratively. We identified themes using constant comparative analysis and generated a theory that underwent member checking and feedback. Implicit standards from group culture imparted high expectations on new attendings and led to internal stress. New attendings also encountered a tacit code of conduct as behavioral elements of group culture. These elements created external conflict between new attendings and group members such as departmental colleagues, consulting physicians, and other health professionals. Depending on the support they received, new attendings responded to the stress and conflict in three ways: they doubted, adjusted, or avoided. These strategies molded their professional identity, and moved them towards or away from the CoP as they navigated their transition and PIF. We describe a novel theory of how tacit group culture shaped new attending physicians' professional identity in a new community of practice. Internal stress and external conflict occurred due to high expectations and tacit culture elements. New attendings' doubt, adjust, or avoid responses, shaped by support they received, in turn crafted their professional identity. Education leaders should prepare graduating trainees to navigate aspects of transition to independent practice successfully.

Paediatric anaesthesiology education: simulation-based 'attending boot camp' for fellows shows feasibility and value in the early years of attendings' careers

Background

Established simulation-based 'boot camps' utilise adult learning theory to engage and teach technical and non-technical skills to medical graduates transitioning into residency or fellowship. However, the transition from trainee to the attending role has not been well studied. The primary aim of this study was to design and execute a simulation-based educational day, exposing senior trainees in paediatric anaesthesia to commonly encountered challenges and teaching critical technical skills relevant to their new role. Secondary aims included assessment of its value and relevance in early years of graduated fellows' new careers as attendings.

Methods

An 'attending boot camp' day comprised the following: two crisis simulations, an otolaryngologist-taught cadaver cricothyroidotomy laboratory, and a difficult conversations workshop. There was a debriefing after each section. Data were collected using end-of-day and early-career e-mail surveys for five consecutive fellow cohorts from 2016 to 2020.

Results

Forty fellows participated; overall feedback was positive. The end-of-day surveys revealed planned changes in practice for 89% (25/28) of fellows, and 54% (15/28) highlighted communication skills as 'most beneficial'. Early-career follow-up surveys found 96% (23/24) identified increased confidence in skill acquisition because of the day; 79% (19/24) experienced scenarios in real life similar to those simulated. The qualitative analysis revealed four high-value themes: delegation, leadership, clinical skills, and difficult communication.

Conclusions

The transition from senior trainee to attending physician remains under-researched. A tailored simulation-based 'attending boot camp' was feasible and valued and may be useful in bridging this transition. Participants identified leadership practice, life-saving technical skills, and difficult communication practice as valuable and relevant in their early careers.

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.

Challenges in the transition to independent radiation oncology practice and targeted interventions for improvement

Numerous radiation oncology residents and junior attendings have identified common weaknesses in residency training that hinder the transition from training to independent practice. Recurrent themes include not only general autonomy but also proficiency in technical skills, such as treatment plan review and image verification, and nontechnical skills, such as leadership, mentorship, and education. While multiple strategies to address these deficiencies have been investigated, many are not widely available or may be difficult to implement. We aim to summarize the frequently cited challenges in the transition to independent radiation oncology practice as well as the pertinent interventions that have been explored.

Transitioning Roles from Residency to Attending Physician in Radiation Oncology

Moving from the role of resident into that of a young attending is one of the most anticipated transitions in a medical trainee's career path. Radiation oncology residency training is typically apprentice-style focused in the outpatient setting, which carries additional unique challenges. Twenty-seven junior attendings at academic institutions within their first 5 years of practice were sent an online open-ended questionnaire in 2018 regarding aspects of their practice using a snowball sampling method. Responses were collected, and a thematic analysis was conducted in which two independent reviewers coded the responses. Nineteen junior attendings (70%) from 18 institutions completed the questionnaire. General themes included the importance of cultivating relationships for peer support and to be professional and polite as confidence was gained to enable them to be seen as an attending. All respondents felt that bringing an open mind, balance, and adaptability was crucial in their transition. Respondents stayed up to date on literature and practices by subscribing to journals, courses, and participation in resident education. Forty-two percent of young attendings were matched with a mentor at their new institution through a formal mentor-mentee relationship. Respondents wished that they had more autonomy during residency to prepare for independent practice. Transitioning from residency to a junior attending provides unique stressors and challenges. Allowing for residents to have more autonomy during their training, such as a senior resident clinic, may help improve this transition by providing an opportunity for independent decision-making with guidance as appropriate.

Tips for Successful Career Transitions in Breast Imaging

Whether beginning a new career in breast imaging or switching into a different breast imaging practice for personal or professional advancement, a leadership opportunity, a need to relocate geographically, or simply a better opportunity, it is critical to transition between positions as smoothly as possible. Thoroughly reflecting on your career priorities and goals is essential prior to undertaking any career transition. Once the decision has been made to move to a new position, it is imperative to learn about the dynamics of the new practice and practice environment. Here, we provide suggestions on how to hit the ground running when joining a new breast imaging practice.

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.

Challenges in the transition from resident to attending physician in general internal medicine: a multicenter qualitative study

BACKGROUND

The attending physician in general internal medicine (GIM) guarantees comprehensive care for persons with complex and/or multiple diseases. Attendings from other medical specialties often report that transitioning from resident to attending is burdensome and stressful. We set out to identify the specific challenges of newly appointed attendings in GIM and identify measures that help residents better prepare to meet these challenges.

METHODS

We explored the perceptions of 35 residents, attendings, and department heads in GIM through focus group discussions and semi-structured interviews. We took a thematic approach to qualitatively analyze this data.

RESULTS

Our analysis revealed four key challenges: 1) Embracing a holistic, patient centered perspective in a multidisciplinary environment; 2) Decision making under conditions of uncertainty; 3) Balancing the need for patient safety with the need to foster a learning environment for residents; and 4) Taking on a leader's role and orchestrating an interprofessional team of health care professionals. Newly appointed attendings required extensive practical experience to adapt to their new roles. Most attendings did not receive regular, structured, professional coaching during their transition, but those who did found it very helpful.

CONCLUSIONS

Newly appointed attending physician in GIM face a number of critical challenges that are in part specific to the field of GIM. Further studies should investigate whether the availability of a mentor as well as conscious assignment of a series of increasingly complex tasks during residency by clinical supervisors will facilitate the transition from resident to attending.

Understanding the Influence of the Junior Attending Role on Transition to Practice: A Qualitative Study

BACKGROUND

The Junior Attending (JA) role is an educational model, commonly implemented in the final years of training, wherein a very senior resident assumes the responsibilities of an attending physician under supervision. However, there is heterogeneity in the model's structure, and data are lacking on how it facilitates transition to independent practice.

OBJECTIVE

The authors sought to determine the value of the JA role and factors that enabled a successful experience.

METHODS

The authors performed a collective case study informed by a constructivist grounded theory analytical approach. Twenty semi-structured interviews from 2017 to 2020 were conducted across 2 cases: (1) Most Responsible Physician JA role (general internal medicine), and (2) Consultant JA role (infectious diseases and rheumatology). Participants included recent graduates who experienced the JA role, supervising attendings, and resident and faculty physicians who had not experienced or supervised the role.

RESULTS

Experiencing the JA role builds resident confidence and may support the transition to independent practice, mainly in non-medical expert domains, as well as comfort in dealing with clinical uncertainty. The relationship between the supervising attending and the JA is an essential success factor, with more productive experiences reported when there is an establishment of clear goals and role definition that preserves the autonomy of the JA and legitimizes the JA's status as a team leader.

CONCLUSIONS

The JA model offers promise in supporting the transition to independent practice when key success factors are present.

'The hardest job I've ever done': a qualitative exploration of the factors affecting junior doctors' mental health and well-being during medical training in Australia

Background

Medical practitioners can experience considerable stress and poor mental health during their careers, with doctors in training known to be particularly vulnerable. Previous research has documented work-related factors that may play a role in the mental health status of junior doctors. However, these and additional factors, need to be explored further by considering theory-driven, social, structural and contextual issues. This qualitative study aimed to explore the experiences of junior doctors working in Australian hospitals to identify factors that impact their mental health during medical training.

Method

Semi-structured interviews were conducted with 12 junior medical officers (JMOs) employed across six hospitals in Australia. Transcribed de-identified interviews were analysed thematically using a data-driven inductive approach.

Results

Four interrelated main themes were identified: i) professional hierarchies; ii) occupational stress; iii) emotional labour, and iv) taking distress home; which detail the complex affective, relational and professional experiences of JMOs. The accounts demonstrate how the social, professional and organisational dimensions of these experiences impact upon trainee’s well-being and mental health, both positively and negatively. Together, the findings document the dynamic, nuanced aspects of junior doctors’ experiences of medical training and practice and highlights the importance of relational connections and the workplace environment in shaping JMOs’ social and emotional well-being.

Conclusion

The current study adds to the understanding of how junior doctors navigate medical training in Australian hospitals and highlights the complexities of this experience, particularly the ways in which mental health and well-being are shaped by different elements. These findings have important implications to inform new strategies to improve JMO mental health and to leverage work and non-work contexts to better support JMOs during medical training.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07381-5.

Well-Being, Burnout, and Resiliency Among Early-Career Rheumatologists: A Qualitative Study

BACKGROUND/OBJECTIVE

Physician well-being is being increasingly recognized for its important role in high-quality patient care, integrity of the healthcare system, and vitality of the workforce. However, little is known about well-being, resiliency, and burnout among rheumatologists, particularly early-career rheumatologists. In this qualitative study, the investigators explore these concepts among early-career rheumatologists.

METHODS

We performed a qualitative study using semistructured phone interviews of rheumatologists who completed fellowship in 2017. Participants were recruited through purposive sampling. Twenty questions were devised by the investigators, covering sample demographics, exploring definitions of well-being, resiliency, and burnout, and probing potential solutions.Interviews were recorded and transcribed independently and verified for consistency. The investigators used grounded theory to code the transcripts and iteratively derive categories, subthemes, and themes until reaching theoretical sufficiency.

RESULTS

Sixty-four rheumatologists were interviewed, accounting for 30.6 hours of material. Seven major themes were identified: (1) well-being as a holistic state where an individual is able to translate one's potential to maximal performance, (2) work-family balance as a dynamic equilibrium changing over time, (3) inadequacy of training in addressing self-doubt over autonomy, (4) uncertainty over career development and progression, (5) excessive administrative burdens, (6) protective nature of longitudinal relationships, and (7) addressing burnout requires a multifaceted approach at multiple levels.

CONCLUSIONS

New rheumatologists face a series of challenges as they enter the workforce. Investments into well-being can help reduce the risk of burnout and enlarge our community. Our results highlight drivers and potential solutions, as identified by recent fellowship graduates.

Transition from trainee to educator in the operating room: A needs assessment and framework to support junior faculty

BACKGROUND

Transitioning from trainee to attending surgeon requires learners to become educators. The purpose of this study is to evaluate educational strategies utilized by surgeons, define gaps in preparation for operative teaching, and identify opportunities to support this transition.

METHODS

A web-based, Association of Surgical Education approved survey was distributed to attending surgeons.

RESULTS

There were 153 respondents. Narrating actions was the most frequently reported educational model, utilized by 74% of junior faculty [JF] (0-5yrs) and 63% of senior faculty [SF] (>6yrs). Other models used included educational time-outs (29% JF, 27% SF), BID teaching model (36% JF, 51% SF), and Zwisch model (13% JF, 25% SF). Compared with 91% JF, 65% SF reported struggling with instruction (p < 0.001). Five themes emerged as presenting difficulty during the resident to attending transition: lack of relationships, ongoing learning, systems-based, cognitive load, impression management.

CONCLUSIONS

Our results represent a needs assessment in the transition from learner to educator in the OR.

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.

Contextual Competence: How residents develop competent performance in new settings

INTRODUCTION

Medical education continues to diversify its settings. For postgraduate trainees, moving across diverse settings, especially community-based rotations, can be challenging personally and professionally. Competent performance is embedded in context; as a result, trainees who move to new contexts are challenged to use their knowledge, skills and experience to adjust. What trainees need to adapt to and what that requires of them are poorly understood. This research takes a capability approach to understand how trainees entering a new setting develop awareness of specific contextual changes that they need to navigate and learn from.

METHODS

We used constructivist grounded theory with in-depth interviews. A total of 29 trainees and recent graduates from three internal medicine training programmes in Canada participated. All participants had completed at least one community-based rotation geographically far from their home training site. Interviews were recorded, transcribed and anonymised. The interview framework was adjusted several times following initial data analysis.

RESULTS

Contextual competence results from trainees' ability to attend to five key stages. Participants had first to meet their physiological and practical needs, followed by developing a sense of belonging and legitimacy, which paved the way for a re-constitution of competence and appropriate autonomy. Trainee's attention to these stages of adaptation was facilitated by a process of continuously moving between using their knowledge and skill foundation and recognising where and when contextual differences required new learning and adaptations.

DISCUSSION

An ability to recognise contextual change and adapt accordingly is part of Nussbaum and Sen's concept of capability development. We argue this key skill has not received the attention it deserves in current training models and in the support postgraduate trainees receive in practice. Recommendations include supporting residents in their capability development by debriefing their experiences of moving between settings and supporting clinical teachers as they actively coach residents through this process.

Transitioning to Practice: Getting up to Speed in Efficiency and Accuracy

The transition from trainee to breast radiologist is challenging. The many new responsibilities that breast radiologists acquire while establishing themselves as clinicians may increase stress and anxiety. Taking inventory of existing knowledge and skills and addressing deficits toward the end of one's training can be beneficial. New breast radiologists should expect to be slower and gain proficiency in the first several years out of training. Having realistic expectations for oneself with respect to screening mammography interpretation and following up on the subsequent diagnostic imaging workup of screening callback examinations can increase competence and confidence. Familiarity with the available literature to guide management in the diagnostic setting can increase efficiency. Planning ahead for localizations and biopsies also allows for efficiency while alleviating anxiety. Ultimately, adapting to a new work environment using a collaborative approach with primary healthcare providers, pathologists, and surgeons while remembering to have mentors within and beyond the field of radiology allows for a more successful transition.

Transition to Independent Surgical Practice and Burnout Among Early Career General Surgeons

Background: The transition from surgical residency to independent practice is a challenging period that has not been well studied. Methods: An email invitation to complete a 55-item survey and the Maslach Burnout Inventory-Human Services Survey (MBI-HSS) was sent to early career general surgeons across Canada. The chi-square test or Fisher's exact test was used to compare demographic and survey characteristics with burnout. Multivariable logistic regression was performed. Results: Of the 586 surgeons contacted, 88 responded (15%); 51/88 surgeons (58.0%) were classified as burnt out according to the MBI-HSS. Most surgeons (68.2%) were not confident in their abilities to handle the business aspect of practice. The majority (60.2%) believed that a transition to independent practice program would be beneficial to recent surgical graduates. Conclusions: Our data showed high prevalence of burnout among recently graduated general surgeons across Canada. Further, respondents were not confident in their managerial and administrative skills required to run a successful independent practice.

On the Transition to Attendinghood

Medical education and training consists of a series of stepped transitions, each marked by increasing autonomy and responsibility. Perhaps the most formidable transition begins upon the completion of one's training and stretches well into the first year of "attendinghood." This period is often defined by colossal changes that can extend far beyond the workplace and that are largely inconceivable beforehand. These changes can have important implications for job satisfaction, well-being, and resilience, especially in oncology, where rates of work-related burnout are particularly high. Unfortunately there is no "standard of care" or evidence-based guideline on how best to approach this period. However, it must be highlighted and deliberately discussed among current fellows and recent graduates not only to stimulate further study but also to provide support and community for those approaching or going through this transition.

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.

Perceptions and processes influencing the transition of medical students from pre-clinical to clinical training

BACKGROUND

The transition from pre-clinical to clinical medical training is often characterised by several challenges which may have different impacts on students' well-being and learning experiences. To ensure smooth transition, it's important to understand how these students navigate through the challenging processes.

METHODS

This study employed a mixed-methods design using a survey, focus groups and interviews among medical students who had entered their first clinical year of study (Year 4). Using a 5-point Likert scale, survey participants rated items which related to their transition experience in the areas of professional socialisation; workload; patient contact; knowledge and skills; and learning and education. The qualitative questions explored challenges in transition, coping strategies and recommendations to foster smooth transitioning. The survey data was analysed using descriptive and inferential statistics while thematic analysis was used to establish emerging themes from the qualitative data. The Westerman Transition Framework was utilised in the triangulation of study findings.

RESULTS

A total of 141 students participated in the survey while 12 students participated in the focus group discussions and interviews. The quantitative part of the study showed that the students were anxious about the process and considered the workload to be heavy while also identifying gaps in their knowledge. Similarly, the qualitative findings revealed that workload and professional socialisation were identified as disruptive novel elements and the students also reported feelings of inadequacy and incompetence due to perceived knowledge gaps. These shortcomings and challenges were tackled by seeking support from peers and senior medical students as a way of coping with the anxiety and stress. As the students progressed, they admitted and accepted that the transition was a gradual process and an essential learning curve.

CONCLUSION

The process of transitioning from preclinical to clinical years is considered stressful and abrupt with the introduction of disruptive novel elements that create feelings of incompetence and unpreparedness in students. Educators need to consider developing social and developmental strategies that emphasise nurturing and empowering clinical learning environments and facilitate reflective and transformative life-long learning opportunities for students.

Practical solutions for implementation of Transition to Practice curricula in a competency-based medical education model

BACKGROUND

Although transition from residency to practice represents a critical learning stage, there is a paucity of literature to inform local curriculum development and implementation.

OBJECTIVES

To describe local curriculum development for Transition to Practice (TTP) for use within a competency-based medical education model, including important content and suitable teaching and assessment strategies.

DESIGN

We reviewed the literature to construct a definition and develop initial curriculum content for TTP. We then gathered local residency program directors' views on TTP content, teaching, and assessment via online survey and an international educational conference workshop.

RESULTS

We identified 21 important TTP content areas in the literature and analyzed 35 survey responses, representing 33 residency programs. Survey participants viewed Further sophistication of clinical skills, How to set up a practice, and Time management skills as the three most important content areas. Views on content importance varied by program. For teaching and assessment strategies, most respondents preferred: assessing what residents could do, providing real-life practice opportunities, and offering workplace-based assessments.

CONCLUSIONS

TTP curricula implementation should reflect nationally set, specialty-specific curriculum elements; locally developed priority content; and assessment and teaching strategies. Individual learner needs and imminent practice context should guide faculty approaches to curriculum delivery.Résumé.

Growth curves: The experiences of Canadian paediatricians in their first 5 years of independent practice

Objectives

Completing training is a rite of passage common to all physicians, yet our knowledge of the components in postgraduate paediatric education that equip learners for successful transition to practice is limited. In order to optimally design training programs, it is critical to develop a better sense of what early career paediatricians (ECPs) experience as they navigate this time of transition.

Methods

We created and distributed a 23-question survey via e-mail to 481 Canadian ECPs in September 2017, specifically to those who received Royal College certification in 2011 or later. Survey responses were obtained confidentially through an online platform (Survey Monkey). Descriptive statistics and thematic analysis were used to analyze responses to closed-ended and free text questions, respectively.

Results

Response rate was 42% with nearly 70% of the respondents self-identifying as general paediatricians. Factors facilitating transition to practice included: dedicated mentorship; supportive new colleagues and workplace environment; and ease of finding work. Identified challenges included: billing, finances, and practice management; adjusting to a different scope of practice and learning local resources; managing comfort level; and achieving work-life balance. Nearly half of the respondents expressed interest in mentoring new ECP colleagues.

Conclusions

Our findings suggest that ECPs find clear value in mentorship, but desire further support to adapt to new practice contexts and activities. As a result, we must consider strategies in both individual programs and nationally that effectively prepare learners prior to transition and align with needs in the first years of independent practice.

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.

Qualified but not yet fully competent: perceptions of recent veterinary graduates on their day-one skills

BACKGROUND

The goal of veterinary education is to prepare learners to successfully enter the profession. However, the transition from learner to professional can be an intense and stressful phase. In this study, recently graduated veterinarians' perceptions of readiness to work independently and to successfully cope with early career challenges are addressed.

METHODS

A survey based on five commonly occurring entrustable professional activities (EPAs) in primary care was sent to newly qualified veterinarians (graduated between six months and three-and-a-half years ago and working in primary veterinary clinics). The survey was a combination of open and Likert scale-type questions and contained items on the self-reported need for supervision for these EPAs. One hundred and fifty-six participants (response rate 41.2 per cent) answered the survey. Descriptive statistics were used to analyse and present the quantitative data.

RESULTS

The day-one after graduation levels varied per EPA between 'with direct, proactive supervision' and 'supervision at a distance'. On average after 6.8 months participants felt ready to execute all five tasks with distant supervision. After almost 10 months, participants had the feeling of being fully competent to execute the EPAs unsupervised.

CONCLUSION

This study provides insight into early career challenges faced by recently graduated veterinarians. The results emphasise the importance of adequate preparation of veterinarians during education and the importance of guidance during early career to foster a successful transition from veterinary school to clinical practice.

Practice patterns among early-career primary care (ECPC) physicians and workforce planning implications: protocol for a mixed methods study

INTRODUCTION

Canadians report persistent problems accessing primary care despite an increasing per-capita supply of primary care physicians (PCPs). There is speculation that PCPs, especially those early in their careers, may now be working less and/or choosing to practice in focused clinical areas rather than comprehensive family medicine, but little evidence to support or refute this. The goal of this study is to inform primary care planning by: (1) identifying values and preferences shaping the practice intentions and choices of family medicine residents and early career PCPs, (2) comparing practice patterns of early-career and established PCPs to determine if changes over time reflect cohort effects (attributes unique to the most recent cohort of PCPs) or period effects (changes over time across all PCPs) and (3) integrating findings to understand the dynamics among practice intentions, practice choices and practice patterns and to identify policy implications.

METHODS AND ANALYSIS

We plan a mixed-methods study in the Canadian provinces of British Columbia, Ontario and Nova Scotia. We will conduct semi-structured in-depth interviews with family medicine residents and early-career PCPs and analyse survey data collected by the College of Family Physicians of Canada. We will also analyse linked administrative health data within each province. Mixed methods integration both within the study and as an end-of-study step will inform how practice intentions, choices and patterns are interrelated and inform policy recommendations.

ETHICS AND DISSEMINATION

This study was approved by the Simon Fraser University Research Ethics Board with harmonised approval from partner institutions. This study will produce a framework to understand practice choices, new measures for comparing practice patterns across jurisdictions and information necessary for planners to ensure adequate provider supply and patient access to primary care.

Enriching medical trainees' learning through practice: a video reflexive ethnography study protocol

INTRODUCTION

Supporting medical students' and junior doctors' development in busy clinical settings is challenging. As opportunities for developing trainees, for example, traditional bedside teaching, are decreasing, teaching outside of clinical practice is increasing. However, evidence suggests that effective learning through practice arises via an interplay between, first, what experiences are afforded by clinical settings and, second, how trainees engage with these affordances. Many studies investigating clinician learning through practice focus on only one of these two factors. Yet, a well-recognised methodological challenge of enabling learners to articulate how and what they are learning through practice exists. We need, therefore, to understand how this relationship plays out in practice in ways that enrich learning.

METHODS AND ANALYSIS

This protocol describes a video reflexive ethnographic approach to illuminate how learning through practice in hospital settings occurs and can be enriched. The study will be conducted in two phases. In phase I, senior clinicians from emergency medicine, medicine and surgical specialties will be interviewed about how they guide trainees' learning through practice. These forms of guidance, analysed using the framework method, will inform phase II comprising observations of practice in: (1) emergency, (2) medical and (3) surgical departments. Video recorded episodes of clinicians' guiding learning through practice will be shared and appraised in reflexive sessions with each clinical team. Relational interdependent learning theory informs the design and data analyses to elicit and evaluate strategies for guiding learning through practice.

ETHICS AND DISSEMINATION

Ethical approval has been received from both healthcare and university settings. The findings should provide important insights for clinicians about workplace learning practices. Findings will be disseminated across the project phases and to diverse audiences-locally, nationally and internationally. The dissemination strategy will use seminars, grand rounds, conference presentations and academic papers to articulate practical, theoretical and methodological findings.

A 9-Step Theory- and Evidence-Based Postgraduate Medical Digital Education Development Model: Empirical Development and Validation

BACKGROUND

Digital education tools (e-learning, technology-enhanced learning) can be defined as any educational intervention that is electronically mediated. Decveloping and applying such tools and interventions for postgraduate medical professionals who work and learn after graduation can be called postgraduate medical digital education (PGMDE), which is increasingly being used and evaluated. However, evaluation has focused mainly on reaching the learning goals and little on the design. Design models for digital education (instructional design models) help educators create a digital education curriculum, but none have been aimed at PGMDE. Studies show the need for efficient, motivating, useful, and satisfactory digital education.

OBJECTIVE

Our objective was (1) to create an empirical instructional design model for PGMDE founded in evidence and theory, with postgraduate medical professionals who work and learn after graduation as the target audience, and (2) to compare our model with existing models used to evaluate and create PGMDE.

METHODS

Previously we performed an integrative literature review, focus group discussions, and a Delphi procedure to determine which building blocks for such a model would be relevant according to experts and users. This resulted in 37 relevant items. We then used those 37 items and arranged them into chronological steps. After we created the initial 9-step plan, we compared these steps with other models reported in the literature.

RESULTS

The final 9 steps were (1) describe who, why, what, (2) select educational strategies, (3) translate to the real world, (4) choose the technology, (5) complete the team, (6) plan the budget, (7) plan the timing and timeline, (8) implement the project, and (9) evaluate continuously. On comparing this 9-step model with other models, we found that no other was as complete, nor were any of the other models aimed at PGMDE.

CONCLUSIONS

Our 9-step model is the first, to our knowledge, to be based on evidence and theory building blocks aimed at PGMDE. We have described a complete set of evidence-based steps, expanding a 3-domain model (motivate, learn, and apply) to an instructional design model that can help every educator in creating efficient, motivating, useful, and satisfactory PGMDE. Although certain steps are more robust and have a deeper theoretical background in current research (such as education), others (such as budget) have been barely touched upon and should be investigated more thoroughly in order that proper guidelines may also be provided for them.

Self-Assessment of Preparedness among Critical Care Trainees Transitioning from Fellowship to Practice

This study evaluated the subjective assessment of preparedness needs of critical care trainees and recent graduates between 2013 and 2014. A questionnaire was developed and validated by the subcommittee of the In-Training Section of Society of Critical Care Medicine (SCCM). The survey was deployed twice between December 2013 and January 2014 via email to any trainee or individual graduated from a critical care fellowship within the previous three years. Six percent (180) of all individuals completed the survey, and 67% of respondents had recently interviewed for a job. Northeast was the preferred location for a job (47%), and academia was favored over private practice (80% vs. 15%). Of the respondents that secured an interview, 55% felt prepared for the interview, 67% felt prepared to build an adequate job portfolio, 33% received formal guidance from their mentor/training program. 89% of total respondents agreed it is important to participate in a formal training course in job search, portfolio development, and interviewing process. The preferred sources of training were equally distributed between their home institution, webinars, and SCCM. There is an ongoing need in education regarding the transition period from fellowship to practice.