The transition from medical student to intern is typically a period of high stress in the professional development of a physician. New interns assume greater workloads and responsibilities while facing difficult clinical and social challenges,1 which can lead to stress and burnout.2 In addition, the quality of care that patients receive from interns during this transition period may be suboptimal. Yet, better-prepared medical school graduates could enhance the quality of care delivered, negating this so-called “July effect.”3
A previous study of program directors across multiple specialties identified several common struggles among new interns, including a lack of self-reflection and improvement, poor organizational skills, and underdeveloped professionalism.4 Additionally, Lypson and colleagues5 reported both that students from different medical schools do not enter their internships with a standard set of skills and that gaps exist between the skills interns possess and those their supervisors expect them to possess. The literature supports the notion that the fourth-year medical school curriculum does not address these needs effectively. A recent review of the literature by Walling and Merando6 revealed three recurring concerns about the fourth year of medical school—a lack of clarity about its educational purpose, problems in curriculum content and organization, and variability in educational quality of courses.
The internal medicine subinternship, or acting internship, is a rotation during which fourth-year students assume the role of an intern, working under the direct supervision of a senior resident or attending physician, typically in an inpatient setting. It has been a long-standing, integral component of the fourth-year curriculum of most medical schools. In 2002, the Clerkship Directors in Internal Medicine (CDIM) developed a formal set of subinternship curriculum guidelines based on a needs assessment survey of key stakeholders.7 Yet, a national survey of CDIM members in 2005 revealed that only 37% of internal medicine subinternships had a formal curriculum, further demonstrating the heterogeneity in the curriculum of even one of the most well-established rotations in undergraduate medical education.8
Meanwhile, graduate medical education is evolving with the introduction of the Next Accreditation System and the Milestones Project by the Accreditation Council for Graduate Medical Education (ACGME) in collaboration with certifying bodies and other stakeholders. One of the goals of this initiative is to develop an educational continuum that spans undergraduate, graduate, and continuing medical education, with a focus on competency-based teaching and evaluation. Such an educational continuum may lessen the stressful effects of transitions in medical education, such as the transition from medical student to intern or from resident to practicing physician. For such a continuum to be successful, stakeholders working together need to identify competencies that are expected at each level of training. To that end, members of the CDIM subinternship task force, working with the Association of Program Directors in Internal Medicine (APDIM) survey committee, developed a series of questions for the 2010 APDIM survey to determine which competencies or skills program directors in internal medicine expect from new medical school graduates.
Yearly, the APDIM survey committee develops and deploys a survey of U.S. internal medicine residencies to track program and program director characteristics, as well as to get input from program directors on current issues. In 2010, the CDIM subinternship task force submitted a 36-item questionnaire to be included on the survey. In August, the APDIM sent e-mails with program-specific hyperlinks to a Web-based questionnaire to each of the 377 member programs, representing 99.0% of the 381 ACGME-accredited U.S. categorical internal medicine residency programs. The survey development and implementation process has been previously described.9
The subinternship section of the survey asked program directors to prioritize a set of skills expected of new interns, assigning each skill a score on a five-point Likert scale (1, which is the lowest priority, to 5, which is the highest priority, with 3 being neutral). These 36 questions encompassed skills in several domains, including transitions of care (9 questions), working in health care teams (7 questions), advanced communication skills (8 questions), ethics and professionalism (3 questions), advanced learning skills (6 questions), and other skills (3 questions), cutting across several of the ACGME competencies. Program directors were also asked to write in the two skills that they felt were most important for new interns.
We summarized responses using mean (standard deviation [SD]) scores and number (%) in categories of interest. For each question, we combined responses of 1 and 2 into our “low” priority category and responses of 4 and 5 into our “high” priority category for statistical analysis. We used paired t tests to assess differences in mean rankings among items and Cochran–Mantel–Haenszel statistics to assess skill ranking differences between several demographic categories. To adjust for multiple comparisons, we set the threshold for significance at .01. We performed all statistical analyses using SAS 9.3 (SAS Institute Inc, Cary, North Carolina). The Mayo Clinic institutional review board approved this study.
Complete question descriptions and basic response rates are available online.10 We received survey responses from 282 (74.8%) of the 377 program directors. See Table 1 for a summary of respondents’ expectations of interns ranked by domain area and competency. Respondents gave “knowing when to seek assistance” the highest priority, with 270 (95.7%) giving it a high priority and none giving it a low priority score. With a mean (SD) ranking of 4.86 (0.41), it was ranked significantly higher than the next-highest-ranked item (“communicating with nurse/nurse triage,” which had a mean [SD] ranking of 4.31 [0.70], P < .0001). Respondents gave “communicating with nurse/nurse triage” the second highest priority, with 251 (89.0%) giving it a high priority score. More than 80% of respondents also gave a high priority score to “time management” (239 respondents, 84.8%; mean [SD] of 4.29 [0.75]), “communicating in a culturally sensitive manner” (227 respondents, 80.5%; mean [SD] of 4.14 [0.79]), and “information management (prioritizing skills)” (226 respondents, 80.1%; mean [SD] of 4.07 [0.75]). Respondents nearly uniformly agreed on their item rankings, with no differences across region, program size, or program director age or tenure (all P > .01).
The 282 respondents provided 559 free-text responses (see Table 2). Respondents most often wrote in organization, prioritization, and time management as the highest-priority skills, followed closely by the ability to perform a history and physical. The next three most frequently cited skills were related to effective communication, knowing when to ask for assistance, and oral presentation skills; interestingly, respondents listed medical knowledge and procedural experience only 16 times and once, respectively. The highly ranked skills in both the item rank list and the free-text responses were similar, with both lists containing communication skills, time management and prioritization, and knowing when to ask for assistance. The free-text responses also complemented the item rank list by adding the clinical skills component of performing a history and physical exam. When taken together, these data provide insight into what program directors are looking for in their new internal medicine interns.
Bridging the gap
To our knowledge, ours is the largest national study of internal medicine program directors’ perceptions of the skills that interns should possess before entering graduate medical education. The lack of significant statistical correlations between the characteristics of the program directors in our study suggests that they uniformly desired that their interns possess similar abilities. In addition, several of the highest-priority items fall into the domain of working in health care teams. This area has received much recent attention—the ACGME added working effectively in interdisciplinary teams to the internal medicine program requirements, and the Alliance for Academic Internal Medicine added this skill as one of the end-of-training entrustable professional activities required for all graduating internal medicine residents.
Other high-priority items, such as “information management (prioritizing skills)” and “time management,” show that program directors want new interns to enter graduate medical education with well-developed organizational skills and a high level of efficiency. The internal medicine subinternship, along with other courses in the fourth year of medical school, seems to be an ideal time to incorporate teaching these skills with the goal of improving medical students’ ability to transition successfully from undergraduate to graduate medical education. In addition to the heterogeneity of internal medicine subinternships,8 internal medicine educational leaders have yet to reach a consensus on what the rest of the fourth year of medical school should look like for medical students matching into internal medicine graduate medical education programs. By contrast, the specialty organizations for family medicine, obstetrics–gynecology, and surgery have developed well-defined recommendations for the fourth-year curriculum for medical students planning careers in those disciplines.7 Now is the perfect time for the academic internal medicine community to develop recommendations for the content of internal medicine subinternships specifically and the fourth-year curriculum in general that bridges the gap between medical school and graduate medical education.
Although we surveyed a large group of program directors and expect that their responses should be generalizable, our study has several limitations. First, our study was partially limited by the question selection and wording used on the 2010 APDIM survey in general and on the 36-item questionnaire submitted by the CDIM subinternship task force specifically. To overcome this limitation, we encouraged respondents to write in the two skills they thought were most important for new interns. Second, although most, if not all, of the skills listed were interdisciplinary and not specific to internal medicine, we only have the point of view of the internal medicine community. If the goal is to restructure the fourth year of medical school to better prepare all students for further training regardless of their specialty choice, then broader input is needed. As the internal medicine community moves toward revising the subinternship curriculum, gathering input from other stakeholders involved will be useful, particularly from clerkship and subinternship directors as well as new interns who may provide additional insights into the skill sets they wished they had possessed before the start of their internship. Despite these limitations, our data provide a framework to begin to bring constituencies together to examine the content of subinternships specifically and the fourth year of medical school in general, to enhance the readiness of our graduating students.
Graduate medical education is undergoing major reform that will undoubtedly influence future generations of physicians. A potential benefit of this reform is the opportunity to create an educational continuum across undergraduate, graduate, and continuing medical education. The identification of expected competencies or milestones at each level of training will help bridge the gaps between the levels of the educational continuum, making the transitions less abrupt and less stressful. Stakeholders should continue to collaborate in the this reform is the opportunity to create an educational continuum across undergraduate, graduate, and continuing medical education. The identification of expected competencies or milestones at each level of training will help bridge the gaps between the levels of the educational continuum, making the transitions less abrupt and less stressful. Stakeholders should continue to collaborate in the development of educational milestones in the curricula across the educational continuum so that professional growth is continuous and seamless. Stakeholders should use the results from our study to help guide the development of the milestones in each of the core competencies required during the subinternship as well as in other courses in the fourth year of medical school. Doing so will make the transition from medical school to internship less of a burden on interns, with the ultimate goal of providing higher-quality patient care and eliminating the “July effect.”
Acknowledgments: The authors are grateful for the support of the Clerkship Directors in Internal Medicine (CDIM) and its subinternship task force, the Association of Program Directors in Internal Medicine (APDIM), the members of the survey committee, and the program directors who completed the APDIM survey. Although the authors report the results of an APDIM survey, they do not speak for the organization, and this report does not constitute an official policy statement of CDIM, APDIM, the APDIM Council, or any other organization with which the authors may be affiliated.
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