The transition from medical school to residency is a precarious moment in medical training. From the instant medical students become doctors and enter residency, they assume new, independent responsibility for learning, managing professional relationships, and caring for patients. Along with this abrupt transition come questions about whether graduating medical students are prepared for these new responsibilities. Residency directors worry that new doctors cannot consistently perform activities that will be required of them.1–3 Even more concerning is that doctors face the highest risk for depression and suicide in the first few months of their residency training.4,5 Stabilizing this transition to improve the well-being of residents and their patients has become a priority for the health professions community. Efforts include curricular interventions at the end of medical school and beginning of residency as well as enhanced handoffs between educators. But little is known about how residents perceive the transition experience. Consequently, it is unclear how best to tailor these efforts to optimize the transition.
In the United States, half of medical schools offer courses in the final year (e.g., capstone courses) aimed at enhancing the transition to residency.6 A meta-analysis demonstrated that these courses can improve learners’ clinical knowledge, skills, and confidence.7 However, residents’ learning needs may center on situational awareness, professional skills (e.g., time management, communication), and identifying the limits of their understanding, rather than the knowledge and skills that are being addressed in these courses.8 Some schools have created a post-Match educational handoff to communicate performance information from undergraduate medical education (UME) to graduate medical education (GME) faculty so that program directors are aware of the strengths and weaknesses of their new interns.9,10 Many institutions are working to assess performance across the Core Entrustable Professional Activities for Entering Residency11 and other frameworks for defining specific competencies expected of new doctors, but the optimal process, feasibility, and use of these assessments to enhance the transition to residency have not yet been defined.12,13
As these efforts to enhance instruction, assessment, and feedback to senior medical students and new residents proliferate, it remains unclear how the information gathered can best be used to improve learners’ experience of the transition to residency. Understanding how new residents experience both expected and unexpected challenges of the transition could inform how educators support them through this important step in their professional development. The study aimed to explore the learner perspective on the transition to residency and to develop a conceptual model for how newly minted doctors experience the transition from medical student to resident to guide future educational interventions.
This prospective, qualitative study used semistructured, one-on-one telephone interviews and borrowed coding processes from grounded theory14 with the aim of better understanding the learner experience of the transition to residency. The New York University Grossman School of Medicine (NYUSOM) Institutional Research Board approved this study (i18-01351).
Setting and participants
A purposive sample of participants was recruited from the cohort of NYUSOM medical students who participated in the weeklong Transition to Residency (TTR) course in April 2018. This intensive elective for fourth-year students reviews a broad range of general knowledge and skills needed for the first year of residency. The course is designed to help participants approach learning from the perspective of a physician instead of a student. In addition to refresher lectures on preclinical and clinical coursework, the course includes simulations focused on specialty-specific issues that arise for new residents. GME faculty and residents deliver workshops in small groups that allow interaction and tailoring of content to students’ learning needs (e.g., radiology, EKG workshops).
All 77 of the April 2018 TTR participants (51.6% of the NYUSOM class of 2018) were invited at the end of the course to participate in future studies. Twenty-seven (35%) provided their personal email addresses and gave permission to be contacted a few months into their residency training. Of those 27, 10 expressed interest in participating in this study and were enrolled to participate as first-year residents. These 10 residents had a consistent undergraduate experience: They attended the same medical school, graduated in the same year, and demonstrated engagement in and awareness of the transition to residency experience. They were enrolled in a range of residency programs across the United States, including internal medicine (n = 4), pediatrics (n = 4), neurology (n = 1), and interventional radiology (n = 1), and 50% (n = 5) were members of the Alpha Omega Alpha Honor Medical Society (AΩA).
A member of the research team (K.L.E.) with no prior relationship with the residents enrolled the 10 study participants via email from December 2018 to April 2019. K.L.E. obtained informed consent from all study participants and performed all telephone interviews. After completing the telephone interviews, participants were provided with a $50 electronic gift card as compensation for their time.
The semistructured interview guide (available as Supplemental Digital Appendix 1 at https://links.lww.com/ACADMED/A955) was developed through iterative review by the TTR course directors (L.Y.C. and A.F.W.), a postdoctoral research scientist in medical education (K.L.E.), and a project coordinator in the Office of Medical Education (D.T.C). It was then shared with medical educators and junior residents across medical specialties, and their expert input was incorporated into the final interview guide. K.L.E. conducted all 10 telephone interviews, which ranged from 40 to 60 minutes each. The interviews were audiorecorded and then professionally and digitally transcribed. K.L.E. reviewed the transcripts against the audio recordings to verify their accuracy. Each deidentified transcript was assigned a unique identifier (starting at 10) based on the order in which the interviews were performed.
The research team used a constructive orientation to identify themes that were common across the interview transcripts.15 A 3-phase coding process used grounded theory methodology to analyze the data using a constant comparison approach.14,16,17 First, A.F.W., L.Y.C., and K.L.E. independently coded the transcripts by assigning inductive, content-driven labels to text segments (open coding). The initial 3 interviews were coded by all 3 researchers. The remaining 7 interviews were all coded by A.F.W. and one other member of the team (L.Y.C. or K.L.E.). A.F.W. reviewed all coded transcripts and created a single, final document that reflected the complete coding scheme. Three researchers (A.F.W., L.Y.C., K.L.E.) met regularly to discuss the initial codes, identify the codes that addressed the research questions, discover relationships across the relevant codes, and organize them into categories. The final codebook containing 46 codes remained stable after 6 interviews. Reflective memos kept by all researchers were reviewed along with the coding framework at regular meetings. Broader themes emerged during the final phase of data analysis of the categories. Thematic saturation occurred after 9 interviews. A tenth interview confirmed the final analysis and thematic saturation. At each of the 3 stages, the data analysis was triangulated during discussions with a multidisciplinary group of UME and GME educators and the Primary Care Research on Medical Education Outcomes team at NYUSOM. Based on the themes, the research team developed a conceptual model of the learner experience of the transition from medical student to resident.
From the perspective of new residents, developing professional identity is the core construct of the transition experience from medical student to resident. Across the interviews, the residents describe the process of “feeling more like a doctor” (Participant 15). They describe an implicit curriculum of professional development occurring through an immersive process of navigating their new role. Eight categories describe the transition experience, grouped into individual aspects—professional identity, self-awareness, professional growth, approach to learning, and personal balance—and external aspects—professional relationships, context of learning, and challenges in the context of their new roles (Table 1). Across these categories, 5 themes emerged. These themes describe an abrupt entry into an immersive experience characterized by interactions with patients and health care team members in the learning environment, generating a wide range of emotional reactions and creating challenges the new doctors struggle to address as they strive to find balance between work and life outside medicine.
Abrupt change in educational environment from medical school to residency.
Participants describe a sudden shift from the organized and structured learning environment of medical school to the less controlled and more authentic reality of learning in the clinical environment of residency. While the residents are not surprised by the differences, they feel unprepared. Although they report medical school gave them the necessary foundation, they commonly share the sentiment that “there’s no way really to prepare” (Participant 17). They have a sense that medical school gave them the required knowledge, but before the lived experience of residency, they did not have a chance to practice navigating the practical challenges of applying their knowledge in the context of responsibility for patients. One says:
At this point, I know how to make an assessment statement, but my goals are more about how to make sure that the differential [diagnosis] is complete or how to think about next steps in management so if this thing doesn’t work out, what am I gonna do 2 days from now? (Participant 11)
Residents find it particularly challenging to get used to new institutions and workflows and to adjust to a new focus on efficiency. They struggle more with aspects of the work that do not align with their perceptions of doctors’ work: “More clerical or nonmedicine stuff in terms of social work or case management or discharge … this is not why I went into medicine” (Participant 16). They describe these as challenges they can face only when situated in the training environment. One resident talks about the “things in terms of time management and being efficient that you just can’t learn in med school. You don’t have this type of responsibility” (Participant 14). Residents feel the preparation medical school provided them was inadequate because the context of practice is so unfamiliar. Being abruptly challenged to learn independently while holding responsibility for patient care requires different habits and skills than those they honed in medical school.
Immersive and experiential nature of learning as a resident.
The participants describe feeling overwhelmed by a sense of immersion in the clinical environment. The volume of clinical work and the omnipresence of nonclinical, administrative tasks get in the way of the reflection that allowed them to put the pieces of their learning process together as medical students. They describe an increase in the volume of work, incomplete information to make decisions needed for patient care, and pressure to prove they deserve to be in their new role. Moreover, they must learn prioritization of administrative tasks and clinical efficiency, which had not been part of their medical school experience. They also describe being unused to the challenge of balancing this volume of medical work with their personal lives:
I think it all comes down to how immersive the job is. When you’re there up to 80 hours a week, in a job that’s emotionally taxing, where you’re seeing people whether it’s die or suffer or you’re in an unusual and sometimes dismal place. It’s very immersive, and so coming out of that is not as easy as flipping a switch. (Participant 10)
Several participants refer to a sense of being swept up into the process of working within the clinical environment and realizing that learning occurs as an almost passive by-product that they can see only in retrospect. One explains: “It’s just going to hit you and you have to be calm and just move through the process and trust that you will come out knowing everything that you need to know” (Participant 17). A few participants comment that the interview for this study is the first time they have had the time and structure in place to reflect on the experience since starting residency.
Most residents describe feeling increasing comfort over time. One anticipates caring for patients on a future rotation: “At this time, I don’t feel comfortable seeing them yet. I will. I’ll be fine. It only takes you a few days to really get into the swing of things” (Participant 14). They describe the overall experience as being abruptly immersed in the clinical environment and surrounded by novel challenges of clinical learning, administrative work, and life balance that provide the substrate around which the residents learn and develop a sense of their professional identities.
Ambivalence and tensions around new role.
Residents describe mixed feelings about the abrupt shift in responsibility. This shift is a source of motivation and perceived as a privilege, but its gravity can be overwhelming. Residents strive for autonomy and to meet expectations—both their own and the perceived expectations of others—to earn the “doctor” title they have assumed. One reflects, “If I’m going to be a doctor, [I] need to start making decisions and getting things going for [my] patients. That’s been both liberating and scary” (Participant 18). The residents feel they are expected to be able to do the work without making mistakes or missing details, and these perceived high expectations add to their stress. They often contradict themselves, revealing their internal conflicts around responsibilities related to their new roles.
Along with the weight of responsibility comes a welcome transition. The residents feel more useful compared with how they felt as medical students:
You have a purpose. A lot of times as a med student, you’re kind of standing around. (Participant 13)
You’re a crucial member of the care team and that is a fundamental change in your self-conception as a health care provider … but it can also come with more stress [be]cause you can put it upon yourself that you should be able to handle more or not be making any mistakes. (Participant 10)
To embrace this change—“to grow to just realize I’m the doctor now” (Participant 17)—the residents feel they must develop autonomy and demonstrate trustworthiness to merit this significant responsibility.
Holding this responsibility while simultaneously figuring out where their learning gaps are generates stress. One resident describes noticing that supervisors give residents more independence to allow for this kind of learning: “They wanted us to basically grow, so they kind of let us figure it out on our own, which I now appreciate, but was very stressful in the moment” (Participant 19). The residents recognize that the effort required to provide patient care creates powerful learning, but they also find this experience stressful.
Navigation of professional relationships.
A critical aspect of building identity within the role of doctor is navigating various professional relationships. The residents emphasize the importance of relationships within their residency teams and with clinical supervisors, allied health professionals, and patients. Successfully understanding and managing these relationships leads to greater confidence within their role identity. One describes the disappointment that comes when this process falls short:
My most challenging days have been when I had supervisors who weren’t particularly supportive or when I felt like I was really doing everything I could, be[ing] … as proactive and communicative and on top of things as possible, and … it still wasn’t good enough either for the patients or the people who were supervising me or for others’ expectations. (Participant 12)
Usually, the residents feel supported, describing a sense that “someone’s always checking you” (Participant 13). Earning the trust of colleagues and supervisors, and understanding these professional relationships, is a primary focus. Residents do not willingly share their vulnerability as they try to earn their supervisors’ respect.
Teams work closely for long hours at a time, providing important social support. Many residents describe their co-residents as tremendous sources of comfort and support. One expresses desire for a more open discourse about the challenges:
Residency is really, really, really hard, and I think more people are scared. Some people are open about it. Some people are not. But everybody’s kind of floundering. I think people should be open with that. (Participant 13)
These relationships among team members are characterized by a tension between the comfort, identity, and belonging they provide and the stress of the challenges new residents face while earning their place in the community.
Balance and integration of working in medicine with personal life and goals.
The residents describe feeling the need to reestablish balance to meet their personal needs and to fit into their social community outside of work. They identify dynamic tensions between the support and satisfaction they find in their personal identities, community, and habits, and the struggle to find time for these things alongside the schedule and demands of residency. Residents reflect on the ways they have had to adjust expectations in their lives based on the sheer workload and time pressures they have not previously experienced. One resident says:
Once I get home from work, I’m kind of just drained … I’m constantly deciding, do I stay up for an extra half an hour to be a normal person or do I just pass out immediately and go to sleep? (Participant 15)
This cycle of immersion, growth, and development requires tremendous energy on the part of the developing physician. Residents describe feeling motivated by the desire to acclimate and earn their place within the health care system and reach their professional aspirations, but they also feel tensions and tremendous stress within the experience.
Conceptual model of the learner experience of the transition from medical student to resident
Figure 1 depicts a conceptual model of the learner’s transition experience where professional identity (the nucleus) is surrounded by interactions with patients and other members of the medical team (intracellular elements depicted in the cytoplasm as mitochondria, nucleoli, and the Golgi apparatus) that create a substrate for learning and further development. The dynamic nature of the intracellular environment highlights the ways that interactions the new resident has with patients, resident colleagues, supervisors, and allied health professionals lead to cascades of learning and transformation. The permeable membrane represents the way the resident is part of the system and is both influenced by and influences the surrounding environment.
For the first-year residents who participated in this study, the core construct of their experience of the transition from medical student to resident was developing their new professional identity as doctors. Adjusting to the learning goals and experiences of residency as well as adjusting to the new pace and experiences of life as a doctor are simultaneous challenges of establishing homeostasis in this new identity. While new residents felt prepared in terms of medical knowledge, they felt unprepared for the priorities and patterns of working in the clinical environment and the challenge of adapting their personal identities to fit the rigorous demands of residency. They described an abrupt transition into a new learning environment where they were faced with new responsibilities and had to navigate the social, emotional, and logistical aspects of their new role. They described learning to care for patients and manage their personal routines, as well as gaining confidence in their new roles in the dynamic clinical environment. Our conceptual model of the developing professional identity as the nucleus located within a cell illustrates the importance of dynamic interactions with patients and other members of the medical team in the transformation of the learner from student to new doctor.
Understanding this perception of the transition experience suggests questions that could be explored with future research.18 Should educational interventions focus on expanding social connections between new residents and their team members, building skills of reflection or self-awareness, and developing organizational skills? Would introducing senior medical students to more authentic responsibilities be more useful in terms of preparedness for the transition than building clinical skills and knowledge? This description of the transition experience echoes sociocultural learning theories19 that view learning as innately tied to context and occurring as a by-product of participation in the community. Theories of workplace-based learning identify learning and participation as inseparable.20 The concept of learning in a community of practice states there is a learning curriculum distinct from the explicit teaching curriculum.21 This type of learning curriculum is reflected in the ways these residents described socialization and identity development as critical aspects of their learning, beyond the knowledge and skills taught in the explicit curriculum. While our conceptual model sacrifices some nuance of meaning, it serves as a visual image of the dynamic and immersive experience from the learner’s perspective.
This study suggests that development of professional identity often cannot take place until doctors-in-training are placed within the situation where they are occupying the role of doctor and assuming the responsibilities of a first-year resident. Electives and additional subinternships in the fourth year of medical school could be training grounds in which students could assume more authentic patient responsibility with more opportunity for feedback and support. In addition, cultivating positive teaching relationships within the training environment, both during the fourth year of medical school and the first year of residency, may encourage more positive development for residents. Coaching could be used in medical education, with faculty trained as coaches working with new physicians on building the skills of reflection and self-awareness that may help them individualize their learning and adapt to challenges.22 Coaching should focus not only on learners’ learning goals but also on personal issues related to integrating the learning experience into the rest of their lives.
For some residents, participating in this study provided a rare opportunity to reflect on their progress, learning goals, and developmental experiences. Reflection in GME has been used to enhance professional development.23 Based on an understanding of the transition experience as an immersive and somewhat overwhelming experience for the learner, we propose that curricular interventions that create structure and teach skills of reflection may reduce stress and stimulate adaptive learning.
The findings of our study echo research on the transition from residency into practice—another moment of discontinuity in professional development. Westerman et al have described how new attendings find this transition to be an abrupt shift as they bear final responsibility for patient care and need to learn to supervise trainees at a distance.24 Their experience is similar to that of new residents, with feelings of incompetence and fear gradually allaying as coping strategies develop and a sense of mastery emerges. In nursing, the phenomenon of “transition shock” has been described among new nurses entering the workforce after graduating from nursing school.25 These new nurses experience overwhelming feelings of anxiety and incompetence, which lead to decreased retention at the end of the first year and high turnover. Efforts to promote mentorship and collegial working relationships are seen as an important aspect of facilitating the transition from student to independent nurse. As in the experience of residents in this study, social support is crucial to easing difficult transitions from student to health care professional.
This analysis adds an important perspective to the conversation around the transition from medical student to resident. As educators focus on optimizing the transition to ensure the safest care of patients and the best support for learners, it is critical to understand how the learners experience it. This study had limitations, however. The participants in this study represented a homogeneous sample, but the thick description of their experience allowed strong themes to emerge that resonate with other research on this transition. Thematic saturation occurred within the analysis despite a somewhat small sample size. By the time the final interviews were conducted, the interviews reflected that the transition experience had passed and those residents were reflecting on an earlier time.
It is important to note that the study participants reflected a sample of activated learners who had similar educational backgrounds and demonstrated engagement with the transition to residency by participating in the TTR elective and in this research. Half of the participants were AΩA members, compared with about 20% of their graduating medical school class. This group’s experiences may not represent the experiences of other types of learners or learners in other settings, which limits transferability to other populations. Nonetheless, these residents’ descriptions of the profoundly destabilizing environment resonated strongly with the members of the research team and other educators who had worked closely with new doctors. While our conceptual model does not account for growth occurring within the individual, it does capture the dynamic interactions between the learner and the environment that shape and mold the professional development of the learner.
This study suggests that, from the perspective of learners, the most impactful efforts to improve the transition to residency will be those that focus on the way new residents adapt to working and learning within the context of their environment. Authentic learning experiences that allow new residents to feel responsibility for patient care, build professional relationships, navigate challenges, and receive support while they process the overwhelming nature of learning to practice medicine are likely to provide opportunities for a more gradual and adaptive transition into the role of doctor.
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