When June 23rd rolls around each year, I remember the very first day of my residency. It was a great, immensely significant—and wholly terrifying—moment in my life.
Despite being very well prepared, I, of course, did not feel ready at all. I did not feel ready for the responsibilities of caring for so many patients. I did not feel ready for the new hospital systems and staff. I was ready for a paycheck but not for the mountain of paperwork from Human Resources and the new dual role as learner–employee. And I certainly did not feel ready for all that I would see and experience in that crucial, formative year.
I survived, of course, and I learned something very important. Day 1 of one’s internship is, in fact, not nearly as frightening as Day 1 of the second year of residency, when you are responsible for your team’s brand-new interns facing their first day, not feeling quite ready.
In this issue of our journal, we have several articles 1–5 on the transition from undergraduate medical education (UME) to graduate medical education (GME). These articles have been written by and for stakeholders in health professions education, including learners, teachers, and leaders in academic medicine and health systems.
According to Hauer et al 1 of the Coalition for Physician Accountability (CoPA), the transition from UME to GME is, in its ideal state,
a system to support a continuum of professional development and learning, thus serving learners, educators, and the public, and engendering trust among them. It also supports the well-being of learners and educators, promotes diversity, and minimizes bias.
Challenges to attaining this ideal state in the undergraduate-to-graduate transition, noted by Swails et al 2 (also of CoPA) in their root cause analysis, include bias, limited resources and cost, a competitive culture, poorly functioning systems, a lack of adequate standards, and lack of sufficient alignment across systems and stakeholders, all of which generate an “ineffective” transition.
This analysis overlaps with 3 persistent issues, identified by Hauer et al, 1 that require greater ongoing attention and management. First, present approaches to assessment are not suited to ranking and sorting candidates for GME placement. A second issue is the inherent tension in the role of resident as a health professions learner and a health system worker. And a third concern is that the current Match process may position the interests and needs of individual physicians-in-training at odds with the interests and needs of the health care workforce and public.
Financial burdens carried by medical students and residents are an additional concern, raised in a commentary by Lin et al 3:
We are acutely aware of the high and growing costs of away rotations, application fees…, and in-person interviews and second looks—on top of increasing median education debt, now greater than $200,000.
The authors, who are former trainee representatives of CoPA, advocate that undergraduate and graduate medical learners be collaborative partners and agents of change in the current system. Lin et al 3 also highlight 2 key recommendations from a final report of CoPA: forming a national committee to manage quality improvement of the UME–GME transition and having pilot interventions to reduce the growing number of residency applications.
The idea of reducing residency application numbers through application “limits” was the most popular possible solution endorsed in a qualitative study performed by Dacre et al. 4 In this project, authors used semistructured interviews to ask 30 participants from 9 medical specialties about 5 residency application reform proposals. The proposals were (1) using a match process to obtain interviews, (2) having preference signaling during the application process, (3) introducing application limits, (4) disclosing geographic preference(s), and (5) eliminating the Match. None of the proposals was embraced by all participants. Interestingly, only 3 of 25 participants agreed with dismantling the Match, and a number of participants expressed concern that such a step would hurt students’ interests. Almost all participants felt that system change was nevertheless warranted, particularly with respect to problems of equity, complexity, or poor outcomes.
The benefits of virtual residency interviews over traditional in-person interviews are outlined by Hampshire et al, 5 who note that the use of virtual interviews reduces the carbon footprint of the field of medicine and fosters greater equity by reducing the cost burden for applicants.
Other recommendations offered by our colleagues are related to developing a common competency framework with aligned assessments, introducing workforce diversity evaluations and equitable recruitment practices, and increasing attention to data-driven studies to improve the UME–GME transition. The authors of several articles 1–4 in this cluster emphasize the need for greater transparency at institutional and national levels and the need for pilot studies of novel programs that could improve matching with preferred programs and, at the same time, produce a more even distribution of physicians and a strengthened medical workforce in the United States.
Taken together, this guidance resonates with past scholarship appearing in Academic Medicine in which Morgan et al 6 emphasized the importance of a responsible educational handover at the UME–GME juncture. The ideal educational handover is one that is learner driven; oriented toward continuous, individualized learning; supported by accurate performance data and appropriate institutional infrastructure; and genuinely helps students actually be prepared for the care of patients. Past work appearing in the journal has similarly reinforced the importance of greater emphasis on competency-based assessments (such as discussed by Murray et al 7), and better preparation in the last year of medical school. 8
“An ideal state cannot be achieved quickly or without compromise,” caution Hauer et al, 1 who also invite our field to seek change, celebrate “early wins,” and show “ongoing flexibility and adaptation.” The experiences of the past few years suggest that we are capable of constructive change, as the example of virtual residency interviews, born out of necessity during the pandemic, illustrates. 5
First days will always be difficult, but we in the field of academic medicine can care for future physicians and their patients by making the transition from UME to GME as seamless and supported as possible. The well-being of our learners, educators, and, most importantly, their patients and the public is at stake.
1. Hauer KE, Williams PM, Byerley JS, Swails JL, Barone MA. Blue skies with clouds: Envisioning the future ideal state and identifying ongoing tensions in the UME-GME transition. Acad Med. 2023;98:162–170.
2. Swails JL, Angus S, Barone MA, et al. The undergraduate to graduate medical education transition as a systems problem: A root cause analysis. Acad Med. 2023;98:180–187.
3. Lin GL, Guerra S, Patel J, Burk-Rafel J. Reimagining the transition to residency: A trainee call to accelerated action. Acad Med. 2023;98:158–161.
4. Dacre M, Branzetti J, Hopson LR, Regan L, Gisondi MA. Rejecting reforms, yet calling for change: A qualitative analysis of proposed reforms to the residency application process. Acad Med. 2023;98:219–227.
5. Hampshire K, Shirley H, Teherani A. Interview without harm: Reimagining medical training’s financially and environmentally costly interview practices. Acad Med. 2023;98:171–174.
6. Morgan HK, Mejicano GC, Skochelak S, et al. A responsible educational handover: Improving communication to improve learning. Acad Med. 2020;95:194–199.
7. Murray KE, Lane JL, Carraccio C, et al.; Education in Pediatrics Across the Continuum (EPAC) Study Group. Crossing the gap: Using competency-based assessment to determine whether learners are ready for the undergraduate-to-graduate transition. Acad Med. 2019;94:338–345.
8. Pellegrini VD Jr, Franks AM, Englander R. Finding greater value in the fourth year of medical school: Accelerating the transition to residency. Acad Med. 2020;95:527–533.