Trainees' Perceptions of the Transition From Medical School to Residency

The transition from medical student to resident is characterized by a marked increase in responsibilities and clinical care demands.^1,2  Residency program directors from diverse specialties perceive that their first-year residents are suboptimally prepared for the expectations of residency.^3,4  There is also emerging evidence that the strain of this transition may contribute negatively to learner well-being, with increases in learner burnout and suicide risk during the first months of residency.⁵ 

In order to address these concerns, many medical schools have developed residency preparation courses (RPCs) for fourth-year students.^6–8  RPCs vary widely in terms of course length, skills, and content.⁹  While there is ample literature that RPCs effectively increase confidence and skills in the short term (ie, immediately post-course⁷), few studies have examined the lasting impact that RPCs have during residency.

Our objective was to determine whether residents and fellows from multiple specialties felt prepared for their intern year, and whether they perceived that they benefited from participation in an RPC. We anticipated that residents who completed an RPC entered intern year feeling prepared more often than those who did not participate.

We sent all residents and fellows at the University of Michigan (UM) an anonymous 15-question electronic survey. The survey was sent a total of 4 times over 6 weeks from July to August 2018.

Survey design involved using local content experts to adapt similar surveys that pertained to the fourth year of medical school and the transition from medical school to residency,^1,10,11  contributing to content validity. We reviewed published resident surveys.¹²  Multiple rounds of piloting with faculty directors of the RPCs (D.T.H., J.S., L.A.H.) and residents at UM led to revisions, with an eye to optimizing response process validity.

Respondents reported their age, gender, residency specialty, and current postgraduate year (PGY). The complete survey, as well as respondent demographics, is included as supplemental material. Specialties were grouped as non-procedural and procedural as previously described in the literature.³ 

The primary outcome was perceived preparedness for intern year, assessed with the prompt, “In hindsight, my medical school prepared me well for intern year,” on a 5-point Likert scale (strongly disagree, disagree, neither agree nor disagree, agree, and strongly agree). For analysis, responses were categorized into 3 groups: Disagree (disagree or strongly disagree), Neither (neither agree nor disagree), and Agree (agree or strongly agree). Participants were asked if their medical schools offered an RPC, if they had participated in the RPC, and the length of the course.

All variables were summarized using descriptive statistics such as frequencies and proportions. Comparisons were made between the Disagree and Agree preparedness categories across different demographic factors using chi-square test or Fisher's exact test. Neither responses were not included in the comparison. All data management and analyses were performed using SAS Version 9.4 (SAS Institute Inc, Cary, NC), and a P value < .05 was used to indicate statistical significance.

The UM Institutional Review Board deemed this study exempt.

The survey response rate was 44% (563 of 1292), distributed evenly across PGYs, with a representative specialty distribution of the trainees at UM. Among the 563 respondents, 283 identified as male (50%), 273 (48%) identified as female, and 7 (1%) did not respond. There were 215 respondents (38%) from procedural specialties, 333 respondents (59%) from nonprocedural specialties, and 15 respondents (3%) who did not list a specialty. A total of 439 respondents (78%) agreed with the statement that medical school prepared them well for intern year (strongly agree: 134 of 563 [24%] or agree: 305 of 563 [54%]), 73 of 563 (13%) neither agreed nor disagreed, and 51 of 563 (9%) disagreed (strongly disagree: 7 of 563 [1%] or disagree: 44 of 563 [8%]). A post-hoc power calculation showed a sample size of 14 (7 per group) was needed to detect a 69% difference in preparedness scores, with 80% power and 95% 2-tailed confidence intervals. There were no differences in feeling prepared across age, gender, PGY, or specialty (table).

Overall, 226 respondents (40%) reported that an RPC was offered at their medical school, and 156 (28%) of all respondents participated in an RPC, which varied in length from less than 1 week to longer than 4 weeks. RPC participants reported feeling prepared more frequently than RPC non-participants (85% [133 of 156] vs 70% [306 of 439]; P = .029). Participation in longer RPCs was also associated with higher perceived preparedness for residency (table).

Our study offers insight into self-perceived preparedness of residents from multiple specialties on their transition from medical school to residency. Residents who participated in an RPC felt more prepared for this transition; this effect was driven by those who participated in an RPC of longer duration.

These findings are consistent with single specialty studies that have examined first-year residents' self-perceptions about preparedness for intern year. In a 2009 study of 158 general surgery interns, respondents felt moderately prepared for the patient care and medical knowledge domain responsibilities.¹  Similar to our findings, the general surgery interns in their study who participated in a fourth-year RPC felt better prepared. Our respondents represented a broad spectrum of specialties, with consistent findings of higher perceived preparedness among those reporting an RPC in the fourth year of medical school. It is essential to note that feeling prepared and being prepared are not necessarily related,¹³  and the ideal fraction of what percentage of learners should feel prepared for this transition has never been defined. More importantly, future studies will need to investigate whether the residents who did not feel prepared were indeed suboptimally prepared for this transition. Nevertheless, there are important curricular implications of our findings across the medical education continuum.

RPCs are becoming increasingly common in medical schools and require a significant allocation of time and resources.¹⁴  Our data provide preliminary rationale for medical schools to consider investing in courses of longer duration, which may provide more opportunities to implement meaningful individualized assessments¹⁵  that better prepare students for the expectations of residency.

This survey is limited in generalizability because it is from one allopathic institution. The survey response rate was about half of those eligible, which may have introduced bias. In addition, recall bias may have altered responses for advanced level residents. We distributed the survey in July, which may be a stressful time, with unknown effects on resident responses. We did not ask respondents which medical school they attended, which could be a confounder, as many residents completed medical school at UM and participated in an RPC that was 4 weeks long. This may have led to an overrepresentation of graduates from our institution. Additionally, we did not further query respondents who elected not to enroll in an RPC at their institution about their rationale. Most importantly, we did not link these anonymous responses to resident performance assessments.

Future work will need to investigate whether residents who feel unprepared are also assessed as such during their residency training. Examination of specific RPC components, including whether components are tailored to student career plans, would also be useful.

This study found that residents from multiple specialties reported greater preparedness for residency if they participated in a medical school fourth-year RPC, with greater perceptions of preparedness for longer duration RPCs. In general, most residents felt that the medical school they attended prepared them for residency.