Background
Medical training is siloed into distinct stages, namely undergraduate medical education (UME), graduate medical education (GME), and continuing medical education (CME).1 Despite the shared purpose of developing competent and humanistic physicians, cross collaboration among leaders and educators of each stage is less common than expected. Medical education is beginning to move toward competency-based assessment at all levels. Over 2 decades ago, the Accreditation Council for Graduate Medical Education (ACGME) introduced competency-based education,2 which is now most prominently demonstrated by the incorporation of Milestones 2.0 and Clinical Competency Committees.3 Thus, the notion of medical education as a continuum, rather than individual stages, has risen in popularity but has not met complete implementation.4
The COVID-19 pandemic resulted in disruptions to all stages of medical education and highlighted shortcomings in transition support, which is particularly notable for learners who have or will have spent their entire training under pandemic conditions or gone through multiple career transitions during the pandemic. For example, in the beginning months of the pandemic, some trainees were reassigned to services where more clinicians were necessary, while some fellows were called on to practice in their core specialties.5 Medical students' rotations were significantly impacted, and many in-person clinical rotations were replaced with distance learning.6
To address these widespread and rapid changes in the clinical learning environment, the ACGME, in collaboration with other GME organizations, developed a series of toolkits to ease transitions between the stages of training. In collaboration with the American Association of Colleges of Osteopathic Medicine, Association of American Medical Colleges, and Educational Commission for Foreign Medical Graduates, the ACGME released its first transition guide in 2021 to address major disruptions to the clinical learning environment caused by the COVID-19 pandemic.7 It was followed by 2 additional guides in April 2022 that addressed the transition from residency to fellowship8 and from GME training to practice.9
Discussion Group Composition and Content
The Council of Review Committee Residents (CRCR) consists of approximately 30 GME trainees who serve as resident or fellow representatives on the ACGME's specialty Review Committees and 2 resident representatives who serve on the ACGME's Board of Directors. This diverse group consisting of trainees from every core specialty program fosters interspecialty collaboration and dialogue. Twice a year, the council meets to discuss topics relevant to the GME community.
At the May 2022 CRCR meeting, council members joined the ongoing conversation of optimizing learners' needs through the transitions in medical education by participating in small group discussions. These discussions were facilitated by CRCR members who volunteered for this group role. A total of 30 CRCR members participated in the topic-focused discussions and were randomly grouped into Zoom breakout rooms. There were a total of 5 groups with 6 members each. Participation in the discussions was voluntary, and participants were informed that the ideas collected during discussions may be included in a future publication.
To start, Dr. Eric Holmboe, Chief Research, Milestone Development, and Evaluation Officer at the ACGME, presented on the effects of COVID-19 on GME. This was followed by a theory of inventive problem solving (TRIZ) exercise,10 wherein discussion participants were challenged to design a transition approach that ensures every graduate of a program is completely unprepared for the next stage of their career.
The next segment of the topic-focused discussion began with Dr. Holmboe presenting theory burst 1, a mini-lecture on competency-based medical education to provide information to support the subsequent discussion. Small group participants were then tasked with discussing how a developmental mindset, grounded in the core components of competency-based medical education,11 can facilitate successful transitions across a career. Results from theory burst 1 have been intentionally excluded due to the presented focused intent on the UME-GME-CME continuum.
Information for theory burst 2 was dedicated to the transition from medical school to residency. Participants returned to their small groups to discuss 2 questions related to this transition: (1) How can residency programs support this transition? and (2) How can peers and near peers support this transition?
Information for theory burst 3 involved the transition from residency to fellowship or independent practice. Participants again returned to their groups to discuss 2 questions related to this transition: (1) How can residency/fellowship programs support this transition? and (2) How can peers and near peers support this transition?
Each small group assigned a scribe who collated participants' discussion responses. The authors of this article then reviewed the responses, identified common themes, and summarized recommendations to address these themes (Tables 1-4).
Transition From Medical School to Residency
Theme 1: Preparedness
Although all incoming residents are required to have passed standardized medical licensing examinations (USMLE Step 1 and Step 2 or COMLEX-USA Levels 1 and 2), the depth and breadth of UME varies by school. In order to create a more equitable starting point for residency, the discussion groups recommended creation of bootcamps and skill labs to address deficiencies or gaps in UME. The purpose of these bootcamps is to provide basic education and skills, thereby promoting an equal opportunity for intern success via adequate and uniform preparedness. Additionally, peers can be empowered to host specialty-specific, focused electronic medical record training for new residents during bootcamps. Specialty-specific bootcamps also appear in the ACGME transition toolkit's recommendations.7
The groups also recognized that, although hospital-wide orientation occurs in all programs, its utility in preparing trainees is often limited. Participants felt it was important to support trainees to obtain the necessary skills to safely care for patients while navigating a new health care system.
Theme 2: Wellness
The discussion groups were cognizant of the impact of major life changes on mental health12 and, as such, recommended that training programs develop preemptive programs to address mental health and trainee wellness using an opt-out approach instead of waiting for the residents to self-diagnose and obtain help. Hosting program- or peer-led community events to foster a sense of belonging and inclusion and providing stipends to offset the financial stress of moving were also mentioned.
Theme 3: Mentorship and Advising
Trainee advising is mentioned in the ACGME transition toolkit7 ; however, it is in reference only to faculty advising. Small group discussion participants noted the importance of expanding on this topic to include peer-to-peer support and resident mentors, particularly in the early months of training, as peers in GME programs often have the greatest understanding of the current training environment. There is an opportunity for peers and faculty to partner in the development of both faculty- and peer-driven mentorship and advising. Furthermore, peers can facilitate an inclusive and safe workplace for junior-level residents.
Theme 4: Support for International Medical Graduates
Finally, the groups recommended programmatic awareness to ensure that efforts made to assist the majority of new interns in their transitions to GME do not inadvertently exclude international medical graduates (IMGs) or create barriers that perpetuate additional inequities that IMGs face. For example, in 2014, the start date for surgical fellowships was changed from July 1 to August 1.13 This afforded incoming fellows time to transition from residency to fellowship, but it resulted in a 1-month lapse in salary and insurance coverage. IMGs who are on visas have strict requirements for insurance coverage and a defined duration of stay in the United States. As such, this 1-month gap may have negatively affected IMGs because of unintended visa violations. It remains unclear if this policy change has resulted in a decrease in IMGs applying to and matching into surgical fellowship programs.
Additionally, IMGs may benefit from activities designed to enhance cultural competence with American culture and systems to facilitate transitions for effective health care delivery.
Transition From Residency to Fellowship/Practice
During theory burst 3 small group discussions, participants discussed transitions from residency to fellowship and autonomous practice and offered recommendations that both the program (Table 3) and peers and near peers (Table 4) can consider. Some themes emerged that were similar to the ones that arose while discussing the transition from medical school to residency, including mentorship and peer advising.
Theme 1: Targeted Educational Opportunities
Clinically, discussion participants stressed that elective time was critical for residents to further develop skills in their desired area of practice, and therefore recommended programmatic protection of this element of training.
In addition to the clinical knowledge and skills necessary to succeed in fellowship or independent practice, participants also recommended that programs provide education for trainees about career-specific health care delivery systems. Programs may consider providing business of medicine lectures for different types of medical practice (private, hospital employed, academic), education on contract negotiation, and even strategies for effective billing and coding.
The discussion also highlighted opportunities for education in behaviors essential for continued growth in autonomous practice, such as reflection, self-assessment, and self-directed learning. The ACGME toolkits for residency to fellowship8 and practice9 similarly provide guidance on informed self-feedback and competency-based education and assessment.
In teaching clinical, systems, and behavioral skills, participants advised creation of graduated practice opportunities as a means to support these ends.
Theme 2: Scheduling
A challenge of the transition from residency to fellowship is the often-rapid turnaround time from the end of residency to the start of fellowship. The discussion groups recognized that some fellowship programs are delaying start dates to allow for some flexibility and support for individuals transitioning from residency to fellowship; however, caution is advised relative to the creation of potential gaps in health insurance, wages, and IMG visa violations, as noted previously.
Theme 3: Well-Being
Trainee well-being is a common theme and priority in all of the ACGME transition toolkits,7-9 with several resources dedicated to this topic provided in each. Imposter syndrome is a well-recognized phenomenon in medical practice associated with increased levels of burnout.14 Recommendations from the small groups' discussion of the transition to fellowship and practice that may help combat imposter syndrome include access to mentorship, alumni networks, storytelling, community building, and self-assessment.
A Note on Assessment
One topic that is covered at length in the ACGME transition toolkit7 from medical school to residency is the acknowledgement of the possibility of faculty's implicit bias on first-year resident performance assessment. While some types of bias (eg, unintentional bias toward IMGs) were part of small groups discussions, this idea of mitigating the potential for implicit bias in assessment did not emerge, despite its importance and relevance within GME. One potential reason for this discrepancy is point-of-view limitations, as participants were trainees and therefore focus less than their faculty educators on how to construct and conduct assessments. In a fully competency-based system, where trainees are engaged with assessment creation, this effect may have been less observable.
Limitations
While the groups included residents and fellows of diverse personal and professional backgrounds, discussion and resultant summaries may be limited given there were only 30 participants. Further, participants volunteered to participate from within the membership of the CRCR, which may limit representation outside of these parties. Additionally, there remains a selection bias by virtue of the types of residents who may volunteer for leadership positions such as those with the ACGME and the CRCR. Finally, given the focus on medical education as a whole, discussion did not explore specialty-specific recommendations.
Conclusions
As trainees progress through the UME-GME-CME continuum of medical education, each stage requires a specific skill set to ensure that patients receive safe and effective care and that trainees achieve the necessary educational experiences to maximize preparedness for the next stage of their career. Although these skills and experiences differ considerably across specialties and stages of training, there are fundamental similarities that can address educational gaps, optimize learning opportunities, and support well-being during each transition. Because of the diversity of the CRCR in specialty and stage of training, small group discussions at the May 2022 CRCR meeting offered a singular opportunity to identify shared recommendations that can optimize transitions in medical training. Many of the discussed opportunities to strengthen medical education transitions were supported by recommendations in existing transition toolkits. Now in its third year, the COVID-19 pandemic continues to evolve current health care practice, and the resulting challenges highlight the importance of ongoing assessment of transitions in medical training to ensure future physicians are prepared at every stage of their career.
References
Author notes
Editor's Note: The ACGME News and Views section of JGME includes data reports, updates, and perspectives from the ACGME and its Review Committees. The decision to publish the article is made by the ACGME.