Grades and test scores do not guarantee that a medical student will be totally ready to practice the art of medicine when they first transition to residency.
One longtime internal medicine residency program director shared his valuable insights on the transition from medical school to residency, what program directors expect from their first-year residents on day one, and where those interns might be faltering.
Steven V. Angus, MD, is assistant dean for graduate medical education at the University of Connecticut Health (UConn). He previously served as the director of UConn’s internal medicine residency program for more than a decade.
From a graduate medical education (GME) vantage point, Dr. Angus pointed out that the handoff between medical school and residency too often leaves much to be desired. The information that schools pass along—beyond the metrics—often comes in the form of the Medical Student Performance Evaluation letter, formerly known as the Dean’s Letter. That document is designed to be a summary of the student’s academic track record and assessment of their potential as a resident.
“Mostly when you talk to program directors, they will say that the information they get doesn't really tell them what they want to know,” he said. “So, what is it that program directors want to know? There is plenty of published data across different disciplines that really gives us a good sense of what specific program directors and specific specialties are looking for in their new interns.”
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Program director expectations
Dr. Angus was able to frame what internal medicine program directors are looking for within the context of the core entrustable professional activities for entering residency (EPAs).
Published by the Association of American Medical Colleges, the 13 core EPAs provide a set of tasks that learners should be able to perform upon entering residency. Rather than focusing on facts and lessons, the EPAs focus on tasks—such as working in an interprofessional team or performing a history and examination—and how a student is progressing toward being able to perform them well without supervision from a faculty member.
Within that group of 13, Dr. Angus’ research has identified five that the majority of internal medicine program directors believed residents must possess upon entering a residency program.
That must-have list is:
- Gather a history and perform a physical examination—a skill set 94% of program directors believed residents must possess.
- Give an oral summary of a patient encounter—87%.
- Document a clinical encounter in handwritten or electronic format—77%.
- Participate as a contributing and integrated member of an interprofessional team—58%.
- Recognize a patient requiring urgent or emergent care, initiate evaluation and management—51%.
While these skills may be the most valued, Dr. Angus found that they are not always the ones new interns possess.
“When we ask people to pick the most essential skill, ‘gather a history and performing a physical examination’ was the top at 97%,” Dr. Angus said. “We also asked them where they saw gaps. When these new interns came into your program, where did you see gaps in their performance? And of the top three required skills, two of those skills had the largest gaps in performance.”
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Pain points in the transition
In looking at areas where residents may struggle, they might not always be clinical, according to John Andrews, MD, the AMA’s vice president of graduate medical education innovations.
“One of the things that a lot of graduating medical students don't realize is that they're well-trained from their experience in medical school,” said Dr. Andrews, during an episode of the AMA’s “Making the Rounds Podcast.”
Medical students, he said, are “technically skilled, and they understand enough from a knowledge standpoint about the field in which they're entering to get by.”
The struggles resident physicians encounter often are related to organizing their work.
“Students have typically provided care to patients in the same way that they'll be providing them to patients when they're residents, but not at the same pace and not at the same volume,” Dr. Andrews said.
“So, time management, prioritization, organizing the work that you're doing are the things that I think present the biggest challenges to new residents and are the biggest revelations over the first couple of months of residency.”
To prepare for the changes in patient volume and workflow, Dr. Andrews recommends speaking with “with current residents about tips and tricks, things that they've learned about the best way to get through the day.”
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More on transitions in med ed
The AMA’s Facilitating Effective Transitions Along the Medical Education Continuum handbook looks at the needs of learners across the continuum of medical education—from the beginning of medical school through the final stage of residency. This book was published by the ChangeMedEd Consortium.
The learner sections help medical students and resident physicians acclimate to the various settings and expectations in the medical training environment. The faculty sections then provide blueprints for transition programming, as well as resources to help students and residents navigate challenges in transitions. Download the handbook now (PDF).
