Grades and test scores do not guarantee that a medical student will be able to practice the art of medicine when they transition into 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 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, in theory, works as 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.”
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 in 2014, 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.”
Looking for solutions
As far as better preparing residents, Dr. Angus believes that communication of student competence as part of an educational handover would be most useful if the information provided were specialty-specific and included students’ strengths and weakness so the program directors could individualize training.
“If a program director had information on a student's strengths and, more importantly, where a student needed to be supervised a little bit more or needed a little extra work, there is evidence in the medical literature that program directors will change their schedules and their curriculum to help new interns get up to speed,” he said.
Working to change GME
The AMA Reimagining Residency initiative is transforming residency training to address the workplace needs of our current and future health care system. It supports bold and innovative projects that provide a meaningful and safe transition from undergraduate medical education to graduate medical education, establish new curricular content and experiences to enhance readiness for practice and promote well-being in training.
The AMA’s Facilitating Effective Transitions Along the Medical Education Continuum handbook guides students and residents in acclimating to the various settings and expectations along the spectrum of the medical training environment.