The first year of physician residency is filled with challenges—there are no two ways about it. But for whatever trepidations fourth-year medical students may have about the prospect of internship come next July, they may find some consolation in the results of a massive cross-sectional study of nearly 30,000 PGY-1 residents.
For a study published in JAMA Network Open earlier this year, researchers from the Association of American Medical Colleges and the American Association of Colleges of Osteopathic Medicine analyzed annual survey data collected from residency program directors from 2020–2023. The results shed light on the high rate at which interns are deemed to be successfully making the transition to graduate medical education (GME), how that varies by specialty, and the areas in which some residents struggle.
The big question: “During the transition to GME (0–6 months of PGY-1 year), did this resident meet overall performance expectations?” Program directors could respond whether an individual resident met expectations, exceeded them, or did not meet them.
The program directors (PDs) who responded provided ratings for 29,461 PGY-1 resident physicians who were U.S. medical school graduates. Of those, only 3.2% of the residents were rated as not meeting expectations, compared with 96.8% who met or exceeded expectations.
That overall result may be reassuring to fourth-year medical students looking ahead to internship. It also arrives amid longstanding concerns about problems in the transition from undergraduate medical education (UME) to GME.
“In recent years, there has been an increased focus on the transition to residency at a national level,” notes the study, which cites recommendations for improvement issued in 2021 by the Coalition for Physician Accountability UME-GME Review Committee.
That coalition is a group of national U.S. organizations—including the AMA—that are responsible for the oversight, education and assessment of medical students and physicians throughout their medical careers. The UME-GME Review Committee issued 34 recommendations to improve the transition from medical school to residency, and there have been efforts by the AMA and others to take action on these recommendations.
Learn more about the AMA Reimagining Residency grant program, which was launched in 2019 and is transforming residency training to best address the workplace needs of the nation’s 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.
Results vary by specialty
The results published in JAMA Network Open suggest that when it comes to ensuring a successful transition from medical school to residency, there may be merit to a specialty-driven focus. That is because the rate at which program directors rated residents as failing to meet expectations varied by specialty.
Here is the rate of “did not meet expectations” by specialty, as detailed in the study:
- Family medicine—6.2%.
- General surgery—5.5%.
- Obstetrics and gynecology—4.4%.
- Emergency medicine—2.8%.
- Internal medicine—2.7%.
- Pediatrics—2.6%.
- Psychiatry—2.4%.
- Other nonsurgical specialties—1.6%.
- Other surgical specialties—1.6%.
- Transitional year—0.7%.
The authors performed a multivariable regression analysis and found that, compared with internal medicine, the odds of residents not meeting expectations were higher for interns in:
- Family medicine—2.09 adjusted odds ratio.
- General surgery—2.05.
- Obstetrics and gynecology—1.64.
By contrast, the researchers found the odds of not meeting expectations were lower for residents in:
- Transitional year—0.22 adjusted odds ratio.
- Other surgical specialties—0.60.
- Other nonsurgical specialties—0.61.
In their discussion, the study’s authors noted that the reputed competitiveness of a specialty—based on the percentage of positions unfilled and the share of positions filled by U.S. senior applicants—did not correspond with its rate of residents who failed to meet expectations.
The findings “suggest a mismatch between how PGY-1 residents who entered GME in the specialty had prepared for the specialty and the expectations of the PDs in the specialty,” says the study. It was written by Douglas Grbic, PhD, Dorothy A. Andriole, MD, Lindsay Roskovensky, Keith A. Horvath, MD, and Lisa Howley, PhD, of the Association of American Medical Colleges, and Mark Speicher, PhD, MHA, of the American Association of Colleges of Osteopathic Medicine.
“Contributory factors are likely complex and vary on a specialty-specific basis, underscoring the importance of UME and GME educators working collaboratively to optimize resident readiness across all specialties,” they wrote.
Read more from the AMA about which physician specialties are seeing a drop in burnout.
Where residents struggled
Of 934 PGY-1s that the surveyed program directors assessed as “not meeting expectations,” there were some areas of performance that stood out as ones where these interns most commonly struggled.
The top area of difficulty among those not meeting overall expectations was “performed tasks in an organized and timely manner,” on which more than 72% were assessed as failing to meet. The area that was next most commonly listed in the “failed to meet” category was “prioritized a differential diagnosis,” with 56% of struggling residents not meeting that expectation.
Other areas of difficulty related to test interpretation, oral presentations, recognizing when patients needed urgent or emergency care, and performance of physical exams.
Learn more with the AMA about why residency training is putting new emphasis on the physical exam.
