Introduction

Early career physicians face numerous challenges during the transition period between residency training and independent practice. In particular, sudden increases in clinical and administrative responsibilities often overwhelm new graduates.^1,2 Consequently, mental health issues such as burnout, depression, and anxiety are frequently reported among early-career physicians.^3,4 Despite its importance, most residency training programs place little emphasis on teaching the non-clinical skills required to successfully navigate this transition phase.⁵

The last several months of residency training are usually dedicated to mastering essential clinical skills.^2,6 Most residents feel comfortable providing independent patient care by the end of their training.⁷ By contrast, residents often find themselves ill-equipped to handle the so-called “non--clinical” tasks associated with independent practice. These may include job hunting, managing finances, building a career, assessing medicolegal risk, developing managerial skills, and maintaining wellness. These non-clinical competencies are infrequently taught by residency programs.⁵ Due to this gap in training, physicians are repeatedly confronted with obstacles in their early careers unrelated to clinical medicine.^4,5,8 These challenges can lead to detrimental effects on personal health. For example, one qualitative study found that a deficiency in non-clinical competencies, but not clinical competencies, was associated with a higher burnout rate among new medical consultants.⁹

For these reasons, many trainees have requested that practical “life and job skills” be taught during residency training.¹⁰ A transition to practice (TTP) curriculum for internal medicine (IM) and general internal medicine (GIM) trainees has not been previously described. In this study, we describe the design, implementation, and feedback received on a novel longitudinal TTP curriculum tailored specifically to IM and GIM residents.

Methods

We developed a longitudinal TTP curriculum addressing the non-clinical aspects of independent practice. The curriculum was implemented at a single academic institution (McMaster University, Hamilton, Canada). Study participants included residents in the GIM subspecialty program (PGY4 and PGY5) and IM residents in their final year of training (PGY4). Sessions were scheduled to occur once every 1 to 2 months between July 2019 and April 2020, and were held during academic half-days.

We used Kern’s 6 steps of curriculum development as a framework for our study (Table 1).¹¹ Our needs assessment was guided by a review of the available literature on non--clinical challenges encountered during TTP, previously reported TTP frameworks,^10,12,13 and the training objectives for TTP defined by the Royal College of Physicians and Surgeons.¹⁴ The curriculum design was also informed by a targeted needs assessment with several relevant stakeholders, including the GIM academic half-day coordinator, program director, chief medical resident, and several faculty members. In addition, a mixed-methods survey was distributed during the 2018 to 2019 academic year to both current and incoming residents of the GIM residency program and the incoming PGY4 residents of the IM residency program. Residents were asked to determine on a 5-point Likert scale (i.e., Strongly Disagree to Strongly Agree) whether specific TTP themes should be included in the curriculum. The selection of survey items was informed by the perceived gaps in non-clinical TTP education identified by local GIM faculty and residents who were consulted during the study and the existing literature.

Based on the results of our needs assessment, we developed an IM/GIM-specific curricular framework around four themes: “Entering the Workforce,” “Managing Your Practice,” “Managing Your Finances,” and “Maintenance of Wellness” (Table A1). Individual sessions were categorized into one of the four themes. We selectively chose physicians trained in IM/GIM to facilitate these sessions whenever possible. We provided the speaker with the primary objective for the session but left the format and content specifics to the speaker’s discretion. The residency program organized a single panel session comprising of community IM and GIM physicians as part of the curriculum. As multiple residents had indicated on the needs assessment that didactic sessions related to wellness were undesirable, we instead organized several group-based activities that would promote discussion and self-reflection on the psychological and social aspects of well-being.¹⁵

We measured the curriculum’s impact on residents using a mixed-methods survey. Anonymized surveys were distributed to participating residents at the middle and end of the curriculum. A 5-point Likert scale (i.e., Strongly Disagree to Strongly Agree) was used to assess each session. We elicited feedback on whether the topic was important to IM/GIM clinical practice, whether the speaker had met the stated objective, and whether the resident felt more prepared after the session. Results were summarized using non--parametric descriptive statistics (i.e., median and interquartile range [IQR]). Participants were encouraged to provide qualitative feedback about each session through the free-text entry. We elicited quantitative and qualitative feedback on the curriculum in the final survey. A waiver for ethics approval was obtained from the HIREB.

Results

Results of the Needs Assessment Survey

We achieved a 100% response rate (n = 17) for our needs assessment survey (Table A2). Most residents agreed or strongly agreed to the proposed inclusion of TTP sessions related to finances, medicolegal issues, leadership skills, and wellness events. However, most residents disagreed or were neutral about including didactic wellness sessions.

Feedback from Individual Sessions

A total of 11 TTP sessions were held during the academic year of 2019 to 2020. Eleven residents participated in the curriculum, including 3 IM PGY4 residents, 3 GIM PGY4 residents, and 5 GIM PGY5 residents. The median attendance of each session was 6 participants. We achieved a 100% response rate across both distributed surveys. Most speakers presented a didactic lecture combined with periods of informal discussion. Most sessions were well received, with participants either agreeing or strongly agreeing that the topics selected were important to IM/GIM, that the stated objectives were met, and that the sessions had helped them feel more prepared for independent practice (Table 2).

The qualitative feedback was mostly positive. Several residents commented that sessions on finance were felt to be particularly useful at this stage of their training. This is highlighted in the overall feedback provided by one of the participants:

Another participant had positive experiences with many individual aspects of the curriculum but specifically chose to highlight one of the finance sessions:

Wellness sessions were also believed to be important. Residents noted that wellness sessions were necessary for team integration and created an informal forum for open discussion amongst residents. One participant indicated that having informal opportunities to debrief with peers was particularly valuable.

The qualitative feedback was somewhat less positive for sessions categorized under “Entering the Workforce” and “Managing your Practice.” Several participants noted that the speakers for these sessions had difficulties balancing the needs of residents who planned to work in a community setting versus those who wished to pursue an academic career. For example, the panel session with community-based physicians was generally well received. However, several participants suggested that a second panel session with academic physicians should also be organized during future iterations of the curriculum. As another example, a session was held about career development and given by a speaker who worked solely in academia. This led one participant to comment:

Similarly, our session on outpatient practice management could not capture the wide variety of outpatient clinic models in the community setting, as our speaker had only worked in the academic environment. One participant noted that the clinic setup described during the session “…did not address a typical [community-based] GIM practice.”

Overall Curriculum Feedback

The majority of participants received the curriculum well, with 91% agreeing or strongly agreeing that it should become a permanent part of the overall academic half-day curriculum (Table 3). Residents indicated that the scope of selected topics was generally appropriate and that the curriculum had been helpful for their future career planning. In the qualitative feedback, one resident noted that the curriculum could be further improved by ensuring that only IM or GIM speakers were selected for each session. Another resident indicated that sessions may have been more valuable if they had been provided earlier during their training.

Discussion

In this study, we designed and implemented a TTP curriculum of the non-clinical competencies required to establish an independent IM/GIM practice. The feedback from our participants was generally positive, and participants indicated that many of the topics covered in our curriculum were a valuable part of their residency training.

Our study demonstrates that teaching TTP competencies to IM and GIM trainees using a longitudinal curriculum is feasible and well-received by trainees. Our findings are similar to those reported by several other residency programs. For example, Lister et al. integrated several sessions on billing practices and outpatient clinic management into a year-long TTP curriculum designed for neurosurgery residents.¹³ The successful implementation of a longitudinal TTP curriculum in emergency medicine has also been described.¹⁰ TTP curricula can be delivered using a condensed “retreat” format. Holak et al. conducted a weekend retreat where experts were recruited to discuss medicine’s “business aspects” with anesthesia residents.¹² As these sessions’ effectiveness was not evaluated, it is unclear whether educators should consider such an approach.

Significant gaps exist in training non-clinical TTP competencies among Canadian IM and GIM trainees.^16,17 Participants in a peer-to-peer mentorship program of recent Canadian GIM graduates reported encountering multiple uncertainties in their early practice that were unrelated to clinical care.¹⁷ Within the Competency by Design model, The Royal College and Physicians and Surgeons of Canada identifies TTP as its own distinct training stage. This stage is meant for residents to hone their competencies during the last several months before graduation.¹⁴ However, even though this educational model was designed to ensure that graduates of GIM programs have the required -abilities to practice in various clinical settings,¹⁸ Entrustable Professional Activities associated with the TTP stage do not currently address non-clinical competencies. Consequently, IM and GIM residency programs have little guidance on how non-clinical training should be provided during TTP. We suggest that IM and GIM residency programs include clinical and non-clinical aspects of TTP in their curricula.

We found it often challenging to simultaneously deliver content relevant to residents interested in academic medicine and those interested in community medicine. Given that our residency program is predominantly based out of academic teaching hospitals, it was easier to identify academic physicians who were willing to facilitate our sessions. Furthermore, as all of the sessions were held in person, the physical distance between our own institution and the practice locations of community physicians was a major barrier to their engagement. Web-based videoconferencing services could be used to overcome this problem. A systematic review demonstrated that videoconferencing and face-to-face medical education can be similarly effective teaching modalities.¹⁹ Another potential solution is to allow both a community physician and an academic physician to co-facilitate certain sessions.

Trainees often carry a significant burden of debt with little to no savings.²⁰ Despite this, it has been repeatedly demonstrated that medical residents have poor financial literacy.^20–22 One study found that less than half of residents had received professional financial advice over the preceding five years.²⁰ Many residents believe that personal finances contribute to their overall health and are keen to improve their financial knowledge if given formal opportunities.²³ The results of our study demonstrate that IM and GIM residents are highly engaged in learning about finance and that IM and GIM residents believe such sessions should be included as part of their training. Our results are similar to those described in other studies about financial education conducted with medical trainees.^24,25

The success of our curriculum stems from several factors. First, we ensured that all relevant stakeholders were engaged in curriculum development. Second, by dedicating part of our academic-half days to TTP, residents had protected time away from their clinical duties to attend these sessions. Third, we selected a broad spectrum of TTP themes to enhance the curriculum’s comprehensiveness. Fourth, the presented content was tailored to IM and GIM trainees to maximize relevance. These features should be considered when designing TTP curricula for other medical trainees. Our study has limitations. Whether our findings are generalizable to all other programs and specialties is unclear, and requires further replication in other settings. Although we demonstrated high satisfaction with our curriculum amongst trainees, we did not assess whether our curriculum led to behavioral change.

Conclusion

We successfully designed and implemented a TTP curriculum of non-clinical competencies that was both feasible and well-received by residents in their final years of IM and GIM training. Our model can be utilized as a framework for developing similar curricula in other specialty training programs. Further research is needed to determine whether teaching non-clinical TTP competencies leads to changes in behavior and outcomes during early independent practice.