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An important overall aim for medical schools is to prepare their students for lifelong work and learning in medicine. A more immediate goal is to prepare them well for their first jobs as doctors. One way of evaluating whether this goal is being achieved is to use independent judgements by professional bodies. However, it is also important to ask the doctors themselves. In our research on medical careers we have sought junior doctors’ views, in the first Foundation (F1) Year, on whether their medical school prepared them well for medical work. The F1 year is the doctors’ 1st year of work after graduating from medical school (see table 1). We have previously reported the views of the graduates of years 1999, 2000, 2002 and 2005 on their 1st year of clinical work (termed the preregistration year in the time of the 1999, 2000 and 2002 cohorts).1–3 We have observed a gradual increase in the proportion of students who indicated that their medical school had prepared them well. We have also found considerable and persisting differences in self-reported preparedness between medical schools (see Box 1 for details). Here we update our findings with data from the graduates of 2008 and 2009.
Summary of our previous findings on preparedness of medical graduates for work
Postal questionnaires were used to survey the medical graduates of 1999, 2000, 2002 and 2005 from all UK medical schools 1 and 3 years after graduation.
The main outcome measure was the level of agreement that medical school had prepared the responder well for work.
The percentage of doctors in year 1 who agreed that they had been well prepared increased from 36% in the cohorts of 1999/2000 to 50% of the cohorts of 2002 and 58% of the cohorts of 2005. Those who disagreed fell from 41% to 31% to 21%. Those who strongly disagreed fell from 11.6% to 7.2% to only 2.8%.
Combining cohorts at year 1 after qualification, percentages who agreed that they had been well prepared ranged from 82% (95% CI 79 to 87) at the medical school with the highest level of agreement to 30% (25–35) at the lowest. At year 3 after qualification, the range was 70–27%.
Design, setting and participants
All graduates of 2008 and 2009 from all medical schools in the UK were identified from General Medical Council registrations. We sent these doctors a questionnaire towards the end of the F1 year, and sent non-respondents up to five reminders (further reminders were not sent to the small number who explicitly asked to be excluded, see Results). Questions about the transition from medical school, reported here, were contained within questionnaires used to study a broader range of subjects including doctors’ career intentions, career progression, future plans and views. The questionnaire design process is described in appendix 1 (available online). Questionnaires were posted to the doctors’ registered addresses, provided to us by the General Medical Council for all doctors in the two cohorts who had consented to be approached by research groups.
The following statement about feeling prepared for work was included in the questionnaires: ‘My experience at medical school prepared me well for the jobs I have undertaken so far’. Respondents were invited to respond to the statement on a five-point scale from ‘strongly agree’ to ‘strongly disagree’. If they did not feel well prepared, respondents were also asked to indicate whether this was in respect of ‘clinical knowledge’, ‘clinical procedures’, ‘administrative tasks’, ‘interpersonal skills’ and ‘physical/emotional/mental demands’. For those who specified anything other than feeling well prepared, we also asked ‘Was lack of preparation a serious, medium-sized or minor problem for you?’.
We compared responses of recent graduates (2008 and 2009) with those of graduates of 1999, 2000, 2002 and 2005, from whom we had collected data about their 1st year of work using similar questions and methods.1
We used descriptive statistics and χ2 tests to compare responses by graduation year and medical school. In comparing results from graduates of different medical schools, we used binary logistic regression to take account of any differences between medical schools in potential confounding factors (sex, ethnicity, graduate status, holding of intercalated degrees and year of qualification). Binary dependent variables were constructed by, for example, combining respondents who agreed or strongly agreed that medical school had prepared them well, as one group, and all other responses as the second group. In making multiple similar comparisons, we regarded the attainment of a threshold of p≤0.01 as evidence of significant difference. We compared the profile of responses from the individual cohorts, 2008 and 2009, and analysed the consistency of results between the two cohorts using Bland and Altman's method.4
The 2008 cohort comprises 6796 doctors; excluding 82 qualifiers who were untraceable and 9 who declined to participate, the survey response was 49% (3302/6705). The 2009 cohort comprises 6565 doctors and the survey response was 46.7% (2918/6252) excluding 292 untraceable doctors and 21 non-participants. However, the fifth postal mailing of these surveys used a shorter questionnaire, which omitted the question about medical graduates’ perceived preparedness for work; 439 respondents from the 2008 cohort and 371 respondents from the 2009 cohort completed this version. In all, 5369 doctors replied to the ‘preparedness’ questions and were included in the study. The response rate relevant to ‘preparedness’ was 44.2% (5369/12147).
Feeling prepared for clinical work
The results for the qualifiers of 2008 and 2009, separately, are shown in table 2. Combining the cohorts, 9.3% of respondents strongly agreed that their medical school prepared them well for the jobs they have undertaken so far, 42.1% agreed, 30.1% neither agreed nor disagreed, 15.9% disagreed and 2.6% strongly disagreed.
Comparison of the responses on the 5-point scale between the two cohorts, using the Mann-Whitney U test, showed that there was no significant difference (p=0.43) between the graduates of 2008 and 2009 in their responses to the ‘preparedness’ question.
Feeling prepared: comparisons with previous cohorts
We compared the responses of the graduates of 2008 and 2009 with those of earlier cohorts (table 2). Over the last decade, the percentage who disagreed or strongly disagreed that their medical school had prepared them well for work fell from 41% of the qualifiers of 1999 and 2000 to 16% of the qualifiers of 2009. The percentage who agreed or strongly agreed that they had been well prepared rose from 36% of the qualifiers of 1999/2000 to 58% of the qualifiers of 2005, falling to 49% of the qualifiers of 2009. There was an increase over time in the percentages of those who scored ‘neither agree nor disagree’.
Differences between medical schools
There were large differences between medical schools in the level of agreement about being well prepared, ranging from a maximum of 83% of the graduates at one school specifying that they felt well prepared, to a minimum of 28% at another school, with a broad spread of percentages between (figure 1). When the data were analysed separately for those who ‘strongly agreed’ that they were well prepared, schools generally ranked in similar ways. For example, the same schools (33, 5, 12) were in the top three on ‘agree and strongly agree’, as were those in the lowest three (23, 16, 14), though not in precisely the same order. The percentages who ‘strongly agreed’ that they were well prepared were 32%, 32% and 27% for the top three, and 4%, 2% and 1.5% for the lowest three. Within the top three schools (33, 5, 12), only one person (<1%) gave a ‘strongly disagree’ response. Within the lowest three schools (23, 16, 14), the percentage who strongly disagreed that they had been well prepared ranged between 22% and 38%.
The cohorts of 2008 and 2009 include the graduates from five new UK medical schools. Their codes in figure 1 are those from 30 to 34. Three of the new medical schools are in the top six, in respect of percentages of graduates feeling well prepared for work, and only one is below the national average percentage.
Considering the 2008 and 2009 cohorts separately, we ranked the medical schools based on their students’ replies and found a high level of correlation (Spearman's r=0.77, N=28, p<0.001), indicating consistency in reports on preparedness from year to year (the surveys of 2008 and 2009 were independent of each other). We further explored the consistency of results (see Method) to assess agreement between the preparedness responses from the graduates of 2008 and 2009 (details available on request from corresponding author) and we concluded that the two cohorts could be combined for analysis by medical school. In appendix 2 (available online only) the findings on preparedness for the recent cohorts, comparing individual medical schools, are compared with those for the cohorts of 1999/2000, 2002 and 2005.
Medical school was a significant predictor of preparedness without allowing for the effects of the five potentially confounding factors to the model (see Method; Wald χ2 27=353.9, p<0.001, comparing the medical schools); and it remained a significant predictor, with very similar results, after controlling for them (Wald χ2 27=345.0, p<0.001). With the outcome defined as disagree or strongly disagree (combined) versus other responses (combined), medical school was again significant without the five predictors in the model (Wald χ2 27=228.2, p<0.001) and with them (Wald χ2 27=227.2, p<0.001).
Extent to which lack of preparation was a problem
Lack of preparedness was a serious problem for 2.7% of respondents in the cohorts of 2008 and 2009, and a medium-sized problem for 22.6%. The combined percentage, 25.3%, was lower than the equivalent in the cohorts of 2002 and 2005, which was 30.0% (χ2 1=30.0, p<0.001).
Differences between medical schools in a ‘serious or medium-sized’ problem
There was wide variation between medical schools in the percentage of respondents for whom not feeling prepared for work was a problem. Only 4.7% of respondents from school 12 specified ‘serious or medium-sized’ problems in being unprepared, compared with 45.3% from school 16.
In general, there was a close correspondence between feeling unprepared for work, overall and its being a serious or medium-sized problem (figure 2). When medical schools are ranked on percentages not feeling prepared, and on this being a problem (whether serious or medium-sized), the correlation between the ranks was very high (Spearman's r=0.93, N=28, p<0.001). There were occasional exceptions: for example, school 32 had a low percentage of its graduates not feeling well prepared for work, but a high percentage indicating that their lack of preparedness was a serious or medium-sized problem.
Aspects of work for which respondents did not feel well prepared
Doctors were asked for which, if any, of several prespecified aspects of their work they felt unprepared. Some respondents who agreed that they felt well prepared overall indicated that they did not feel well prepared for one or more of the specific aspects. Their replies were included in the findings in table 3.
The category with the highest percentage of ‘feeling unprepared’ was that of administrative tasks (32% overall), and that with the lowest was ‘interpersonal skills’ (3% overall).
There were large variations between medical schools in the percentages feeling unprepared in four out of five investigated aspects of work. The findings are summarised in table 3 and results for each individual medical school are displayed in figure 3 (excluding the results for Interpersonal Skills as, for this, fewer than 10% of respondents in each school felt unprepared).
Representativeness of respondents
In order to ascertain whether there is likely to be non-responder bias in our findings we compared the responses of those who replied to the first or second survey mailing and those who replied to one of the subsequent mailings. The reasoning behind this is that late respondents are likely to be similar in their characteristics to non-respondents, since we would not have received a reply from them if we had confined the survey to just two mailings. χ2 Analyses showed that there was no significant difference between the early and late respondents in either the distribution of their responses on preparedness, or in whether lack of preparedness was a problem, or in whether they felt unprepared in particular areas of work.
Main findings and interpretation
There are still considerable differences between medical schools in their graduates’ views on whether their medical school prepared them well for work. There are also big differences between medical schools in whether feeling unprepared was much of a problem. Most of the new medical schools had relatively high proportions of graduates who reported feeling well prepared.
We have commented elsewhere1 that ‘Most people starting a new professional job probably will, and probably should, feel unprepared to some extent. The vast knowledge base of clinical practice makes full preparation an impossibility’. Interpretation of our findings should be tempered by these considerations, though they cannot explain the differences between medical schools that we report.
Feeling unprepared may be a function of insufficient induction at the commencement of work as well as insufficient preparation at medical school. We did not explore doctors’ views on induction, across our cohorts, though others have done so in recent years.5 A national training survey in the UK in 2011 reported that 65% of Foundation trainees rated induction as good or excellent, and 10% rated it as poor or very poor.6
Since our earlier surveys, there have been important changes in the support for training in the ‘receipt’ of new graduates for foundation training, including the establishment of a Foundation curriculum, Foundation Schools and local Foundation Programme directors providing support structures with links between medical schools and the hospitals in which the newly qualified doctors work.7 Individual medical schools need feedback from their graduates about elements of medical school training that could improve preparedness for medical work. They also need feedback from Foundation programme directors about the ‘readiness’ of the medical schools’ graduates for work.
Overall, only a very small percentage of respondents reported that their lack of preparedness was a serious problem. However, a quarter said that it was a serious or medium-sized problem. Thus the issue of preparedness remains a cause for concern. Nevertheless, junior doctors’ 1st year of medical work is undertaken under close supervision by senior doctors; and, providing that this supervision is in place, lack of feeling prepared is much more an educational than a patient safety issue.
Strengths and limitations
The strengths of our study include its large size and the inclusion of all UK medical schools. We are independent of organisations that employ, or provide training for, or could influence the careers of, the respondents. Therefore, we believe that we get honest answers from the doctors.
As in any voluntary survey, a potential weakness is non-responder bias. Our finding that early and late respondents did not differ appreciably in the profile of their responses about feeling prepared suggests that this is unlikely to be a major factor. It is becoming apparent in a variety of survey areas—not just in medicine—that younger generations are less likely to become participants than their predecessors. At the time of surveying the UK qualifiers of 2008 and 2009, we also did a follow-up survey of the UK qualifiers of 1993. The response rate from the latter, at 72%, was considerably higher than that from the qualifiers of 2008 and qualifiers of 2009.
We collected respondents’ self-reported views on their preparedness. It could be argued that such self-assessments would not necessarily correspond with independent assessments of the trainee doctors’ professional competence. Congruence and incongruence between self-reported and objective measures of preparedness for work have been reported.8 ,9 However, objective assessments might miss the trainee doctors’ difficulties if the trainees are reasonably quick to correct them. They may also be less all-embracing in scope than our simple but broad questioning. It is beyond the scope of the present study to compare the doctors’ views, by medical school, with other measures (such as medical schools’ curricula) or to report in detail on readiness for specific tasks. A recent report by Illing et al10 is a good source of information on the latter.
It could also be argued that the acquisition of knowledge about administrative tasks—the area where the highest percentage of respondents reported feeling unprepared—is basically trivial. These are skills that one would expect competent, efficient medical graduates to acquire with ease. This may explain why some medical schools appear to allocate little time to them. Against this, real or perceived lack of preparedness may cause stress, worry and perhaps reduce doctors’ confidence. It seems reasonable to expect all schools to achieve the level of preparedness, even in fairly minor tasks, that are achieved by some.
An obvious area for further investigation would be a detailed study, perhaps including focus groups and interviews, of the relevant aspects of the medical courses in the medical schools in (say) the top five and lowest five schools in respect of their graduates’ scoring of preparedness.
Findings from elsewhere include a study in Holland11 that found that vertically integrated programmes (a type of curriculum used by some medical schools) are associated with higher levels of self-reported preparedness for work. The key features of these programmes are earlier clinical experience, longer clerkships and increased levels of responsibility. Several other studies identified adequacy of ‘hands on’ clinical experience as an important factor in feeling ready for work.3 ,10–13 A number of British studies report that shadowing of the outgoing F1 officer increases self-reported preparedness.10 ,14–17 Evans et al16 have shown that it also improves independently assessed preparedness for work. The benefits of shadowing have been recognised by medical educators and policy makers.18–20 A recent editorial in the Postgraduate Medical Journal21 has summarised current initiatives to improve preparedness, including shadowing, and discusses what level of preparedness is achievable.
Sir Bruce Keogh, NHS Medical Director, has recently (2012) stated that starting from summer 2012 there will be a mandatory paid shadowing period in England lasting a minimum of 4 days for all new F1 appointees.22 This is the first step, nationally, to making shadowing more uniform. However, a number of issues need to be considered. These include duration and content. Some schools currently run shadowing programmes longer than 4 days for final year medical students (eg, 2 weeks,23 4 weeks24 or even 7 weeks25). Trainee doctors have commented in focus group discussions that the quality of their experience during shadowing depended on the approach taken by the outgoing house officer.14 Thus there is a need for sound guidelines regarding what activities the shadowing programmes should include. Optimal timing of the shadowing period is important too.
In summary, there are still large differences between medical schools in the extent to which their graduates feel prepared for the early days of medical practice. It seems likely that there are some reasonably straightforward lessons that the schools could learn from one another.
Approximately half of F1 doctors who studied in 2009 and 2010 agreed that their medical school had prepared them well.
The proportion who felt unprepared has fallen from a third to a fifth over the last decade.
There remain large and consistent variations between medical schools in the extent to which their graduates feel prepared.
There is scope for schools to learn from one another to improve preparedness, and scope for further study of the differences between high and low scoring schools.
Current research questions
What do the medical schools with the best scores on preparedness do differently from the rest?
What is the optimum period, method and timing of shadowing?
Will recent changes in the guidelines about shadowing be successful?
Salisbury E, Frankel A. Just how prepared can we expect new medical graduates to be? (editorial) Postgrad Med J 2012;88:363–4.
Illing J, Morrow G, Kergon C, et al. How prepared are medical graduates to begin practice? A comparison of three diverse UK medical schools. Final Report for the GMC Education Committee. General Medical Council/Northern Deanery, 2008.
Berridge EJ, Freeth D, Sharpe J, et al. Bridging the gap: supporting the transition from medical student to practising doctor—a two-week preparation programme after graduation. Med Teach 2007;29:119–27.
We are very grateful to all the doctors who participated in the surveys. We thank Emma Ayres for administering the surveys, Janet Justice and Alison Stockford for data preparation and Louise Laxton for programming support.
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