Westerman, Michiel MD; Teunissen, Pim W. MD, PhD; van der Vleuten, Cees P.M. PhD; Scherpbier, Albert J.J.A. MD, PhD; Siegert, Carl E.H. MD, PhD; van der Lee, Nadine MD; Scheele, Fedde MD, PhD
The transition from residency to independent practice as an attending confronts physicians with a multitude of new challenges: final responsibility for patient care, management tasks, educational tasks, and a new workplace with new colleagues. Research has shown that such changes can be stressful and burdensome.1–7 The complexity of the tasks and demands of attending physician positions are increasing because of changing regulations and societal demands. In response, changes in residency programs may be an inevitable step in preparing physicians to meet new requirements. These developments require new insight into the current relationship between residency training and hospital practice as an attending. One way to gain insight into this alignment is by exploring how physicians experience the transition from resident to attending.
Insofar as medical education research has addressed career transitions, the focus has been on students and their transition from preclinical to clinical training.8–10 The transition at the end of residency has been relatively sparsely covered in the literature, and none of the published studies have resulted in an empirically founded conceptual framework.11–17 Such a framework should preferably transcend disciplines and local situations, as recommended by Higgins et al18: “There is an urgent need to conduct empirical research on the needs of new consultants with a wider scope than local or specialty specific surveys.”
We addressed two research questions to investigate the transition from resident to attending: (1) What factors in the transition to their new position are perceived as salient by recently appointed attending physicians? and (2) Are these factors unique to certain specialties, or do they have broader applicability? We aimed to represent emerging factors in a conceptual framework of the transition.
We conducted the study in the Netherlands, where residency training lasts three to six years, depending on the discipline, and is preceded by six years of undergraduate medical training. Residency programs are offered by university medical centers and general teaching hospitals. After completion of training, physicians usually take on a post as an attending in a university hospital or general (teaching) hospital.
Because the transition to attending is an underresearched domain of medical education, we conducted a qualitative study using grounded theory. The grounded theory approach originates from the work of Glaser and Strauss19 and involves inductively generating a conceptual framework or theory that is grounded in the data.20,21 It is therefore well suited for initial exploration of relatively underresearched areas.22 Over the years, Glaser's and Strauss' ideas on grounded theory diverged.23,24 We used Glaser's approach, which focuses on the emergence of concepts and categories from a process of constant comparison of the data without fixed preconceptions during all phases of the research (i.e., study design, data collection, and analysis). We were prompted to use individual interviews instead of focus groups by anecdotal information that participants might be reluctant to openly share their emotionally charged experiences of the transition in a group setting.
A tentative structure for the semistructured interviews was developed based on our research questions and an initial literature search in the domains of medical education, transition psychology, and organizational socialization. This procedure is consistent with Glaser's24 approach of grounded theory. The interview structure covered perceptions of the transition to attending, the impact of the new workplace on the physician in transition, and the role of residency training as preparation for a post as an attending. The starting questions were
1. How did you perceive the transition from resident to attending?
2. Which salient issues can you identify in the transition?
3. In which way did residency training prepare you for your work as an attending?
4. How did your socialization take place within the organization?
Participants and procedure
Physicians who had become attendings for the first time between six months and two years before participation in the study were interviewed by M.W. between January and May 2009. Possible participants were identified through various contacts throughout the country. We approached 19 new attendings by e-mail; 14 agreed to participate, after which an appointment was scheduled by telephone for an interview either at their home or office. Attendings in general medicine and obstetrics–gynecology from different teaching hospitals were interviewed to widen the scope of the study beyond one discipline and location.18 This purposive sampling enabled us to identify similarities and differences between disciplines and different stages of the transition. After conducting two pilot interviews with attendings in the home institution, the wording but not the content of the first question was changed slightly. We planned the interview duration for 45 minutes, which was shown to be reasonable after the pilot interviews. We continued data collection until theoretical saturation was reached. Ethical approval was received from the local ethical committee, and confidentiality was guaranteed by informed consent from participants with the understanding that the data would be processed anonymously.
The recorded interviews were transcribed verbatim and entered into qualitative data analysis software (maxQDA, Marburg, Germany). As a respondent validation procedure, the participants were asked to comment on a one-page summary of their interview, which they received within one week after the interview.21 Of the 14 participants, 13 responded and 2 suggested a minor change. Analysis commenced as the data were being collected in order to facilitate exploration of newly emerging issues in subsequent interviews.20 After the interviewer (M.W.) had completed the open coding of eight interview transcripts, a second researcher (P.W.T.) recoded one of the transcripts by using the codes of the first coding round. Emerging differences were discussed and resulted in a set of adjusted codes. All researchers reached full consensus on the coding system. Discrepancies that emerged mainly consisted of misinterpretation of the initial codes due to their description. A second level of analysis consisted of continuous comparison and interpretation of the codes and their interrelationships to arrive at more comprehensive categories and themes. The themes are the highest level of abstraction, showing the conceptual relationships between categories and their properties.24 At this point we returned to the literature, reexamining our initial search of Medline and searching the databases PsychINFO, SocINDEX, and ERIC using the terms “transition,” “life events,” and “career change.” The research team discussed the results until full agreement was reached.
Saturation was reached after 14 interviews. Participants held positions in nine different general teaching hospitals and had done their residencies in six different university hospitals. Seven participants (three male, four female) were attendings in internal medicine and seven within obstetrics–gynecology (three male, four female). Mean age was 36 (range 33–41) for internal medicine attendings and 38 (range 36–40) for obstetrics–gynecology attendings. The mean number of months after the transition was 12.3 (range 9–23) and 13.3 (range 4–24), respectively, for internal medicine and obstetrics–gynecology attendings.
Results from attendings in internal medicine and obstetrics–gynecology showed great similarity to each other, and no discipline-specific factors were present. We will consecutively describe the three themes (disruptive novel elements; perception and coping; and personal development and outcome) and the three recurring categories (task, role, and context) that emerged from the analysis.
The first theme, disruptive novel elements, deals with identified differences between residency training and working as an attending in relation to the categories of task, role, and context. These same categories recur in the second theme, which deals with the perceptions and coping strategies of attendings in relation to the disruptive novel elements. The third theme addresses the attendings' personal development and outcomes in relation to both other themes.
The task category relates to different aspects of an attending's clinical and nonclinical work, whereas the role category covers the attending's position held within the organization and that position's impact on the attending's behavior. “Task” refers to what an attending is supposed to do. “Role” refers to the way he or she acts or is expected to act within the organization. Factors inherent to the settings in which the transition is enacted, the physician's workplace and personal life, are joined in the context category. After separate presentations of the themes, their interactions are described. Illustrative quotes derived from almost all interviews are presented within the text. Table 1 shows a schematic, static overview of the main topics within the themes and categories but not the interactions between them.
Disruptive novel elements
Newly appointed attendings face multiple novel tasks. They experience a huge chasm between their work as residents and their new tasks, characterized by elements like final responsibility for patient care and supervision and management tasks, which are uncharted territory for them. Carrying the final medical responsibility is a major novel experience and is felt most acutely during on-call shifts:
As a resident you know the attending is nearby if you need help with a breech delivery, so you think, “Yeah a breech!” But now you realize that you're the one who has to take over if needed! Normally, when you couldn't cope there was a safety net, but now I am that safety net!
Another new aspect of being on call during nights and weekends is supervising at a distance. Work as a resident is literally “hands-on,” but when attending physicians are consulted they are unable to examine the patient. Additionally, attendings frequently supervise residents they do not know, and having no firsthand knowledge of a resident's expertise adds to the burden of supervision. Finally, attendings are responsible for but have no experience with tasks like management, financial matters, and writing business plans.
Participants identified a change in role and position in patient care and in the hospital organization. As residents, they had had one specific task assigned to them, such as running a ward or outpatient clinic, but as attendings the expectations were very different. Colleagues, residents, nurses, and patients expect attendings to perform multiple tasks simultaneously and to assign tasks to team members. Other new responsibilities relate to training residents and accountability in financial and management matters. This role shift toward headship demands leadership competencies, in which participants found themselves wanting. As one participant observed,
… at first you're planning to do everything yourself because then you know it will be done right … and that's important because I'm responsible and that's the way I have always done things. But it's essential to entrust others with certain tasks and not do them all yourself.
Attendings have to get used to a new context, both at work and at home. The new hospital is unfamiliar, and its organizational structure, culture, patient population, policies, and atmosphere are completely unknown. Participants talked about not knowing their colleagues, the nurses, other staff, or their tasks and positions in the hospital. Hospitals differed in the socialization programs they offered. Most participants received a warm welcome and, during their first months, had opportunities to confer on their tasks and any difficulties they encountered, but the majority of hospitals offered no structural socialization programs. Finally, attendings often had had to move to a different place, and geographical relocation in itself is a life-changing event.
Perception and coping
The participants perceived the period of change surrounding the transition from residency to attending physician from two perspectives. It signified their arrival at the final destination of residency training, but at the same time it marked the onset of a new period in their professional careers. Besides feelings of achievement and success, feelings of incompetence and fear of failure were evoked by their responsibility for unaccustomed tasks. When asked about their preparation for the new position, participants generally said they felt well prepared and residency had provided them with sufficient medical knowledge and skills. Coming to grips with their new nonclinical tasks and roles, by contrast, is much more stressful and would have been easier if they had been introduced to these aspects of clinical practice during residency training. As one participant put it, “I found that step too big. One day you're taken by the hand as a resident and the next day as an attending you have to supervise a resident, so that step is far too big!”
Participants remarked that they felt they had to identify expectations from colleagues, nurses, and the board while trying to establish their own routine and position at the same time. “There are expectations, you have obligations, and I believe it could be constantly on your mind as a new attending.… Do they believe that I've got what it takes?” wondered one participant.
New attendings use various strategies to cope with the new challenges. Most frequently mentioned was the need to be proactive right from the start of their new job so as to overcome their lack of experience by finding out how to perform tasks and identifying what was expected of them. For example, one participant realized “that I have no experience, so yeah … um … I am more controlling than others.”
Perceptions regarding context factors were influenced by the support attendings received from colleagues and social contacts. Feeling supported and being able to consult with colleagues in a safe setting were of crucial importance during the first months. Some hospitals provided structured coaching groups, which offered much appreciated peer support. Commenting on the importance of this type of support, one participant noted a particularly valuable characteristic:
…space and safety with your colleagues, I would say. Knowing that you can always ask questions without getting nasty comments. Even if you don't do so, it is knowing that you could, if needed. That's the main thing!
Personal development and outcomes
The transition to attending is the start of a gradual process, which participants reported to last for extended period of time. For example, “I think it took approximately 18 months for me to find my way … I mean within the organization, with colleagues and in just doing my job.”
Initial challenges subside and new ones arise as time passes. Feelings of incompetence and fear of failure tend to ameliorate over time as a sense of mastery develops.
Changes in context also have a strong impact. It takes time for attendings to settle in, both at work and in their personal environment:
The first five months … you're experiencing multiple life events at the same time … they are all positive, but it is very tiresome! Now after a year things are starting to take shape, our new house, family life, etc., and that's an important foundation for my work.
We have described the three themes individually for comprehensiveness, but in reality they are in constant interaction. For instance, when a novel element is perceived and acted on in a certain way, this affects personal development and outcome, which, in turn, alters the perception of other novel elements and thus influences further areas of personal development. This interrelatedness makes the transition a longitudinal process. Table 1 displays the main issues within the themes and categories but not the interactions and longitudinal nature of the transition. Newly appointed attendings enter a process in which disruptive novel elements relating to tasks, role, and context are perceived and acted on. As attendings progress through the transition, there is constant interaction between novelties, perceptions, and personal development. Both the ongoing interaction between the themes and the longitudinal character of the transition are pivotal to our preliminary conceptual framework of the transition.
Our grounded theory study generated an initial conceptual framework of the key processes in the transition experienced by newly appointed attendings. The findings are supported by recently published medical education research and evidence from research in transition psychology and occupational and organizational socialization.2,25
The model is supported by notions from transition psychology, which also distinguishes different phases in transitions and conceives transition as a longitudinal process.26,27 In transition psychology, transition is defined as a process of change in which individuals experience a personal awareness of discontinuity in their life space, forcing them to develop new behavioral responses to cope with a new situation.26 Nicholson28 described different phases in a transition model, which resemble the themes of our model: preparation, encounter, adjustment, and stabilization. The latter three phases seem to be congruent with our themes of disruptive novel elements, perception and coping, and personal development and outcome, whereas residency training could be conceived as the preparation phase. Furthermore, transition psychology contends that personal perceptions and context are important in transitions, which also confirms our findings.29,30 Finally, the transition psychology literature shows that the greater the discrepancies, such as those between tasks during residency and those of an attending, the more stressful the transition is likely to be.31
Our results are also concordant with theories from occupational and organizational socialization research on the process of learning behaviors and attitudes required for assuming a role within an organization.32,33 Morrison34,35 identifies newcomers as proactive when they are in search of developing themselves within four areas: task mastery, role clarification, acculturation, and social integration. These areas seem to resonate with our results. As our participants progressively clarified their roles over time, they developed task mastery, and it took time for them to adjust to the existing culture in the hospital.
Although transition psychology and organizational socialization are different research areas with different outcomes, Nicholson's28 observation that the possible interdependence of these outcomes is not sufficiently recognized is consistent with our findings. Interdependence is a key element in our results and, thus, in our conceptual framework, in which continuous interaction between disruptive novel elements, perceptions, and personal development in relation to task, role, and context shapes an ever-changing longitudinal process. Glaser24 contends that use of unrelated literature findings keeps up the researchers' continual theoretical sensitivity to conceptualization and theorizing of data. This and the similarities between our results and notions from different research domains offer support for our initial conceptual framework as sound and grounded.
On the basis of our findings and the resulting framework, we propose three implications for practice from which suggestions for interventions can be derived. First, it seems to be important to minimize disruptive novel elements in the transition, a goal that can be accomplished for tasks and role by adapting residency training to the requirements of the practice of attendings. This could be achieved, for example, by including nonclinical skills, such as management and leadership training, in residency programs and by giving residents more responsibility for patient care, such as supervision. It should also be considered, however, that some discontinuity between training and practice is most likely inevitable and may even promote rapid personal development. Nevertheless, striking a good balance between discontinuity and a comfortable progression seems desirable to facilitate the transition.
A second intervention we propose is setting up socialization programs to familiarize new attendings with the organizational structure and culture of their new workplace and clarify their position within it. Such a program should incorporate context-specific and longitudinal aspects of the socialization process. Finally, peer groups in which new attendings can share experiences could foster effective coping skills and thus ease the transition.
Strengths, limitations, and further research
To our knowledge, this is the first research project to present a conceptual framework of the transition to attending that is firmly grounded in empirical data and seems to be in line with notions from related literatures. Furthermore, we used a transdisciplinary approach by investigating the transition in a broader setting than one specialty or location,18 which enhances the transferability of our results. Transferability (i.e., applying research findings from a particular study to a similar setting) is much debated within qualitative research,20 but, in accordance with our epistemological view, transferability can be aspired to in qualitative research. Nevertheless, transferability within this study is possibly limited because we conducted our study in just two different specialties in general teaching hospitals. Therefore, the second research question, concerning the identification of factors applicable beyond boundaries set by specific disciplines, cannot be fully answered by this study. We present a first and sound conceptual framework for the transition to attending within internal medicine and obstetrics–gynecology, but the validity of this framework with respect to other disciplines needs further investigation. Transferability will be further investigated in a planned nationwide questionnaire study among new attendings from all clinical disciplines in different hospitals. Other future research projects will formulate and test new hypotheses to test the framework. Finally, the interventions we propose also require further investigation and development.
The authors wish to thank Mereke Gorsira for her invaluable assistance in English grammar and style, and the attendings who participated in the study.
Ethical approval was received from the local ethical committee. All participants gave informed consent verbally after full explanation of the goals and purpose of the research project. Confidentiality was guaranteed by anonymous processing of the interview data.
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