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Preparation for frequent transitions during training.

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Rosenbaum JR. — Yale School of Medicine

Bernabeo EC. — American Board of Internal Medicine

Holtman MH. — National Board of Medical Examiners

Ginsburg S. — University of Toronto

Holmboe ES. — American Board of Internal Medicine

Presented: Society of General Internal Medicine, May 2010

Background: The traditional “rotating” model of inpatient training is the gold standard of residency, requiring residents to move through different systems every two to four weeks. Rapid transitioning is presumed necessary to expose trainees to varied experiences to promote clinical expertise and guide specialty choice, yet little is known about how residents prepare for and learn from transitions.

Methods: Four focus groups were conducted at each of three residency programs involving faculty only; residents only; nurses, social workers or other ancillary staff; and one mixed group for a total of 12 focus groups. Participants were recruited via e-mail, collecting a sample representative of each institution with regard to gender, PGY year, specialty and years of experience. A guided protocol of open-ended questions was developed and used by the researcher who conducted all focus groups. Data were analyzed using grounded theory. NVivo software was used to facilitate coding.

Results: Though the majority of residents expressed that there was “no way” to prepare for a transition, residents revealed several strategies for new clinical rotations. Many described establishing rapport (particularly with other residents and nurses), completing sign outs, rounding on patients the night before and preparing patients by letting them know that a transition is occurring. Many residents ensured completion of responsibilities from the previous rotation, and got their personal affairs in order.

Some nurses prepared by posting photos of new residents at work stations; some held small group meetings the first day of a transition to set expectations and greet trainees. However, such innovations were rarely shared across systems, and successful processes were often lost as residents moved to new rotations.

Faculty infrequently formally prepared trainees for transitions, relying on residents to “figure it out,” despite recognizing the potential harmful effects on patients. Faculty often relied on nurses to set systems’ expectations for new residents, citing the floor as the nurses’ “home.”

Residents rarely mentioned studying content areas of medicine as important for preparation, except for “high stakes” rotations (i.e., those perceived as more important or with a higher acuity of patients, such as the ICU). Many spoke of the need to simply start the new rotation and learn as you go, valuing self-directed learning and autonomy. The majority of residents reported a strong reliance on each other, highlighting peer-to-peer learning as critical to transition preparation.

Each group (residents, faculty and staff) cited a lack of effectiveness of the formal start of year orientation, recommending more innovative orientation to new systems, such as spending a day of the transition shadowing. They also noted that during transitions, residents are often held to vague and varying standards, resulting in heightened stress, frustration and anxiety.

Conclusion: Although frequent transitions during medical training provide opportunities for development of particular skills for adaptation to new systems and environments, other learning may be compromised. As substantial effort is spent on learning a local system, less is spent on clinical content. Clearer communication of expectations for transitions, increased standardization of the transition process and greater faculty involvement in residents’ preparation for transitions may improve the associated educational and clinical outcomes.

For more information about this presentation, please contact Research@abim.org.