Supporting transition to the medical registrar role from an educational perspective

In a previous issue of Clinical Medicine, Professor David Black described the new UK internal medicine curriculum as including a ‘supported transition into a medical registrar year during the third year of internal medicine’.¹ It will be interesting to see the plans for how trainee needs and the educational value of this transition period will be maximised.

An interview study of physician specialty trainees (n=11) focusing on the transition to the medical registrar role identified multiple themes. Trainee autonomy was initially challenging because of anxiety and an increased sense of responsibility. Although this originally seemed to stem from individual characteristics, this could be modified by network support and feedback in both positive and negative ways. Trust in independent decision making was a positive reinforcement but limited feedback created uncertainty.

Trainees recognised that autonomy was essential for the learning process. This is consistent with cognitive learning theory, whereby learner experience is essential to constructing a new perspective. At transition points, engagement through experiential learning and not being a bystander is particularly important – trainees participated in this with varying degrees of confidence.²

Participants felt that their performance was being judged, but did not always have explicit feedback to frame their experiences. For example, clinical supervisors engaged with them about patient issues but gave little feedback on leadership or non-technical skills. In addition, fear of making mistakes could impede autonomous working. However, trust was given to those who had insight and recognised their limitations, and this had a positive impact.

There were tensions around workplace factors that impacted on the time and space provided for quality learning experiences, including prioritisation of service provision, and having inadequate time for adjustment and variable understanding of adult learning processes. Workload pressures impact on both trainee and consultant time, making it difficult for trainees to ask for, receive and reflect on directly observed feedback. On-the-job learning experiences were not always recognised, signposted or maximised. In some cases, this further perpetuated the discomfort of working autonomously while others became accustomed to the circumstances.

Core medical training in its current format was criticised for being primarily regarded as service provision and trainees suggested this period as a potential space for adjustment to a more senior role; this appears to be recognised in the new curriculum although details of how this would be implemented would be beneficial.

Engagement with on-the-job learning experiences is essential to the whole training process, but this is particularly relevant to the transition process: empowering trainees to accelerate the learning process is essential to concepts of self-efficacy and resilience.³ In addition, educational concepts acknowledge that moments of ‘critical transformation’ require a ‘troublesome’ period but once achieved, are usually ‘irreversible’ and ‘integrative’.⁴ Learning and leadership can only happen effectively when the transition period has been navigated successfully and it is therefore essential to recognise the importance of transition and its impact on learning and development in the trainee pathway.

Conflicts of interest

The author has no conflicts of interest to declare.