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August 2022, Volume 72, Issue 8

Research Article

Adapting and preserving through sturdy journey to create a new normal: A phenomenological insight into factors affecting medical resident's journey to consultant practice

Marium Sohail  ( Department of Medical Education, Poonch Medical College, Rawalakot, )
Rahila Yasmin  ( Department of Medical Education, Riphah International University, Islamabad, )
Haris Rauf  ( Department of Diagnostic Radiology, Combined Military Hospital, Rawalakot, Pakistan )

Abstract

Objective: To explore factors promoting and hampering a medical resident's journey from residency induction to role adaptation into consultant practice.

 

Method: The qualitative, phenomenological study was conducted at the Fatima Memorial Hospital and Sir Ganga Ram Hospital, Lahore, Pakistan, from February to July 2019, and comprised junior residents, senior residents, newly qualified consultants and supervising consultants from four departments. Semi-structured interviews were conducted to achieve theoretical saturation. The interviews were audio-recorded, transcribed verbatim, and along with nonverbal cues notes by the researchers were analysed using Atlas.ti 7. Using interpretive phenomenological analysis protocol, codes were merged into categories to form main themes.

 

Results: Of the 16 subjects, 4(25%) each were junior residents, senior residents, senior registrars and supervising consultants. There were 7(44%) males and 9(56%) females. The mean age of the residents was 30.9±5.03 years and that of the supervisors was 55.3±0.97 years. Overall, 157 codes were developed which led to 18 categories and subsequently to 2 main themes; intrinsic factors and extrinsic factors. The former encompassed physical and emotional health, personality traits, style, personal skills, core knowledge, attribution training, self-selection of career, and previous life experiences. Extrinsic factors included physical/non-physical environment, economic stability, communication of expectations, structured residency programme, regular programme evaluation, society and culture, family, support system, preparation for transition, psychological assistance, role of supervisor, involvement into communities of practice, time for relaxation, opportunity provision, work-life boundaries, and reflective practices.

 

Conclusion: The resident's transition through residency depended upon the interplay of extrinsic and intrinsic factors. A seven-tier resident support model is proposed to corelate the phases and provide a roadmap for resident's assistance and sustenance planning.

 

Keywords: Hampering factors, Medical residents, Promoting factors, Resident support, Transitional journey.

(JPMA 72: 1483; 2022)

 

DOI: https://doi.org/10.47391/JPMA.1520

 

Introduction

 

According to W.R. Inge, "We must cut our coat according to our cloth, and adapt ourselves to changing circumstances". A medical doctor needs to lucratively navigate several transitions across medical education trajectory, from novice undergraduate to postgraduate to consultant to become entitled to the title of expert.1

This transition of medical residents to consultancy is a challenging journey. William Bridges associated "Transition" with the story of "Alice in Wonderland" where Alice was naïve, ambiguous, ever-changing and confused, wandering in a wonderland, just as residents feel in the transition phase. Transition from residency to consultancy is drastic and dramatic, like a caterpillar making a transition into a butterfly. It is an avenue for change and harbours rich sources of learning and scholarship, but is puzzling, perplexing and traumatic.2  One of every three budding doctors suffers an episode of major depression during their postgraduate training.3  Burden of responsibilities, lack of role preparation, personal and professional hitches coupled with high societal expectations increase negative socio-emotional effects of transition.4,5 This transition across facets of educational, psychological and socio-cultural variations has a huge impact on identity formation and development of sense about one's self.6  The key to successful transition is deeply rooted in the concept of self-value, which, in turn, helps in self-efficacy and self-regulation.7  As such, transition is conceptualised as a holistic and dynamic amalgamation of educational, psychological and socio-cultural variations.8

In the words of Roger Crawford, "Being challenged in life is inevitable; being defeated is optional". Residents' working environment is nerve-wrecking due to hectic work timeframe, lack of sleep and social interactions, and is a prime factor for depression among the residents.9  Understanding transition from a system's perspective helps medical educators address the challenges of transition and designing transition interventions.10

There is a need to explore the experiences of medical residents about their transitional journey to understand the promoting and hampering factors and to identify the facets that require support. This can then help in resource management for successful transition.11  Effective transition management has a pivotal role in residents' adaptation, and decreases negative socio-emotional effects of transition, like depression, dropouts, self-harm, demotivation and suicides, and ensures better performance by doctors.12

On the basis of such studies, relevant strategies may be devised because structured programmes and fostering of progressive independence are effective ways to support transition.13

The current study was planned to explore factors promoting and hampering a medical resident's journey from residency induction to role adaptation into consultant practice.

 

Subjects and Methods

 

The qualitative, phenomenological study was conducted at the Fatima Memorial Hospital and Sir Ganga Ram Hospital, Lahore, Pakistan, from February to July 2019. After approval from the ethics review board of the Islamic International Medical College, Rawalpindi, Pakistan, permission for data-collection was taken from the relevant hospital administrations. Data was collected using an interview guide based on evidence and validated by experts, which was pilot-tested before using it for the semi-structured interviews in the current study (Figure-1).

 

 

Using purposive sampling technique, the sample comprised participants from four different strata of Medicine, Surgery, Gynaecology and Paediatrics departments. Those included were junior residents, senior residents, newly qualified consultant for primary data collection, and supervising consultant for triangulation of the findings. Informed consent was obtained from each subject.

The interview pattern and questionnaire were the same, but prompts used for each stratum were different. Each interview, conducted by the primary researcher, lasted about 35-55 mins. Interviews were audio-recorded, and data was transcribed verbatim using anonymous names. Nonverbal cues during the interviews were recorded personally. The transcribed interviews were member-checked by the participants. Urdu excerpts were translated by an expert to English language, while those in English were written as such. Concurrent data analysis to modify the data-collection process was done to include the emerging themes in subsequent interviews. Theoretical saturation of the data was achieved after 14 interviews, and the remaining interviews were done for confirmation of data saturation.

The interviews were imported to Atlas.ti 7, coded line by line by using codes from both analytical framework and in-vivo coding. After bracketing (epoch / self-reflection) and horizontalisation (phenomenological reduction / participant's statements are equally valued), data was analysed using the Interpretive Phenomenological Analysis Protocol.14  Codes were merged into categories to form the main themes for structural and textural description of the phenomenon. The composite description of phenomenon was done by abstraction.

 

Results

 

Of the 16 subjects, 4(25%) each were junior residents, senior residents, senior registrars and supervising consultants; and 4(25%) each were from the four departments. There were 7(44%) males and 9(56%) females. The mean age of the residents was 30.9±5.03 years and that of the supervisors was 55.3±0.97 years (Table-1).

 

 

Overall, 157 codes were developed which led to 18 categories and subsequently to 2 main themes; intrinsic factors and extrinsic factors.

The intrinsic factors encompassed physical and emotional health, personality traits, style, personal skills, core knowledge, attribution training, self-selection of career, and previous life experiences. The importance of physical and emotional health and attributional habits did not vary across gender; the females perceived the role of personality traits and personality styles more strongly compared to men; males considered pre-transitioning skills and core knowledge to be of prime importance; and the importance of intrinsic factors and provision of learning resources was highlighted more strongly by the supervisors (Table-2).

 

 

Extrinsic factors included physical/non-physical environment, economic stability, communication of expectations, structured residency programme, regular programme evaluation, society and culture, family, support system, preparation for transition, psychological assistance, role of supervisor, involvement into communities of practice, time for relaxation, opportunity provision, work-life boundaries, and reflective practices. The extrinsic factors of physical environment, family and child issues, time out for relaxation and provision of psychological support were represented more strongly in the female cohort; the factors of financial stability, learning resource provision, society's attitude, peer-assisted learning and family support was regarded as major factors by the male cohort; the factors of role of supervisor and importance of nonphysical environment were perceived equally across the genders; the factors of economic and financial stability and role of supervisor were strongly represented of the residents; and the supervisors regarded finances and salary to be of least importance (Table-3).

 

 

 

Discussion

 

The study identified intrinsic and extrinsic factors. The former relate to "within self", while the latter relate to the "externally defined" variables.

Literature has also reported various promoting and hampering factors for transition. Zamanzadeh et al. reported lack of practical skills, limited academic knowledge, inadequate social skills, poor self-confidence, lack of independence, frustration, stress and loneliness as the causes of transition crises.15  One study described professional accountability and competency, personal adaptation attitude and ability, interpersonal relationships with colleagues and institutional support and orientation, while another study highlighted familiarity with people, place, routines and previous experiences as prime contributory factors to ease out transition.16,17

A study identified the role of an individual in terms of perception of and control over transition as a prime factor affecting transition.18  Similar results were reported in undergraduate medical students.19  One study recognised individual characteristic, self-perception and pre- and post-transition environment as the affecting agents.20  A study reported personal factors, contextual factors and task readiness as the major groups affecting transition.10  Self-efficacy and self-regulation leading to concept of self-value and motivation is the key to successful transition.7  The factors reported in literature have many similarities to that found in the current study, but factors, like financial and economic stability, attributional training, explicit mapping and communication of expectations, structured residency programme, appropriate implementation and regular evaluation of residency programme, involvement into communities of practice and opportunity for reflection are the distinctive factors that emerged in the current study due to difference in the context of the residents. Context is defined by the region of the study site. The current study was conducted in both public- and private-sector institutions in Punjab. As such, the culture of Pakistan, the culture of Punjab and the nature and types of supervisors and resources may exert contextual influences on the findings. However, the residency programme structure is the same throughout Pakistan, but has variance from international residency programmes.

The exploration of these factors from the participants indicates that diverse factors alone or in amalgamation affect the expedition towards adaptation to a role. It is not the factor alone that exerts the effect. It is the fine balance involving the person, the factors and the context which affects the transitional journey.21  Some of the stated factors promote learning and resident settlement, while some factors hamper the transitional process and both types of factors always cohabit in an environment.

The transition is an oscillating journey and the to and fro movements are affected by the factors.22  Current findings reflect that if the balance is towards the promoting factors, the transitional process will be supported and vice versa. Moreover, the transitional management also contributes towards the transitional journey. The presence of hampering factors cannot be eliminated, but can be decreased and managed appropriately to prevent the negative effects of transition.

The factors identified by the residents contribute to their overall wellness. Based on the findings, a seven-tier resident support model has been developed, which corelates different phases of a resident's transitioning to the type of support and help required (Figure-2). This model can provide a foundation for chalking out a structured resident's transition support programme. The knowledge and development of intrinsic traits and skills, and management of extrinsic forces will promote transition management, better adaptation and decreased negative socio-emotional effects.23

 

 

The phenomenological orientation of the study is a limitation, and such studies need to be followed up with longitudinal studies for prospective data collection at 6-month intervals for 4-years residency programme for re-verification and triangulation of the findings. Also, in qualitative studies the influences of context are always diverse, and as the transitional phenomenon has not been much researched for medical or dental doctors, therefore, comparison of results in the similar context was unavailable in literature. However, a thick description of the phenomenon is explicated in the study in order to ensure transferability of results. Thirdly, there was no formal, publicly-implemented and evaluated resident support programme existing in our context, and, as such, efficacy or applicability with respect to resource utilisation could not be established.

 

Conclusion

 

The factors affecting residents' transition through residency to consultancy can be extrinsic or intrinsic. The development of intrinsic traits and skills, and management of extrinsic forces will promote better adaptation and decrease negative effects of transition. The interplay of promoting and hampering factors affects the transition process. The proposed seven-tier resident support model can provide a guideline and roadmap for residents' assistance and sustenance planning.

 

Disclaimer: The text is based on the second part of an academic thesis. The first part, already published, explained the stages and nature of transitional journey22.

 

Conflict of Interest: None.

 

Source of Funding: None.

 

References

 

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