Table 3. The three key themes of personal and professional growth that characterises medical students’ transition experience through their degree programme

D. The Transition into a Graduate-Entry Medicine Degree Programme

During this period, all students had to learn new scientific and non-scientific concepts covering a broad range of topics that they had not learnt before. Some students found the change from being a knowledgeable person to a complete novice as overwhelming and some even viewed themselves as generic university students unconnected to the medical community. As they adapted to their new status as students of a graduate-entry medicine degree programme, many students reported noticing changes to their learning styles (as compared to their previous degrees), financial situation (a change to their standard of living on their return to student status) and socialisation experience (challenges in maintaining existing relationships and forming new ones in the medical school).

“We are still learning how to be a medical student.”

(First-year medical student)

“I have thrown off many indulgences that I was quite used to when I was having salaried work. At one stage when I was a locum, I spent one weekend in [work] and one weekend in Europe [on holiday]. I had some extravagance, I used to eat in very nice restaurants, used to have a personal [fitness] trainer… [as a medical student now] just trying to cut down on the extravagance.”

(Third-year medical student)

“…that was quite a big transition [moving from being a clinical assistant practitioner to a medical student]. Going from being part of a functional team achieving goals, dealing with people coming in, having a specific role that was valued and respected [as a clinical assistant practitioner], to being a passive observer and a consumer [as a medical student]. It was a change from focusing on the needs of the people coming in and my colleagues who were working to the same ends, to suddenly being told that everything I was doing [as a student] was for my own benefit and if I wanted to succeed, I had to do x, y and z to meet the learning objectives set out for us.”

(Fourth-year medical student)

E. The Transition from Phase One to Phase Two of the Curriculum

This transition period occurred halfway through the second year of the degree programme. Learning in phase one predominantly took place in a classroom-based environment with students reporting the curriculum objectives was clearly defined. They learnt about basic medical sciences and individual body systems, had some exposure to the clinical environment and there was a strong emphasis on group work and collaborative learning. On the other hand, learning in phase two predominantly took place in clinical settings as a pair of students. They had to learn to integrate and apply their prior knowledge during their clinical placements. The rotational nature of their clinical placements meant they were frequently meeting new clinical staff. Phase two had a strong emphasis on self-directed learning and students had to keep a learning portfolio of their clinical encounters. The learning outcome of the phase two curriculum was perceived by the students to be less clearly defined as compared to phase one. Together with the self-directed learning nature of the phase two curriculum, students initially found it challenging to organise and make sense of their learning experience, monitor their learning progress and to be certain that they were achieving the curriculum objectives. When they encountered new first-year medical students, they were able to reflect upon their own experience and noticing their personal and professional growth in the degree programme.

“You suddenly see the newbies [new first-year medical students] coming in who do not know anything yet and makes you feel you have actually learnt a lot in a year. It does feel like a big step up to second year.”

(Second-year medical student)

“[The challenge of phase 2 was] being able to link things together. Because at the moment I feel like I am very focused on a certain system. If I go and do a history I will be very cardiology orientated. Whereas next year I need to start thinking about [differential diagnosis]… I need to think more about if they are in the emergency room, they are not going to tell me I have got an endocrine problem. So thinking more laterally… but for at the moment I am doing cardiology, so I only think cardiology and heart failure.”

(Third-year medical student)

F. Approaching Qualification as Newly Qualified Foundation Year 1 Doctors

This transition period occurred around the fourth (final) year of the degree programme. During this transition period, students described one of their key tasks was to prepare for professional practice as doctors. As they progressed through the fourth year of their degree programme, they had to develop competency in applying their knowledge and skills into actual practice, develop the confidence in their own decision making and learning to prioritise their workload.

“I have seen myself as a junior doctor when I was doing my nights [night shift] last week. We were in the Acute Medical Unit. There were fifty patients and one registrar. Basically, he told us to do as much as we want to do. So we ended up prescribing—obviously he [the supervising registrar] signed it. We ended up doing everything a junior doctor would do like cannulation, prescribing, history taking, assessing and talking to relatives. That is the only time I felt like actually I can do this [being a doctor]. Whereas if I am sitting in a clinic at the back of a room and not talking to a patient then I do not feel like I am a doctor, I do not feel I am involved.”

(Fourth-year medical student)

G. Challenges Encountered by Medical Students During Their Transition and Their Coping Strategies

The challenging issues students encountered during their degree programme could be categorised under three broad themes according to the nature of the challenges. These categories were challenges related to the curriculum, challenges related to the social role of medical students and generic life challenges. Table 4 provided examples of these challenging issues. Most challenging issues, especially generic life challenges, were relevant to all transition periods. However, some challenging issues were much more likely to be encountered or its impact more noticeable at specific transition periods. For example, the difficulties in learning a large volume of concepts in students’ transition into a graduate-entry medicine degree programme, and the challenges of dealing with death and dying as they approached qualification as newly qualified doctors.

Table 4. The challenging issues medical students could encounter during their graduate-entry medicine degree programme

Students described they used a wide range of coping strategies to manage the challenging issues arising from their transitions and degree programme. Using the categorisation system by Weiten and colleagues, these coping strategies could be categorised under adaptive and maladaptive coping strategies (Weiten, Lloyd, & Dunn, 2008, p.136). Examples of coping strategies students used in managing the challenges presented by their degree programme were summarised in Table 5.

Table 5. Examples of adaptive and maladaptive coping strategies used by medical students when dealing with challenging issues arising from their degree programme

IV. DISCUSSION

The transition into university was a well-recognised transition period perceived by most university students as a particularly challenging and stressful time (Fisher & Hood, 1987; Fisher & Hood, 1988; Thurber & Walton, 2012). Despite an in-depth literature search, only one study from the medical education literature was noted to have acknowledged the start of an undergraduate medicine academic programme as a transition period (Radcliffe & Lester, 2003), which was associated with a change in the medical students’ lifestyle, socialisation experience and learning style. However, Radcliffe and Lester (2003) only included final year medical students in their study sample and students in other year groups may offer a different perspective about their transition experience.

In this study, students’ description of the term transition was used to define and identify the three major and the minor transition periods within a graduate-entry medicine degree programme, which was in keeping with findings from the published literature on medical student transition experience. This study offered further insights into student experience at the start of their graduate-entry medicine degree programme, which could be associated with significant changes to medical students’ identity, approach to learning, socialisation experience and standard of living.

This study reported there could be a series of minor transition periods within the phase two curriculum as students rotated to different clinical placements. They were described as minor transitions in this study as only one student had explicitly reported encountering these transition periods and its impact on the student was limited as compared to the major transition periods. Seltz, Montgomery, Lane, Soep and Hanson (2014) explored medical students’ experience of working with frequently rotating paediatric inpatient attending physicians who change over on a weekly basis. The authors reported that these frequent changes could be an emotionally stressful experience for some students, as they had to adapt to different patient care and teaching styles. Furthermore, the lack of continuity with the attending physician made it more challenging for students to demonstrate their learning and personal growth as well as building a professional relationship (Seltz et al., 2014). The challenging issues described by Seltz et al. (2014) could be relevant to the experience of medical students in this study as they offered a potential explanation towards the finding of minor transition periods and their potential impact on medical student experience. 

This study highlighted a wide range of challenging issues graduate-entry medicine degree programme students could encounter in their degree programme, which were also in keeping with the findings from the literature review. The exploration of these challenging issues provided an alternate avenue to examine students’ development of a professional identity. The development of a medical student’s professional identity involved complex social interactions between individual medical students and the social structure they belong to (Goldie, 2012). Mann (2010) described “professional identity development is both a personal and social process and is not separable from the knowledge and skills that are required” (pp. 64-65). In this study, phase one medical students spent the majority of their time learning in a classroom-based environment focusing on the acquisition of basic knowledge and skills. It was possible that due to limited professional socialisation opportunities with health professionals, some students perceived themselves simply as a university student only as they did not feel connected to the wider doctor and healthcare communities. When second-year students met the new first-year medical students, they were able to reflect upon their personal and professional growth. 

Hay, Smithson, Mann and Dornan (2013) described experience-based learning, learning through supported participation, helped to address medical students’ learning skills needed to be effective workplace learners. This has an impact on medical students’ sense of belonging to a community and professional identity development (Hay et al., 2013; Wenger, 1998). In this study, when students commenced phase two, they frequently observed doctors and other health professionals providing care to patients. Their level of participation in community activities gradually increased over phase two. Through their situated learning experience such as observation of role models and active peripheral participation in patient care activities (such as undertaking the tasks expected of newly qualified Foundation Year 1 doctors), they gradually solidified their professional identity as a doctor.

Despite the modest study sample size of 21 volunteers from a single centre, this has yielded 35 datasets. The volunteers originated from across all year groups and they were highly motivated in sharing their experience, including sensitive information such as disability, examination failure and the challenges they encountered during their medical school journey. By interviewing study participants twice, this provided the opportunity to follow-up their progress. However, this study has limitations. Only 14 of 21 study participants attended the stage two follow-up interviews. Very few study participants had volunteered examples of their shortcomings or their negative attitudes or behaviours, potentially due to social desirability bias, recall bias and the lack of trust.

V. CONCLUSION

This study provided a broad overview of the transition experience of students in a graduate-entry medicine degree programme. Developing an awareness of the challenging issues students could face during their degree programme, their transition experience and professional identity development, could empower faculty and clinical staff in identifying students potentially in need of support. The study findings could also be useful to prospective and existing medical students in understanding the realities of undertaking a graduate-entry medicine degree programme. 

Note on Contributor

Simon Tso, MD, MB BChir, MRCP, is a consultant dermatologist. He completed this research project as part of his Doctor of Medicine degree with the University of Warwick, United Kingdom. He was responsible for all aspects of the study including the approval of the final version of the article.

Ethical Approval

This study was approved by the University of Warwick Biomedical Research Ethics Sub-Committee (Reference: 169-01-2012).

Acknowledgements

The author would like to thank Asim Yousuf, Nina Owen, Mike Smith, Emma Kirk, Dr Jane Kidd and Dr Mandy Barnett for their assistance with refining the conception and design of the study, Dr David Davies for supervising the final submission of the research degree thesis, and Dr William Hunt for his valuable feedback on the manuscript.

Funding

This study was supported by the Institute for Advanced Teaching and Learning, University of Warwick, United Kingdom.

Declaration of Interest

The author report no conflict of interest. The author is responsible for the content and writing of the article.

References

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77-101. https://doi.org/10.1191/1478088706qp063oa

Dyrbye, L. N., Thomas, M. R., & Shanafelt, T. D. (2005). Medical student distress: Causes, consequences, and proposed solutions. Mayo Clinic Proceedings, 80(12), 1613-1622. https://doi.org/10.4065/80.12.1613

Fisher, S., & Hood, B. (1987). The stress of the transition to university: A longitudinal study of psychological disturbance, absent-mindedness and vulnerability to homesickness. British Journal of Psychology, 78(4), 425-441. https://doi.org/10.1111/j.2044-8295.1987.tb02260.x

Fisher, S., & Hood, B. (1988). Vulnerability factors in the transition to university: Self-reported mobility history and sex differences as factors in psychological disturbance. British Journal of Psychology, 79(3), 309-320. https://doi.org/10.1111/j.2044-8295.1988.tb02290.x

Goldie, J. (2012). The formation of professional identity in medical students: Considerations for educators. Medical Teacher, 34(9), e641-e648. https://doi.org/10.3109/0142159X.2012.687476

Hay, A., Smithson, S., Mann, K., & Dornan, T. (2013). Medical students’ reactions to an experience-based learning model of clinical education. Perspectives on Medical Education, 2(2), 58-71. https://doi.org/10.1007/s40037-013-0061-4

Lamdin, R., Weller, J., & Kerse, N. (2011). Orientation to dissection: Assisting students through the transition. Clinical Anatomy, 25(2), 235-240. https://doi.org/10.1002/ca.21244

Levinson, D. J. (1978). The seasons of a man’s life. Random House Inc https://doi.org/10.1177/105960117900400214

Mann, K. V. (2010). Theoretical perspectives in medical education: Past experience and future possibilities. Medical Education, 45(1), 60-68. https://doi.org/10.1111/j.1365-2923.2010.03757.x

Parkes, C. M. (1971). Psycho-social transitions: A field for study. Social Science & Medicine (1967), 5(2), 101-115. https://doi.org/10.1016/0037-7856(71)90091-6

Prince, K. J., van de Wiel, M., Scherpbier, A. J., can der Vleuten, C. P., & Boshuizen, H. P. (2000). A qualitative analysis of the transition from theory to practice in undergraduate training in a PBL-medical school. Advances in Health Science Education, 5(2), 105-116. https://doi.org/10.1023/A:1009873003677

Radcliffe, C., & Lester, H. (2003). Perceived stress during undergraduate medical training: A qualitative study. Medical Education, 37(1), 32-38. https://doi.org/10.1046/j.1365-2923.2003.01405.x

Rapport, F., Jones, G. F., Favell, S., Bailey, J., Gray, L., Manning, A., … Williams, R. (2009). What influences student experience of graduate entry medicine? Qualitative findings from Swansea school of medicine. Medical Teacher, 31(12), e580-e585. https://doi.org/10.3109/01421590903193570

Rees, C. E., & Monrouxe, L. V. (2011). “A morning since eight of just pure grill”: A multischool qualitative study of student abuse. Academic Medicine, 86(11), 1374-1382. https://doi.org/10.1097/ACM.0b013e3182303c4c

Schlossberg, N. K., Waters, E. B., & Goodman, J. (1995). Counseling adults in transition: Linking practice with theory. New York, NY: Springer.

Seltz, L. B., Montgomery, A., Lane, J. L., Soep, J., & Hanson, J. L. (2014). Medical students’ experiences working with frequently rotating pediatric inpatient attending physicians. Hospital Pediatrics, 4(4), 239-246. https://doi.org/10.1542/hpeds.2014-0016

Thurber, C. A., & Walton, E. A. (2012). Homesickness and adjustment in university students. Journal of American College Health, 60(5), 415-419. https://doi.org/10.1080/07448481.2012.673520

Tso, S. (2019). The impact of graduate-entry medicine degree programme students’ prior academic and professional experience on their medical school journey. The Asia Pacific Scholar, 4(1), 62-64. https://doi.org/10.29060/TAPS.2019-4-1/PV1066

Weiten, W., Lloyd, M. A., & Dunn, D. S. (2008). Psychology applied to modern life: Adjustment in the 21st century (9th Ed.). Wadsworth, OH: Cengage Learning.

Wenger, E. (1998). Communities of practice: Learning, meaning, and identity. Cambridge, England: Cambridge University Press.

*Simon Tso
Department of Dermatology,
Warwick Hospital, Lakin Road,
Warwick, CV34 5BW, United Kingdom
Tel: +44 1926 495 312 Extension 4569
Email: simontso@doctors.org.uk