Blumenthal D, Gokhale M, Campbell EG, Weissman JS. Preparedness for Clinical PracticeReports of Graduating Residents at Academic Health Centers. JAMA. 2001;286(9):1027-1034. doi:10.1001/jama.286.9.1027
Author Affiliations: The Institute for Health Policy, Massachusetts General Hospital and Partners Health Care System; and Departments of Medicine and Health Care Policy, Harvard Medical School, Boston, Mass.
Context Medical educators are seeking improved measures to assess the clinical
competency of residents as they complete their graduate medical education.
Objective To assess residents' perceptions of their preparedness to provide common
clinical services during their last year of graduate medical education.
Design, Setting, and Participants A 1998 national survey of residents completing their training in 8 specialties
(internal medicine, pediatrics, family practice, obstetrics/gynecology, general
surgery, orthopedic surgery, psychiatry, and anesthesiology) at academic health
centers in the United States. A total of 2626 residents responded (response
Main Outcome Measures Residents' reports of their preparedness to perform clinical and nonclinical
tasks relevant to their specialties.
Results Residents in all specialties rated themselves as prepared to manage
most of the common conditions they would encounter in their clinical career.
However, more than 10% of residents in each specialty reported that they felt
unprepared to undertake 1 or more tasks relevant to their disciplines, such
as caring for patients with human immunodeficiency virus/acquired immunodeficiency
syndrome or substance abuse (family practice) or nursing home patients (internal
medicine); performance of spinal surgery (orthopedic surgery) or abdominal
aortic aneurysm repair (general surgery); and management of chronic pain (anesthesiology).
Conclusions Overall, residents in their last year of training at academic health
centers rate their clinical preparedness as high. However, opportunities for
improvement exist in preparing residents for clinical practice.
The last comprehensive study measuring the preparedness of physicians
early in their practicing careers, the 1991 Robert Wood Johnson Foundation's
survey of young physicians, found that 80% of respondents thought their formal
medical education did a "good" or "excellent" job of training them for clinical
practice. However, many respondents felt unprepared for a variety of conditions
they would encounter in their professional life, such as identifying depression,
treating patients with severe disabilities, and treating elderly patients.1 Subsequent specialty-specific studies have underlined
these apparent gaps in physician readiness for practice. Physicians in pediatrics,2 general preventive medicine,3
rural practice,4 and neurosurgery5
have been found to be underprepared for conditions and tasks for which residency
ideally should have prepared them.
A number of observers have concluded that many physicians are also not
prepared to provide services and manage conditions with particular relevance
to underserved populations, such as dietary counseling,6
alcohol abuse,7 human immunodeficiency virus/acquired
immunodeficiency syndrome (HIV/AIDS),8 child
abuse,9 or to care for patients with chronic
conditions, such as asthma10 or complex conditions,
such as cancer.11 These deficiencies may seem
surprising, given that nearly half of US physicians train at academic health
centers (AHCs), which care disproportionately for underserved populations
and patients with complex diseases.12 While
most studies show that focused short-term training can remedy some gaps in
physicians' skills, such approaches seem inherently less desirable than providing
adequate preparation as a part of routine training.
Questions have arisen as well about whether there exists a "residency-practice
mismatch": a failure of graduate medical education to provide proper role
models, supervised instruction, and diversity of patient experience that residents
need for practice.13 There is concern that
the current guidelines ensuring the adequacy of residency training, which
focus on regulating the locus and content of residents' experience, may be
insufficient and that these should be complemented with a competency-based
system, as was implemented for neurosurgery at Johns Hopkins University.5
These findings and questions suggest the need for ongoing monitoring
of residents' preparedness for practice at the end of their graduate medical
education. We surveyed a national sample of residents in their last year of
training in 1998 at AHCs (defined as medical schools and their closely affiliated
or owned clinical facilities) in the United States. This survey provides benchmark
data on self-reported preparedness of residents to undertake a wide variety
of tasks common to their specialties.
We identified a stratified random sample of residents in 8 specialties
(internal medicine, pediatrics, family practice, obstetrics/gynecology, psychiatry,
general surgery, orthopedic surgery, and anesthesiology) who were scheduled
to complete their training at AHCs in July 1998. For ease of presentation
and because of space constraints, this article focuses on results for disciplines
and problems relevant to adult patients. Findings concerning preparedness
to care for children for pediatricians and family practitioners will be presented
We limited our study population to residents in their last year of training,
so that we could elicit data about the entirety of respondents' graduate medical
education experiences, including perceived preparedness for practice at the
completion of residency. Because of resource limitations, we studied selected
specialties chosen with advice from representatives (P. Griner, MD, and R.
Meyer, MD, oral communication, February 1998) of the Association of American
Medical Colleges. We studied residents in AHCs because these institutions
often are at the forefront of educational reform and because data from the
University HealthSystem Consortium (UHC) enabled us to assess the market competitiveness
of local AHC environments.
We used a multistage process in compiling our sample of residents. First,
we constructed a list of the major teaching hospitals most closely associated
with US medical schools. We started by matching the 121 4-year US medical
schools (excluding Puerto Rico and the armed forces) with the Association
of American Medical Colleges list of integrated academic medical center hospitals.
Integrated facilities are defined as hospitals that are owned by a college
of medicine or those in which the majority of chiefs of service are also chairs
of medical school departments. All integrated facilities were included in
our sample. For medical schools with no integrated hospitals, we added hospitals
identified as having a major affiliation14
with that school. In cases in which there was more than 1 hospital either
affiliated or integrated with a given school, we selected the hospital with
the most residents.15 Finally, to ensure that
we captured other major teaching hospitals associated with AHCs, we compiled
a list of the 100 hospitals with the largest numbers of residents, based on
hospital reports to the Medicare program.15
We added all such hospitals if they were not already included on our list.
The final hospital list included 162 US hospitals training 40 000 of
the nation's 98 000 residents in 1998.16
In the second step of our sampling process, we identified all training
programs at these facilities in our 8 selected specialties using the American
Medical Association's Graduate Medical Education Database.16
These programs were then stratified by level of local market competition according
to the classification of their parent hospital in the UHC staging algorithm.
All AHC hospitals were assigned a market stage based on the UHC's market evolution
model, which assessed the competitiveness of health care markets by metropolitan
statistical area containing AHCs. Ratings ranged from least (stages 1 and
2) to most (stage 4) affected by competitive forces.17
Although the usefulness of the market evolution model has been questioned
(1 study found that it failed to accurately predict the tendency of health
care organizations to form integrated systems18),
other analyses have found it to be a useful gauge of market competition in
the 1990s19 and the resulting impact of competitive
pressures on faculty attitudes, levels of AHC research productivity, and support
for academic missions.20- 23
In the final sampling step, we randomly selected programs within each
market stage and specialty to achieve a target sample size of approximately
4800 subjects with 600 in each specialty and 1600 in each market stage. Because
the numbers of stage 4 markets and thus AHC residency programs were fewer
than in other stages, fewer than 1600 residents were included in the stage
4 stratum. Our final sample consisted of 4832 residents in 632 programs.
A total of 8 survey instruments (1 for each specialty) were designed,
based on literature review, focus groups of residents, review of the relevant
policies of the Accreditation Council on Graduate Medical Education, and comments
from experts. The instruments were tested for understandability and accuracy
of response (cognitive testing) by the Center for Survey Research at University
of Massachusetts, Boston. Surveys were designed to take 15 minutes to complete.
The surveys were administered in the spring of 1998. All respondents
received a mail survey administered by Datastat Inc, Ann Arbor, Mich. A sample
of those failing to respond to the mailed instrument were contacted for telephone
administration of the same survey performed by Atlantic Survey Research Inc,
Boston, Mass. Response enhancement techniques included advance notification,
multiple mailings, telephone follow-ups, and flexible scheduling. Furthermore,
respondents were eligible to receive 1 of 3 cash prizes or in some cases payment
for completed interviews. This protocol was approved by the Massachusetts
General Hospital institutional review board. Our final response rate, adjusted
for invalid sample (people who left their program or were assigned to the
wrong specialty) was 65%.
Preparedness of Primary Care Residents to Counsel Patients. Residents in primary care or related disciplines (internal medicine,
family practice, obstetrics/gynecology) were asked how prepared (very unprepared,
somewhat unprepared, somewhat prepared, or very prepared) they felt to counsel
patients about conditions (smoking, diet and exercise, HIV testing, domestic
violence, substance abuse, depression, pain management, palliative care/end-of-life
issues, and compliance with care issues), which other studies have found physicians
to be underprepared to address.1,6,7,11,24,25
Responses of "somewhat prepared" and "very prepared" were considered "prepared."
Preparedness of Primary Care Residents to Care for Different Types
of Patients. Residents in primary care and related disciplines were asked how prepared
they felt to manage types of patients whom they might be asked to care for
but for whom preparedness might be inadequate1,26
(inpatients, ambulatory patients, critically ill patients, terminally ill
patients, elderly patients, chronically ill patients, nursing home patients,
HIV/AIDS patients, and substance abuse patients).
Preparedness of Residents to Diagnose and Treat Conditions or to Perform
Tasks and Procedures Typically Associated With a Specialty. The residents in each specialty were asked how prepared they felt to
manage a range of specialty-specific conditions or to perform services typically
associated with their specialty. Conditions and services were chosen using
input from focus groups and from clinical colleagues, including department
chairpersons and training program directors who played a major role in graduate
In some analyses, scaled questions were collapsed into dichotomous variables
(eg, prepared vs unprepared). Analyses were weighted to accurately represent
national estimates, and to correct for nonresponse bias and for the probability
of selection within a given stratum. We used SAS version 6.12 (SAS Institute
Inc, Cary, NC) to construct the sample and to calculate descriptive sample
statistics such as averages and proportions. Results of the analyses are presented
as sample-weighted responses by category and may not always sum to 100% due
to rounding. Because of their dual status as both surgical subspecialists
and primary care providers for women, obstetrician/gynecologists are, as appropriate,
grouped with primary care providers in some analyses and with surgical subspecialists
Table 1 provides weighted
and unweighted characteristics of our sample. On a weighted basis, 59% of
respondents were male and 73% were graduates of US medical schools. Residents
in internal medicine (34%) constituted the largest group of respondents by
specialty with pediatricians (16%) and anesthesiologists (11%) ranking second
Overall, 96% of primary care residents (internal medicine, family practice,
and obstetrics/gynecology) were "very prepared" or "somewhat prepared" to
counsel patients about smoking, 94% about HIV testing, 91% about diet and
exercise, 89% about compliance with care issues, 87% about palliative/end-of-life
issues, 85% about substance abuse and depression, 74% about pain management,
and 67% about domestic violence. A total of 11% of internal medicine residents
rated themselves as "very unprepared" to counsel patients about domestic violence
(Table 2), 12% of family practice
residents felt "very unprepared" or "somewhat unprepared" to counsel patients
about compliance with care issues (Table
3), and 19% of obstetrics/gynecology residents felt "somewhat unprepared"
or "very unprepared" to counsel patients about depression (Table 4).
Overall, 99% of all primary care residents felt prepared to treat inpatients,
94% to treat ambulatory patients or elderly patients, 91% to treat chronically
ill patients, 90% to treat critically ill patients or terminally ill patients,
75% to treat substance abuse patients, 70% to treat HIV/AIDS patients, and
66% to treat nursing home patients.
More than 90% of internal medicine, family practice, and obstetrics/gynecology
residents felt prepared to treat inpatients and ambulatory patients; more
than 90% of internal medicine residents felt prepared to treat critically
ill patients, chronically ill patients, and terminally ill patients; and more
than 90% of residents in family practice felt prepared to treat elderly patients.
Populations for which more than 15% of residents felt unprepared included
nursing home patients, HIV/AIDS patients, and substance abuse patients (Table 2, Table 3, and Table 4).
Large majorities of residents reported high levels of readiness to undertake
many common clinical tasks associated with their specialty but gaps in perceived
preparedness were also evident.
Primary Care. More than 90% of all residents in internal medicine, family practice,
and obstetrics/gynecology felt prepared to diagnose and treat diabetes, upper
respiratory tract infection, and hypertension (Table 2, Table 3, and Table 4).
Psychiatry. More than 95% of psychiatry residents felt prepared to diagnose and
treat schizophrenia, minor depression, major depression, suicidal tendencies,
panic disorders, delirium, and obsessive-compulsive disorders, and to provide
psychopharmacologic services. However, more than 10% felt unprepared to treat
borderline personality or substance abuse, to provide short-term or long-term
psychotherapy, to diagnose and treat patients with loss/bereavement issues,
to diagnose and treat somatization, or to diagnose and treat eating disorders
Surgical Specialties. More than 90% of residents in obstetrics/gynecology felt prepared to
perform cesarean deliveries, abdominal hysterectomies, and vaginal hysterectomies
(Table 4); more than 90% of orthopedic
surgery residents felt prepared to perform total knee replacements and total
hip replacements (Table 6); and
more than 90% of general surgery residents felt prepared to perform herniorrhaphies,
appendectomies, total colectomies, femoral-popliteal bypass, and biliary tract
surgeries (Table 7). More than
90% of all surgery residents felt prepared to communicate with referring physicians
and to manage patients preoperatively and postoperatively (Table 4, Table 6, and Table 7).
However, like residents in primary care specialties and psychiatry,
significant proportions of residents in surgical specialties reported feeling
less than fully prepared to provide certain types of care. In orthopedic surgery
62% of residents rated themselves as prepared to perform spinal surgery and
54% to perform cancer surgery (Table 6).
In general surgery, 81% reported themselves prepared to perform pancreatic
surgery and 88% to repair abdominal aortic aneurysms (Table 7).
Anesthesia. More than 90% of anesthesiology residents felt prepared to administer
spinal and epidural anesthesia, general anesthesia for patients with complex
illnesses, anesthesia in day surgery, cardiac anesthesia, perform preanesthesia
testing, manage acute pain, and administer postoperative intensive care (Table 8). However, 32% of anesthesiology
residents felt unprepared to manage chronic pain.
Although limited by the use of residents' perceptions and by the cross-sectional
nature of the survey, our data nevertheless provide some useful insights into
the preparedness of residents completing graduate medical education. Residents
tended to have a positive view of the overall quality of their training and
overwhelming majorities were leaving their programs feeling somewhat or very
prepared to manage most of the common clinical problems they are likely to
encounter. These high levels of preparedness should provide reassurance about
the overall quality of graduate medical education in the United States.
However, if residents' evaluations are any indication, their preparedness
in nontraditional locations (eg, nursing homes) or for nontraditional patient
populations (patients with substance abuse problems) may lag behind their
preparation for care in traditional training environments. These findings
suggest that AHCs now face the challenge of ensuring the quality of training
for nontraditional educational experiences. Furthermore, in every specialty
we studied, more than 1 in 10 residents in their last year of training felt
unprepared to manage some clinical problems that they are likely to encounter
The implications of these reported gaps in preparedness are uncertain.
Modern medicine is complex and diverse, and it is difficult to gain equal
competence in all areas. Some residents go on to get additional training (especially
in procedural specialties) that will prepare them better for some of the conditions,
such as pain management among anesthesiologists, vascular surgery among general
surgeons, or spinal surgery among orthopedists. Undoubtedly, some physicians
will avoid treating problems they feel unprepared to manage. Nevertheless,
the potential consequences of residents' perceived lack of preparedness in
a number of important areas of practice deserves further assessment to evaluate
implications for curricular design.
The discrepancy between our findings and the many recent anecdotal reports
of the deterioration in medical education under the pressure of managed care
and other stresses deserves further exploration. One possible explanation
is that AHCs have succeeded in protecting educational missions through working
both harder and smarter. If so, our data may testify to the ingenuity of AHC
faculty and managers, but also raise questions about whether coping mechanisms
can face additional pressures, such as the Balanced Budget Act of 1997. Alternatively,
anecdotal reports may have overstated the problems facing the educational
missions of AHCs. Only further research, including longitudinal studies of
the content and quality of graduate medical education experiences, can shed
light on these alternative explanations.
Our study had a number of limitations that should be mentioned. Perhaps
most important is our reliance on reports of residents to assess their preparedness
for practice. It is possible that self-perceived preparedness has little correlation
with actual competency. However, others have shown that residents are as capable
as their teachers at predicting their examination scores,27
that students tend to underrate their preparedness relative to the assessments
of their supervisors,26,28 and
that self-reported high levels of preparedness are correlated with good performance.29 Additionally, self-reported preparedness has been
used as an indicator of educational quality in other published studies.1,30 Residents' reports at the end of training
are not complete or definitive indicators of the quality of training but are
clearly relevant. Student perceptions are widely used in education as an indicator
of quality of educational experiences.
Overall, our data suggest that in 1998 residents finishing their training
programs felt well satisfied with their preparedness for clinical practice.
However, our data also suggest that gaps may still exist in the preparedness
of physicians to manage the full range of patients, problems, and procedures
they may confront as practitioners. These findings indicate the need for training
programs to continue evaluating the appropriateness and diversity of experiences
and instruction that residents encounter during their training.