Perceptions of preparation for further training: how our medical schools prepare graduates and the perceived factors influencing access to training

Obtaining a primary training position in a specialist field is just one of the many outcomes of undergraduate medical education. Decisions to undertake primary training (the first level of formal or basic postgraduate medical training after medical school) and subspecialty training are affected not only by personal preference, but also by the available pathways between undergraduate and postgraduate training. Facets of the undergraduate curriculum reported to affect the career paths of graduates include the use of problem-based learning,1 different grading systems2 and depth of basic sciences teaching.3 The selection process in medical colleges is highly competitive. We surveyed doctors who were registered to practise in New South Wales between 1995 and 2006, to investigate the factors that graduates perceive to help them obtain a training position.

Although there is little about this issue in the literature, it is relevant to current debates about specialist training and career pathways. There is a need for greater collaboration between stakeholders, such as medical schools, specialist training colleges and postgraduate medical education councils, to better understand and meet the expectations and needs of new graduates.4 The results presented here will enhance such collaborations.

The original sample was reduced to 1915 due to inaccurate addresses. Of this reduced sample, 375 returned surveys (19.6% response rate). Despite the inclusion criteria for selecting the 2000 doctors to participate, some had graduated before 1995 (41/375 [11%]). These were excluded from analysis, along with seven doctors who had completed their medical school training overseas and five who did not provide sufficient information, leaving complete data for 322 respondents. There was no follow-up of non-respondents because of budgetary constraints.

Our results have clear implications for junior doctors preparing for primary training and for medical schools planning their programs and admissions criteria.

In helping to prepare graduates and junior doctors for primary training, the importance of mentors cannot be overemphasised. This was commented on throughout the survey and has also been reported by others.5,6 There is a clear need to foster and preserve this relationship in all training institutions, perhaps through the establishment of structured mentor programs in internship that can be followed through long term. This relationship is especially important given the changes in training that are currently occurring and the possibility of completing training over a shorter period of time. Nevertheless, there are issues in ensuring that there is equal opportunity for junior doctors to engage with supportive mentors.

In line with previous research, our study found that age, graduation with honours, or having a grade rather than “pass/fail” on one’s transcript had no effect on access to further training.2 This finding needs to be widely publicised among medical students to reduce anxiety about choosing a medical school. There is much discussion and debate about grading in particular,2,7 and more research is needed on this issue in the Australian context.

In terms of preparation for primary training, personal and weekly study groups were considered to be a positive influence and a major source of preparation. This observation extends previous research on the role of study groups in medical school8 and suggests that junior doctors may need support, allocated time, encouragement and space to participate in these activities.

Our findings may also have implications for undergraduate program planning. First, it was clear that graduates felt their personal attributes of motivation and persistence carried them through and were the main reasons for their success. Strategies may need to be devised to foster the development of these skills, especially the ability to deal with stress and the capacity to cope in the long term. Second, most graduates commented that communication and clinical skills were the most helpful aspects of their undergraduate degree program. This was an interesting finding, given the evidence that students frequently complain about the amount of time courses spend on teaching communication skills.9,10 Revealing our findings to medical students may enhance their appreciation and understanding of the significance of communication skills in accessing postgraduate training. Finally, there was an emerging trend for junior doctors to recognise the importance of research to their future careers. The role of research was not emphasised in some undergraduate courses, and consequently those students failed to realise its significance at the time. This observation aligns with previous research that indicated most Australian medical students had narrow perceptions of what research involved. Previous involvement in research offered both opportunities for, and constraints against, further consideration of a career involving this pathway.11 Some junior doctors lamented the lack of exposure to research in their undergraduate degree and recognised that more opportunities to engage in research would have been an advantage.

Although most graduates obtained their first preference for a training position during the period of the study (96%), the expected increase in new medical graduates seeking a position between now and 2012 may affect the nature of these results. New approaches are needed to ensure access to training, and new training positions will need to commence immediately.12 After 2008, junior doctors from three of the seven medical schools in NSW will be from graduate-entry programs and may therefore have different perceptions and preferences for certain career pathways.13 It will be important to review these issues.

The findings also need to be interpreted in light of the limitations of our study, including the low response rate, characteristics of the sample, and interpretation of questions about meeting career goals. Although the low response rate is a threat to validity, the results of the study are similar to those of other studies of junior doctors with no follow-up.14 At the time the survey was distributed, acceptance rates to medical colleges for vocational training were 100% for all but three.15 This is reflected in our findings, where 99% of graduates were accepted into their preferred training program at first attempt. Further, the sample reflects the distribution of graduates from 1995 to 2004, also noted by the Medical Training Review Panel.15 This enhances the validity of the findings. However, our survey results require greater validation and will be enhanced by future follow-up focus groups with a cross-section of graduates to explore the issues raised in more detail. Our sample may have over-represented those who were successful at gaining entry to the courses of their choice on first attempt and may be biased by those who felt their personal characteristics carried them through. There was also an over-representation of respondents from urban areas and at the registrar level.

The results for meeting career goals need to be interpreted with caution because of some confusion about how to answer the questions. Although the choice of options was limited to a scale of negative to positive influence, 18 respondents felt that the term “negative influence” meant “no influence” or not a “bad” influence. This was interesting given that the pilot elicited no such comments, even though respondents were specifically asked to comment on the clarity and wording of all items.

Although circumstances in some medical schools have changed since the survey was conducted, the data provide a potential baseline for all stakeholders to consider, and can contribute to future decision making and further research.

2 Perceived helpfulness of medical school course areas for accessing further training (n = 321)

EBM = evidence-based medicine. * Mean score on Likert scale, range: 0 = definitely not helpful, 4 = very helpful, 5 = not applicable.