Making the transition from medical student to junior doctor

Introduction

The transition from medical student to junior doctor is a notoriously difficult and stressful process, that is well-documented in medical literature.^1,2 In fact, the harrowing experiences of a newly minted junior physician were humorously described in Adam Kay’s 2017 best-selling book This is Going to Hurt: Secret Diaries of a Junior Doctor. ³ The reasons for this challenging transition are aplenty, including heavy clinical responsibilities, long working hours, poor working conditions, steep learning curves and having to deal with emotionally challenging situations such as medical errors, facing harsh criticisms, dying/deteriorating patients and ethical challenges.^1,2,4

Over time, many junior physicians inadvertently develop imposter syndrome and self-doubt on their abilities to cope with the demands of the profession. ⁵ Burnout rates are also unsurprisingly high due to the aforementioned workplace stressors and work–life role conflicts. ⁶ In a previous piece, I shared candidly about what an aspiring medic should know about this profession before making the decision to join it, ⁴ stemming from an observation that there appears to be a significant disconnect between how those who are not in the medical field perceive this profession and the actual realities of clinical work. In this article, I hope to offer some perspectives as a resident-in-training on important guiding principles that could help ease the difficult transition from medical students to junior doctors.

Adopt a self-regulated growth mindset for professional development

First, it is important for junior medical trainees to adopt a self-regulated growth mindset. Medicine is a unique career that offers professional longevity, which requires doctors to continually learn and keep up with new developments in the field. Adoption of a growth mindset in medical education and training is founded on the belief that there is always room to learn, adapt and attain mastery in various aspects of clinical care. ⁷ In pursuit of professional growth, cultivating self-regulation in the developmental process is necessary, where medical trainees/practitioners take charge of their learning through appropriate goal setting, process monitoring, self-reflection/appraisal and receiving of feedback to be attuned to personal strengths and weaknesses. ⁸ In the same vein, assessments of clinical performance should be viewed through the lens of entrustability, where time and effort are needed to develop domain-specific expertise/competencies to enable greater entrustment of clinical responsibilities that can have serious implications in patient care. ⁹ By adopting such a view, medical trainees will be more mentally receptive to competency assessments and view them as less of a value judgement, but more of a guide on training progress in attaining the necessary professional milestones.

To this end, emotional self-regulation is equally important, given that the clinical training and work of junior physicians often involve unpleasant encounters, conflicts, harsh criticisms and setbacks. As such, cultivating good personal insight through metacognitive reflection, self-appraisal and feedback literacy is important to maintaining a healthy, balanced and objective view of self. ⁸ In addition, targeted psychological self-help interventions can also be utilised depending on the stressful situation. For instance, Lazarus and Folkman’s stress-coping model helps to cultivate an objective appraisal of a stressful situations and availability of coping resources, which help individuals avoid catastrophic thinking and adopt healthy coping mechanisms. ¹⁰ Cognitive-behavioural strategies are useful to recognise and self-regulate inner thought processes and emotions in order to avoid maladaptive actions. ¹¹ Lastly, mindfulness-based interventions help to promote kind, objective and non-judgemental acceptance of one’s current situation and experienced emotions. ¹²

Strengthen clinical reasoning skills for optimal decision-making

Real-world clinical decision-making can be highly complicated, where errors in thought processes can lead to serious consequences in patient care and professional practice. Unfortunately, much of the content knowledge that we have learnt in medical school is, by itself, inadequate for real-world practice which involves many nuanced contextual challenges and considerations. As such, Scott observes that flawed clinical reasoning in professional practice is typically ‘not due to incompetence or inadequate knowledge but (rather) to frailty of human thinking under conditions of complexity, uncertainty, and pressure of time’. ¹³

In reality, the principles of clinical practice differ across contexts – for instance, efficiency, pattern recognition/script activation, prioritisation (of sick/deteriorating patients), composure and decision-satisficing are particularly important in emergency, critical care or on-call situations, while more analytical processes in synthesising complex clinical information to arrive at unifying diagnoses (i.e. Occam’s razor ¹⁴ ) may be adopted in ward-based and subacute ambulatory settings. Therefore, cultivation of clinical reasoning skills requires both the strengthening of cognitive models (e.g. dual process thinking, clinical heuristics, illness scripts, and hypothetico-deductive algorithms), and understanding how it applies to different situations and environments (i.e. situated cognition and ecological psychology). ¹⁵ For instance, eventual decision-making may not be based on clinical considerations alone, but may also be influenced by additional situational, emotional and environmental factors such as patient–physician interactions, resource availability/allocation, time constraints and implicit biases. ¹⁵ Ultimately, the standard or acceptability of clinical decisions would depend on evidence-based principles, professional stipulations (Bolam–Bolitho standards ¹⁶ and patient-centricity of decision-making.

Cultivate good clinical communication skills

It is known that patient satisfaction with clinical care and willingness to adhere to medical recommendations is contingent on how they perceive their doctor through clinical communications. ¹⁷ On the contrary, poor communication is a major cause of patient complaints. ¹⁸ Hence, good communication skills are clearly necessary for professional success and avoidance of conflicts and workplace stressors.

To improve communication skills, one can learn from senior/experienced clinicians or proficient colleagues in how they connect and build relationships with patients, adopt/practise evidence-based communication techniques (e.g. empathic, normalising and reflective statements, validation, turning the receipt, learning the back story, verbalising the difficulty and seeking common ground)^{19 –21} and be willing to practise under adequate supervision the communication skills needed to navigate difficult clinical encounters in simulated and real-world settings.

Actively develop mentor–mentee and collegial relationships

A lot of clinical skills and expertise can be acquired through apprenticeship, where physicians immerse themselves in a training department and learn from their seniors. In fact, Halsted’s ‘see one, do one, teach one’ model used to be the archetypal method of training in procedure heavy/surgical subspecialties, ²² and the overarching principles of learning by observation and guided practice still apply today. As a corollary, clinical mentorship is also highly valuable, where mentors must have a willingness to coach, share and educate on knowledge and skills, as well as demonstrate commitment to the professional growth and success of the mentee. ²³ At the same time, with increasing complexities of clinical cases and the importance of multidisciplinary, holistic medicine, it is important to develop collegial and collaborative relationships with colleagues within the medical fraternity. Therefore, junior doctors should take the opportunity during their various ward/subspecialty rotations to establish meaningful relationships and collaborate on projects/initiatives with like-minded peers and clinical mentors.

Pursuing meaning and fulfilment

Professional fulfilment in medicine comes from practising in an area where one has aptitude (where one’s strengths and inclinations can be used to create something of value) and interest (what one finds exciting and a source of passion), and is aligned with personal convictions and beliefs. The benefit of the medical field is that it is broad and presents a whole spectrum of opportunities to practise in different subspecialisations, clinical and para-clinical areas, and participate in non-clinical activities such as education, research, innovation and health systems development. Therefore, it is perfectly fine to take the necessary time needed to explore the most suitable career path based on the above criteria, and if possible, identify a niche to build an expertise oriented at addressing a currently unmet clinical need. For instance, in recent years, new burgeoning fields have included cancer immunology to deal with the complexities of novel immunotherapies and their associated immune-related adverse events, medical informatics to manage data-driven precision medicine and health technological applications, and telehealth services in light of a post-pandemic rise in demand for off-site/virtual clinical care. ²⁴

In Atul Gawande’s best-selling book Being Mortal: Medicine and What Matters in the End, he writes that there is more to the medical profession than ensuring ‘health and survival’ – instead, it is to ‘enable well-being’ of others, as ‘our ultimate goal, after all, is not a good death but a good life to the very end’. ²⁵ I suggest that, in a similar vein, caring for dying or seriously ill patients in the course of clinical work also allows us to reflect on our own mortality, find meaning in medical practice and pursue what is truly important and meaningful in our lives and careers. ²⁶