Conceptualising the pandemic as a critical incident allowed for re-examination of mentoring and support provision, exposing inherent strengths and weaknesses. Collectively, the findings suggested that participants felt underequipped to deal with the transition from graduation to internship.
Specifically, FYM’s demonstrated a sense of being under-supported and identified a perceived lack of adequate mentoring and support, with a compensatory increased dependency on peer support. Additionally, participants felt underprepared and regressed due to reduced exposure, believing this would impact their future career trajectories. ‘Compensatory teaching’ and sporadic positive mentoring occurred, but this appeared highly variable and unstructured. Communication and contingency planning were highlighted as particularly deficient areas of support by participants.
Interestingly, a key subtheme, ‘The COVID Doctors’, provided a rich insight into the narrative and development of a shared identity amongst participants. FYMs further described potential difficult transition periods and stigma as a result.
The findings of this study align with previous research, particularly themes surrounding transition and preparedness [8, 29,30,31,32], and point to a disconnect between FYM expectation and institutional provision. There was a clear perception of a dysfunctional compensatory system that was unable to deliver adequate mentoring and support. It was apparent that participants expected explicit communication and contingency plans in the face of uncertainty. A possible cultural shift was noted, in line with the observation that the identity of current students is increasingly consistent with that of a “consumer”, [33].
Nevertheless, positive role models/mentors and increase in peer support was observed. FYMs reported ‘compensatory-teaching’ and ‘bottom-up’ mentoring and support, although usually sporadic and reliant on student initiative. Notably, these positive experiences were perceived as resulting from individual efforts rather than a cohesive effort from academic staff within the university. Variance in policy and teaching content was reported by many participants, alluding to commencement/suspension of clinical placements at various times during the year in relation to changes to pandemic restrictions.
The Covid-19 pandemic appears to have had a largely disruptive effect on FYMs. Both as a critical incident, revealing fragilities in current mentoring and support provision; and as a pandemic, directly impacting FYMs and their futures. FYMs were divided in their belief that the pandemic impacted their career trajectories but were unified in identifying potential stigma and issues at transition.
With a notable sense of agency and alignment through legitimate peripheral participation [9], FYMs envisioned a role for graded exposure, criticising the abrupt overnight change associated with status and responsibility [29]. The public expect newly qualified doctors to be ‘oven ready and self-basting’ [34], which may now extend to deal with patients with COVID-19 sequelae. However, the current study indicates that due to policy adherence and reduced exposure, students have not had opportunities to learn from patients symptomatic of COVID-19. Correspondingly, a pre-pandemic study described students were rarely able to practice managing acutely ill patients due to patient-safety concerns [1]. Participants observed the somewhat paradoxical expectation to be treating such patients shortly after graduation.
FYMs expected formal transition periods, placing such large emphasis on its importance by deciding to take on this experience without compensation. It was evident that, at an early stage in their trajectory, participants acknowledged that the expectations and responsibilities of the doctor-role comes before learning. This observation lends support to the theory of transition beginning earlier than graduation [35], representing a prolonged developmental process [30]. Our findings support the evidence that “sub-internship” may improve self-assessed preparedness in this regard [31, 36, 37]. Furthermore, FYMs anticipated the need to cope with pressures and uncertainty regardless of its challenges, adding to their burden of stress [1], “bracing for an experience to be endured, rather than enjoyed” [29]. Concerningly, there is evidence that the ‘transition shock’ which accompanies abrupt changes in role and responsibilities [29, 38, 39], produced by disparities between expectations and role-transitions [8, 30, 40], can lead to the development of dysfunctional strategies [29, 41].
Previous research suggests the presence of inadequate mentoring and support during the transition period, not only at provision [30] but also in terms of access [29, 30, 40]. The observations in the current study are in-line with previous work suggesting that students may be reluctant to ask for support, for fear of appearing vulnerable and ‘imperfect doctors’ [40]. Effective mentoring and support practices represent complex solutions to the complex problem of transition, particularly in the face of critical incidents. Effective supervision and role-modelling are essential factors in professional identity formation and the development of clinical competence but require balancing with societal needs [42, 43]. As performance of newly graduated doctors is contingent to a large extent by organisational practices and cultures, situated and relational mentoring and support practices can be considered vital [8] to engender sociocultural learning processes and progressive participation in practice [9]. Thus, stakeholders reframing the transition period as critically intensive learning periods (CILPs) may allow students to better engage with the idiosyncrasies of the workplace environment [8]. In alerting stakeholders of the challenges faced by this cohort during transition, there is potential for expectations to be tempered and access to and provision of adequate mentoring and support enhanced. Indeed, as one-third of trainees report being affected by burnout during the COVID-19 pandemic [44], significant cultural change may be required to create environments that foster effective mentoring and support practices.
‘The COVID doctors’
The ‘COVID doctors’ subtheme provided a rich insight into the participants’ construction of a shared narrative in relation to social identity theory [45].
Participants anticipated transition to be challenging, choosing to present themselves in a vulnerable way, leaning on the narrative to manage expectations of colleagues, supervisors and possibly themselves. This impression management [46] may serve a further purpose in managing expectations of future career trajectories. Furthermore, FYMs appeared to require validation of their unique status, as a rationale for perceived deficiencies in clinical knowledge/skills when undergoing the transition from a learning to a performance orientation [30]. The pre-term infant metaphor may extend beyond the ‘catching-up period’, having implications for professional development and identity formation. It can be assumed this narrative is not static and may serve as a performance management tool for this cohort to navigate this transition. For instance, FYMs may present a resilient facet of this shared identity, describing how challenges were overcome in their final year as students. These challenges may retrospectively be made to fit narratives of strength, creativity and overcoming adversity [47]. The findings suggest the utility or stigma of the narrative is likely to be context dependent. Nonetheless, a disrupted final-year remains a potential risk factor for increased medical errors and mortality associated with transition [41].
This study highlights how a critical incident affected FYMs undergoing transition to intern and exposed underlying strengths and weaknesses in their medical education. There are several implications for this study in a post-pandemic era and for pandemic-preparedness, both rapidly growing areas of research in medical education [48,49,50,51]. Recommendations include updating outdated contingency plans [48, 51], balancing clinical exposure with patient safety issues [49], and providing support to ‘bottom-up’ mentoring practices [48].
Strengths & limitations
This study provides rich, detailed and contextually novel perspectives of FYMs in transition during a critical incident. Methodologically, rigour was applied in reflexivity and researcher triangulation. Our intentions are the rich description allows readers to interpret this study in relation to their practice, indubitably also affected by the COVID-19 pandemic.
The sample may not represent views of all, but data saturation with nine participants is considered acceptable [52]. Interviews were conducted by a member of faculty known to students. Although all precautions were taken in relation to power dynamics, complete omission remains impossible. Thus, it remains possible interviewees were not fully honest during their accounts, potentially leaving layers to these perspectives uncovered.
