Article Text

Original research
Transition to clinical practice during the COVID-19 pandemic: a qualitative study of young doctors’ experiences in Brazil and Ireland
  1. Erik Montagna1,
  2. Jessica Donohoe2,
  3. Victor Zaia1,
  4. Eileen Duggan2,
  5. Paula O'Leary2,
  6. John Waddington3,4,
  7. Colm O'Tuathaigh2
  1. 1Faculdade de Medicina do ABC (FMABC), Centro Universitário Saúde ABC, São Paulo, Brazil
  2. 2School of Medicine, University College Cork, Cork, Ireland
  3. 3School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
  4. 4Jiangsu Key Laboratory of Neuropsychiatric Diseases and College of Pharmaceutical Sciences, Soochow University, Suzhou, Jiangsu, China
  1. Correspondence to Dr Colm O'Tuathaigh; c.otuathaigh{at}ucc.ie

Abstract

Objectives To explore and compare the perspectives of junior doctors in Brazil and Ireland regarding transition and professional socialisation during the COVID-19 pandemic, with the purpose of identifying better ways to support doctors as they assume their new professional role.

Design 27 semistructured interviews. Transcripts were analysed using qualitative thematic analysis. Cruess’ framework of professional socialisation in medicine supported the interpretation of these data.

Setting Public health hospitals across four Brazilian states (Santa Catarina, São Paulo, Ceará, Paraíba) and County Cork in the South of Ireland.

Participants Twenty-seven male and female medical junior doctors who had graduated between November 2019 and April 2020.

Results Fourteen Brazilian and 13 Irish junior doctors were interviewed for this study. Entry to clinical practice during the pandemic had a significant impact on factors influencing the professional socialisation of junior doctors. This impact was reflected across the following six thematic areas: lack of preparedness; disrupted trajectory of role adaptation; fewer opportunities for experiential learning; solidarity and isolation; altered interactions with patients; challenges to health and well-being.

Conclusions Transition to clinical practice is an important stage in junior doctors’ professional socialisation and identity formation. The COVID-19 pandemic created the opportunity for medical graduates to enter the workforce earlier than usual. Entering the workforce during this period created a lack of confidence among junior doctors concerning the boundaries of their new role and responsibilities, while simultaneously disrupting their social integration. Priorities to mitigate the impact of COVID-19 and future pandemics on this transition are presented.

  • education & training (see medical education & training)
  • general medicine (see internal medicine)
  • medical education & training

Data availability statement

Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information.

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Strengths and limitations of this study

  • This is the first study to employ a detailed and comprehensive qualitative approach to compare the impact of the COVID-19 pandemic on factors influencing the professional socialisation of junior doctors entering clinical practice across two international locations.

  • Use of a retrospective design precludes any conclusions about the long-term effects of the pandemic on these doctors’ professional identity formation.

  • The study design does not allow us to fully disambiguate transitional challenges unrelated to the current pandemic which are experienced by junior doctors, relative to concerns which might be exacerbated by COVID-19.

Introduction

COVID-19 was declared a pandemic by the WHO on 11 March 2020. It quickly escalated into a global health crisis, prompting an unprecedented emergency public health response from governments worldwide. Such changes have also impacted on delivery of healthcare, including a shift to telehealth for primary care, deferral of scheduled elective procedures and restructuring of clinical teams.1

The first cases of COVID-19 in the state of São Paulo (SP) in Brazil and Ireland were confirmed on 26 and 29 February 2020, respectively. In both locations, the number of confirmed cases grew in a classical exponential curve, with a rapid rate per day (~25%), comparable to that observed in other countries internationally.2 Within 23 days of the first case, emergency public health decisions were taken in both locations to protect the vulnerable, minimise its impact on healthcare and reduce community transmission.3 4

Medical education has also been severely impacted by COVID-19, requiring substantive immediate and longer term adjustments. In line with other university courses, the pandemic gave rise to the closure of medical school campuses and a rapid switch to online-based teaching and assessment.1 5 In both Brazil and Ireland students had clinical placements interrupted or cancelled, with many of these activities adapted to virtual learning environments.6–8 The scale of the public health crisis prompted many medical schools to bring forward graduation, to allow graduates to enter the workforce months earlier than usual.9–11 Continued provision of medical education in the ongoing pandemic environment has necessitated radical restructuring of curricula and assessment.9 12

The transition from medical school to clinical practice is a time of uncertainty for the new doctors. How they experience the transition can affect their developing professional identity13–15 and these issues can persist beyond the immediate transition period.16 17 Assuming the role of junior doctor requires a shift in perspective from the predominant position of observer to that of active participant, adapting to workplace demands and taking on independent responsibility for patient care.18 A recent study of newly graduated Irish doctors revealed a complex picture of the hopes and fears of medical students at the threshold of clinical practice.19 The experience of anticipation of transition was characterised by expectation of an abrupt transition, mixed feelings regarding commencing practice and a key role for the hidden curriculum in shaping participants’ understanding of what was expected of them.19 This account is consistent with the theoretical framework proposed by Cruess and colleagues,20 21 where the transition journey from medical student to doctor is described as one of professional socialisation. This process involves adaptive integration of work-based norms, values, knowledge and expected roles. Therein, significant factors influencing professional socialisation include role models, clinical experience, features of the clinical learning environment, attitudes of colleagues and peers and interactions with patients.20

Despite ongoing uncertainty regarding the remaining duration of this pandemic and its sequelae, it is recognised that measures such as social distancing and quarantine periods are likely to be in place for an extended period22 23 and that these necessitate exploration and discussion of how best to manage transition to clinical practice under these conditions.1 Lack of pandemic preparedness may leave medical students vulnerable to negative physical and mental health outcomes, a particularly relevant challenge for those transitioning from student to doctor.9 Consequently, examination of the transition experience of junior doctors during public health restrictions, which can vary between countries, is necessary to devise better ways to support doctors as they assume their new professional role.

Due to broad similarity in terms of the standardised undergraduate medical curriculum in both countries, as well as the public health circumstances which lead to early entry to frontline service for both sets of medical graduates, we sought to explore and compare Brazilian and Irish doctors’ expectations and experiences of entering clinical practice during the COVID-19 pandemic. Specifically, the aim of this study was to examine and compare for the first time the perceptions of junior doctors in both countries regarding the impact of COVID-19 on the transition and professional socialisation process. The results are discussed in the context of Cruess’ conceptual framework of junior doctors’ professional socialisation.

Methods

Study design and setting

A descriptive qualitative design was adopted. Individual semistructured interviews with junior doctors who had graduated during either late 2019 or 2020 addressed their experiences of the transition from medical student to junior doctor. This study adopted the Consolidated Criteria for Reporting Qualitative Research.24

Participants were selected through a purposive sampling method. Junior doctor participants were recruited by EM (Santo André, Brazil) and JD (Cork, Ireland). All participants were approached to participate via email or face to face based on the personal networks of EM and JD. Former students/peers were asked to distribute the invitation to participate to eligible junior doctors with the aim of obtaining a gender-balanced sample of junior doctors. Additionally, for the Brazilian sample, researchers also sought to recruit a geographically diverse sample including representatives from different regions of Brazil. The only inclusion criterion was that all participants were required to have entered clinical practice during 2019/2020. Two of the Irish junior doctors approached were unable to contribute due to clinical commitments but none of those approached refused to participate or dropped out. Interviews were conducted until data saturation was achieved. All Brazilian and Irish participants were working in teaching hospitals and clinics at the time of the study. Brazilian interviewees comprised recently qualified doctors (2–10 months since graduation) working in the public health service of four different states (Santa Catarina, São Paulo, Ceará, Paraíba). Irish interviewees comprised a sample of new doctors (<2 months since graduation) working at Cork University Hospital, a public hospital that is academically affiliated with University College Cork School of Medicine.

Undergraduate medical education programmes in Brazil are typically delivered across three 2-year cycles over a 6-year period characterised by early emphasis on preclinical science training and at least 2 years of clerkship rotating across major specialties25; the last 2 years are called the cycle internship (ciclo do internato), where students focus on clinical practice through training in teaching hospitals and clinics. Newly qualified doctors are permitted to work in general practice and can apply to undertake postgraduate training (ie, residency). Residency is not mandatory and some medical doctors begin work immediately after medical school, usually in emergency or primary care settings, where many will simultaneously apply to enter residency programmes in specific specialties. In April 2020, in recognition of the pressure on health and care sectors due to COVID-19, the Education Ministry of the Brazilian government issued an ordinance authorising federal universities to fast-track graduation of medical students who had completed 75% of their internship credits.26

Medical education in Ireland begins with 4–6 years of undergraduate university programme. For programmes that are 5 or 6 years in length, entry is based on secondary school qualifications, while programmes that are 4 years in length require previous university degrees. The first 2 years consist almost entirely of biomedical science subjects and clinical skills teaching, followed by integration of clinical training in the affiliated teaching hospitals and primary care centres during the remaining years in a spiral approach. In contrast to Brazil, where doctors are fully registered on graduating from medical school, Irish medical school graduates receive only provisional registration and 1 year of postgraduate experience (internship) in hospital-based medicine is necessary to obtain definitive registration. During April 2020, Irish medical schools expedited graduation of medical students to allow them to start their internship posts early in May 2020.27

Data collection

A series of questions was developed (based on previous qualitative investigation of the transition to clinical practice19) that would allow us to compare both the expectations of junior doctors prior to commencing work and their experiences following 1 month of practice. The interview guide outlined this study purpose to participants and invited them to reflect on four areas: (1) their expectations concerning transition to clinical practice and how these were influenced by entering the workforce during the COVID-19 pandemic; (2) their experiences at work during the initial month of clinical practice and how these were impacted by working in a pandemic environment; (3) the impact of working as a junior doctor during a pandemic on life outside of the hospital; (4) strategies employed to manage stress in a pandemic working environment.

JD conducted all Irish interviews and EM conducted all Brazilian interviews, each of which took place in person (and without others present) or online (using Skype, Zoom or FaceTime) in a workplace setting and ranged in duration from 20 to 40 min. All face-to-face interviews were conducted in compliance with ongoing public health measures which were in force during the pandemic at the time of data collection, the most prominent of which were 2 m social distancing and mask wearing. Previous studies have suggested that in in-person study interviews are comparable in terms of quality of data collected using video calls.28 Neither interview transcripts nor thematic results were returned to participants for comment or feedback. EM is a non-clinical lecturer in medical education based in the Faculty of Medicine at Centro Universitário Saúde ABC. JD is a medical graduate and clinical researcher who commenced her medical internship during May 2020.

The interviews were audio recorded. Irish interview data were transcribed using the Otter (otter.ai) transcription app and CO’T reviewed the transcripts against the audio to ensure their accuracy. Brazilian interview data were digitally transcribed using Microsoft Word and this transcription was then reviewed by EM to verify accuracy. The Brazilian-Portuguese transcript was then translated into English using the Google Translate (translate.google.com) service. EM and VZ are Portuguese-English speakers, and they checked the translation accuracy and performed a back translation of the interviews. Finally, each English translation was then jointly reviewed and finalised by CO’T and EM, addressing both grammatical errors and issues related to idioms and expressions. Each transcript was allocated a unique identifier (Cork (CK) 1–13; Brazil (BR) 1–14) according to the order in which the interviews were completed.

Data analysis

Interview data were analysed using Braun and Clarke’s thematic analysis approach,29 30 a method for identifying, analysing and reporting themes within qualitative data. First, ED and CO’T completed an independent analysis of all 27 transcripts using open coding to assign inductive, content-driven labels to interview extracts. CO’T reviewed all coded transcripts and created a single, final document that reflected the complete coding scheme. Both researchers (CO’T, ED) met regularly to discuss the initial codes, identify the codes that addressed the research questions, discover relationships across the relevant codes and organise them into themes. Any discrepancies were discussed until consensus was reached. During the final stage of data analysis, meetings were held to review the analyses and to develop the final list of six themes. Throughout, researchers wrote conceptual memos about the initial codes and finalised codes being developed.

With respect to reflexivity, both ED (with a professional clinical background in midwifery) and CO’T (a non-clinical lecturer with a background in translational neuroscience) have worked for many years in medical education, with a particular focus on students in the clinical years of the undergraduate programme. This experience influenced their interpretation of interview data collected here. Additionally, both researchers have previous experience of conducting thematic analysis on semistructured interview data.31–33 This experience influenced their interpretation of interview data collected here.

The theoretical lens

The theoretical framework of professional identity formation (PIF) in medical doctors proposed by Cruess and colleagues20 21 describes the transformation from medical student to doctor as one of professional socialisation, where professional identity is a representation of the integration of work-based norms, values, beliefs, knowledge and expected roles. Here, identity formation is affected by several factors including role models, clinical experience, clinical learning environment features, attitudes of colleagues and peers and interactions with patients (figure 1). These factors interact with existing traits and support networks to influence the development of a professional identity.34 This framework20 was used to inform the interpretation and discussion of study findings. It did not inform the design or development of the interview guide; rather, we conducted a primary-level thematic analysis to determine and identify themes, and we used Cruess’ framework as a conceptual lens for a theory-driven interpretation of the study findings.

Figure 1

Schematic representation of factors influencing the process of junior doctors’ professional socialisation in identity formation, as described in Cruess’ conceptual framework.20

Patient and public involvement

It was not appropriate or possible to involve patients or the public in the design of this research.

Results

Fourteen Brazilian and 13 Irish junior doctors were recruited and interviewed. In the Brazilian sample, most of the participants were female (8/14), with an average of 27.4 years (range: 24–35), and the majority (9/14) commenced their postgraduate training during February 2020. In the Irish sample, most of the participants were male (7/13), with an average age of 24.9 years (range: 23–32), and all commenced their hospital internship posts during May 2020. Demographic and educational details for participants are available in online supplemental table 1.

Six overarching themes emerged from the analysis: lack of preparedness; disrupted trajectory of role adaptation; impact on opportunities for experiential learning; solidarity and isolation; altered interactions with patients; challenges to health and well-being. Direct quotes are used to support the interpretations as evidence that they are grounded in the data. Illustrative quotations are provided in tables 1–6 for each of the themes.

Table 1

Illustrative comments for the theme ‘Lack of preparedness’

Table 2

Illustrative comments for the theme ‘Disrupted trajectory of role adaptation’

Table 3

Illustrative comments for the theme ‘Impact on experiential learning opportunities’

Table 4

Illustrative comments for the theme ‘Solidarity and isolation’

Table 5

Illustrative comments for the theme ‘Altered interactions with patients’

Table 6

Illustrative comments for the theme ‘Challenges to health and well-being’

Lack of preparedness

When asked to outline expectations regarding the first 2 months as a qualified and practising junior doctor, interviewees reported a strong perception of lack of preparedness (see table 1 for illustrative comments; C1). Unrelated to the public health situation, their concerns were based on a lack of confidence around managing clinical uncertainty, absence of familiarity with hospital systems (eg, information technology (IT), ordering investigations, etc), as well as a sharp appreciation of the challenge of translation of theoretical knowledge into practice as a responsible physician (C2, C3). These anxieties were heightened by their expectations concerning starting work during the COVID-19 pandemic, where they reported additional trepidation related to early and abrupt entry to the workforce, lack of preparedness of health systems for the pandemic and a general sense of being ‘thrown in at the deep end’ (C4, C5). When asked to reflect on their first month in the role of junior doctor, lack of preparedness was again cited as a significant factor; this was centred on increased responsibility for patient care and included day-to-day challenges related to case, task and time management, as well as working within hospital systems. Among Brazilian interviewees, these challenges were worsened by the reorganisation of hospital services in response to COVID-19, leading to a reduction in time available with, and clinical supervision from, senior colleagues (C6). Among Irish interviewees, these challenges were ameliorated by the presence and support provided by senior interns (C7, C8). All respondents confirmed that the undergraduate curriculum could not have better prepared them for their roles as junior doctors working during COVID-19, given its unprecedented nature. However, they recommended that early patient exposure and a greater focus on the practicalities of the professional duties of a junior doctor would lessen the impact of the perceived abruptness of the transition.

Disrupted trajectory of role adaptation

Junior doctors expressed anxiety and a lack of confidence concerning the expectations and boundaries of their new professional role and the added independent responsibility of care (in domains of clinical decision-making, avoidance of medical error), and they expected a trajectory of adaptation to new role and responsibilities (see table 2 for illustrative comments; C1–C6). Both sets of interviewees acknowledged the expectation that confidence would increase with experience and support from senior colleagues, but also expressed concern that this trajectory would be disrupted by reduced clinical opportunities and supervision due to COVID-19 (C7–C9). At the end of the first month in their current position, they reported a partial sense of adaptation to the demands of their new role, with anxiety giving way to reassurance based on both increased knowledge and experience, as well as use of evidence-based medicine skills to manage unfamiliar clinical scenarios (C10, C11). Negative influences on this process of adaptation were confirmed to include less clinical exposure during the pandemic, due to cancellation of elective procedures and outpatient surgeries, as well as absence of information related to management of patients with COVID-19 (C12). Their concerns extended to training opportunities available during the months ahead. Among both groups, there were concerns that limited clinical exposure and COVID-19-related disruption to medical research (including conduct of research and presentation opportunities; C13) would reduce the competitiveness of their applications to residency or postgraduate training posts. Additionally, they noted that early entry of graduates into the health workplace during 2020, as well as the increase in the number of returning overseas medical graduates, would translate into increased competition for future specialty training positions (C14).

Impact on experiential learning opportunities

Unrelated to the public health situation, interviewees expected an overwhelming workload, long hours and the challenge of managing complex clinical situations (see table 3 for illustrative comments; C1–C3); these concerns were heightened by entering the workforce during COVID-19. They expected ‘wartime conditions’, including long shifts and increased stress related to management of serious COVID-19-related emergencies, yet simultaneously fewer opportunities for gaining clinical experience in preferred areas (C4, C5). In particular, the experiences of Brazilian interviewees during the first month reflected these concerns, especially as they relate to COVID-19 adding to case complexity; this added challenge was enhanced by the lack of information around the management of this new diagnosis and the requirement for training in relevant procedural skills (C6, C7). In contrast, Irish junior doctors highlighted that fewer patients without COVID-19 in hospital during this period meant more time for clinical teaching and closer supervision from senior colleagues (C8, C9). Both groups noted that while their undergraduate curriculum provided strong grounding for a generalist, further training in management of complex emergency cases (potentially using simulation methods) and increased training in COVID-19-relevant procedural skills (eg, intubation) would be beneficial.

Solidarity and isolation

Young doctors’ professional socialisation is guided by experiential learning opportunities and by interactions with other doctors and health professionals. Here, junior doctors expected that increased independence and responsibilities would be accompanied by support from colleagues when required, especially in relation to managing uncertainty in clinical situations (see table 4 for illustrative comments; C1). At the same time, they noted that one of the biggest challenges expected of their role would involve working as part of a clinical team and securing the support of senior colleagues (C2). Irish interviewees expected that early entry to the workforce during COVID-19 would be accompanied by extra support from senior colleagues and doctors in internship from the previous year’s graduating class who were still in post (C3). Brazilian and (to a lesser extent) Irish doctors noted great camaraderie among medical colleagues, as well as more knowledge sharing across specialties and additional collaboration during a period of ‘shared adversity’ in that first month of practice (C4–C6). They experienced significant interprofessional collaboration and a greater appreciation of the distinct contribution of other hospital-based health professionals. At the same time, both hospital and wider infection control measures, as well as fears regarding contracting COVID-19, meant fewer opportunities for socialisation among trainee peers and for the integration and teamwork that can lead to professional trust (C8, C9). Irish doctors also noted the hindrance effect of personal protective equipment (PPE) on interprofessional communication.

Outside of the working environment, both groups noted the isolating effects of working in a hospital with patients with COVID-19, where the obligation to reduce social contact and associated social distancing requirements may reduce social support (including the opportunity to share concerns with peers) during a particularly stressful time (C10).

Altered interactions with patients

In advance of starting work in hospitals, both groups noted that one of the challenges of working with patients during the COVID-19 pandemic would include both interacting with patients in an infection control environment and attempting to give evidence-based information regarding transmission risk and management of COVID-19 to patients in the absence of definitive evidence (see table 5 for illustrative comments; C1, C2). Following 1 month in post, junior doctors highlighted the disruptive impact of PPE and other infection control measures on doctor–patient communication, as well as other important aspects of clinical interactions (C3). They noted significant patient distrust and anxiety towards the hospital environment (manifesting as avoidance of hospital appointments and investigations) due to fear of contracting COVID-19 from other patients or healthcare workers (C4, C5). On the other hand, both sets of interviewees reported hastier functional examinations and less physical examination to reduce patient time in the clinical area (C6). They also reported greater difficulty in establishing rapport and building empathy with patients and highlighted the need for doctors to focus their efforts on empathic communication in order to allay patients’ anxieties and fears, build trust and foster relationships (C7, C8). PPE, especially masks, were reported to have a particularly negative impact on communication with elderly and hard-of-hearing patients (C9).

Challenges to health and well-being

Both groups reported feelings of generalised anxiety, stress and insecurity in advance of commencing their first post (see table 6 for illustrative comments; C1, C2). These concerns were in part focused on the personal health risks of working in a clinical environment during the COVID-19 pandemic and the same comments were recorded following 1 month of practice (C3). Approximately half of interviewees expressed fears about contracting COVID-19 and three volunteered that they had indeed contracted the disease. Those who reported no fears of contracting the virus or who reported a reduction in their concerns over time emphasised either that they were taking all precautions or that their concerns were assuaged due to nascent understanding of risk stratification for severe COVID-19 illness (C4, C5). Brazilian doctors felt adequately protected by available PPE, despite initial access limitations and the variable quantity and quality of PPE during the early stages of the pandemic (BR12). While Irish interns confirmed that PPE was available, they noted instances of poor adherence to infection control measures in the clinical areas and highlighted the necessity for senior clinicians to embody such measures so as to constitute appropriate role models (C7). Both groups noted that their undergraduate curriculum had prepared them for working in infection control environments (eg, gowning, aseptic and handwashing techniques).

Nearly all participants expressed concerns about transmission of infection to family or household members and several interviewees had moved away from home and/or avoided contact with friends or family to mitigate such risk (C8). Those who were not concerned lived alone and/or did not live near family members or have parents/siblings/housemates who also worked in health settings. Two doctors expressed concerns regarding housemates (also doctors) who were either interacting with teams having multidisciplinary contact or based in several different clinical settings (C9). While the majority of interviewees (16/27) across both groups were aware of mental health supports available to junior doctors, those who indicated awareness also stated that they would not be interested in availing of such supports. One interviewee commented: ‘I believe that the professionals, some professionals even feel a little ashamed to say that they follow [attend] these programs’ (BR1). While recognising potential stigma associated with accessing help, interviewees paradoxically advised future graduates in the importance of self-care and support seeking (eg, ‘… because if you don’t think about yourself, you won’t be able to help other people’; BR1).

Discussion

Here we demonstrate in both Brazil and Ireland that entry to clinical practice during the COVID-19 pandemic impacts adversely on several factors that are known to influence smooth transition, commencement of professional socialisation and PIF in young doctors. Cruess and colleagues have noted that the trajectory of professional socialisation is characterised by initially tentative and peripheral participation, followed by progressively fuller engagement via social interactions, during which the doctor’s identity aligns with the community’s values and norms.34

Impact of COVID-19 on the transition and professional socialisation of junior doctors

Our analysis reveals that the transition into practice during COVID-19 was perceived as more abrupt and stressful than it might otherwise have been, principally due to feelings of being ‘thrown in at the deep end’ during a period of reorganisation of hospital services, disruption of normal patterns of clinical supervision and fewer experiential learning opportunities, as well as insecurity due to lack of information about transmission and management of COVID-19 and its effect on non-COVID-19 case complexity. Communication with both other health professionals and patients was also judged to be impaired during the COVID-19 pandemic, with quality of communication degraded due to the use of PPE and imposition of other infection control measures. Additionally, typical rapport and empathic communication with patients were replaced by feelings of mutual distrust, as well as a shift towards reduced consultation time with the patient.

Our findings elaborate previous reports by identifying many of the transitional challenges experienced by junior doctors while also identifying COVID-19-related exacerbation of associated concerns. A recent qualitative examination of transition to residency in a sample of US doctors revealed a similar constellation of themes centred around individual and contextual aspects of the transition experience.35 These themes described abrupt entry into a busy and unstructured clinical environment that was characterised by ongoing challenges during their interactions with patients and healthcare team members. Feelings of lack of preparedness and a sense of being ‘thrown in at the deep end’ are also recurring themes in related studies.18 19 A recent survey of final year medical students in the UK indicated that almost 60% of students were lacking in confidence and perceived preparedness going into their first intern post during the COVID-19 pandemic.5 It has been suggested that expedited graduation and placement at the frontline may have exacerbated this transition anxiety.11 Heightened anxiety at the prospect of transitioning during COVID-19 chimes with anecdotal reports of increased stress among new doctors starting work during this pandemic.36

Professional socialisation involves adaptation as junior doctors move from ‘legitimate peripheral participation’ in medicine’s community of practice to full participation37; this represents a gradual process of acquiring the identity of members of the community.21 Cruess’ model posits that clinical experiences with patients and relatives are important in professional socialisation, contributing to the junior doctor’s emergent clinical confidence and understanding of the values and behaviours expected in their professional role.38 The present study reports a decrease in the quantity and quality of such junior doctor–patient interactions. This finding is in line with reports of disrupted doctor–patient communication during the pandemic, where it was noted that ‘the barrier of isolation has impacted patients and patient care, and has also affected the experience of the physician’.39 Here, interviewees noted that their interactions with elderly and hard-of-hearing patients were particularly affected by PPE measures and similar concerns have been documented elsewhere (eg, ref 40).

Exacerbation of transition-related anxiety during the pandemic

A sense of personal well-being and the support of family and friends are among the most important influences on a smooth transition to clinical practice and commencement of the professional socialisation process.21 34 Difficulties in adapting to this early period of professional socialisation can result in anxiety, stress and feelings of burnout among young doctors.20 Importantly, young doctors are already known to exhibit elevated levels of stress39 40 and burnout41–43 as well as anxiety and/or depression44 45 during more typical circumstances. That these symptoms are most pronounced during the immediate period of transition from medical student to doctor46–49 may increase vulnerability to adversity when making that transition during the COVID-19 pandemic.

Junior doctors across both locations reported increased anxiety during this period due to fears of contracting the virus or passing it on to friends/family. This led many to effectively isolate from their social support networks during what is already a typically stressful period in their training. In a quantitative survey of palliative care health workers, we have recently demonstrated the profound impact of COVID-19 on personal and professional well-being of patient-facing clinicians.50 Similar to that observed in the current study, among the highest rated sources of stress were fear of contracting COVID-19 or transmitting it to friends/family, and reduced social interaction with colleagues. Congruent with previous reports,18 interviewees in the present study reported a limited awareness of mental health supports and services available to junior doctors, none indicated that they had sought assistance. Previous research has also revealed a reluctance among junior doctors to admit to feeling overstressed, or to access support services, for fear of professional repercussions, for example, they would be perceived as less competent or employable.51

Strategies for managing the impact of pandemic on the transition experience

Development of strategies for minimising the impact of pandemic-related changes in the clinical environment on the transition experience must focus on areas most affected. These include preparedness for practice, doctors’ health and well-being, communication with colleagues and patients and experiential learning opportunities. A review of the literature on transition interventions has noted the paucity of rigorous and outcome-focused studies looking at educational interventions targeting areas of unpreparedness.52 Choi et al5 reported that the provision of ‘student assistantship’ rotations offered by selected UK medical schools, where medical students are better integrated within a clinical team so as to develop both their clinical and practical skills, played a key role in enhancing preparedness for medical student transitioning during COVID-19. Reconfiguration of such initiatives could be effective in addressing the needs of junior doctors graduating and transitioning during the COVID-19 (or indeed another) pandemic. Notably, in the present setting, Irish junior doctors stated that the acute challenge of adapting to workplace demands following early entry to practice was lessened by the overlapping presence of the previous year’s medical graduates, confirming the value of near-peer support and supervision in facilitating successful transition to practice.53 This is an area which merits further research.

Our data suggest that approaches to promoting resilience in such cohorts must incorporate individual, organisational and cultural commitment to the well-being of junior doctors.54 Resilience-promoting programmes for doctors working during this and other pandemics should specifically focus on enhancing adaptive strategies for coping and building self-efficacy.9 Interventions targeting any one of these areas can also impact in a positive sense across other related domains. For example, it has been noted that activities designed to enhance PIF can build a strong sense of shared social identity that buffers against adverse influences on mental well-being.34 55 Another review of the efficacy of intervention for preventing burnout in junior doctors suggested that structural and organisational strategies (eg, restrictions in working hours) might also be effective for improving well-being of new doctors.56

Use of a retrospective, qualitative design precludes any conclusions about the long-term effects of transitioning during the pandemic on these doctors’ PIF. Additionally, during the time frame of this study, the impact of the COVID-19 pandemic on healthcare systems was more pronounced in Brazil than in Ireland. The daily number of COVID-19-related hospitalisations and intensive care unit cases across Irish hospitals was in steady decline during the time when Irish doctors were commencing practice.57 In contrast, the daily number of such COVID-19-related cases in Brazil was rapidly rising during the corresponding period.58 Thus, although interviewees have identified commonalities across both groups with respect to their transition experiences, these were manifested on a background of differences between the study locations in relation to patterns of COVID-19 transmission and their impacts on health systems during this period. For example, as outlined in the Results section under the ‘Challenges to health and well-being’ theme, we note that Brazilian interviewees highlighted the impact of PPE shortages during the early stage of the pandemic crisis, whereas PPE availability was not cited as an issue by our Irish interviewees. This is because PPE availability for Irish healthcare staff was perceived to be sufficient at the time of data collection (October 2020) compared with earlier in the pandemic (March to April 2020).59 The cross-sectional design of the study precluded a more nuanced examination of the challenges faced by junior doctors which would likely fluctuate across the phases of the COVID-19 pandemic.

Limitations

One of the limitations of the study is that it may be assumed that the specific work context would have influenced the young doctors’ experience during the pandemic, but this factor was not explored in the current analysis. The current sample was based (and in some case rotated through several) across diverse range of hospital-based clinical settings, and previous studies have shown that those with greater direct exposure to patients with COVID-19 in terms of proximity and time reported greater levels of stress and anxiety during the first 6 months of the pandemic.50 Additionally, the study design does not allow the distinction to be made between transitional challenges unrelated to the current pandemic which are experienced by new medical graduates, relative to concerns which might be exacerbated by COVID-19. This would highlight the need for longitudinal studies which may inform on the PIF of these junior doctors, and the long-term psychological sequelae and supports required. Lastly, despite the identification of common themes across both groups, sociocultural differences across both locations might have contributed to the results in a manner not measurable using the present design.

Conclusions

In summary, optimising the preparation and graduation of qualified doctors is needed now more than any time in living memory. The impact of COVID-19 on undergraduate medical education and preparation for clinical practice is likely to be long lasting and significant. We have demonstrated in an international sample of young doctors that entering clinical practice during the COVID-19 pandemic affected several factors that influence the process of professional socialisation. The insights arising from this study are expected to inform undergraduate and postgraduate curricular design and the implementation of appropriate interventions to support transition during the current pandemic.

Data availability statement

Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information.

Ethics statements

Patient consent for publication

Ethics approval

The Institutional Research Ethics Committee of Centro Universitário Saúde ABC (CAAE: 40227120.1.0000.0082) and the Social Research Ethics Committee of University College Cork (07/20) gave approval for this study.

References

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Footnotes

  • Contributors CO’T and EM developed the premise of the work. CO’T, ED, JD and VZ developed the interview guide, recruited participants and collected the data. CO’T, ED, EM, JW and VZ completed the data analysis. CO’T, EM, JW and PO’L wrote the first draft of the article. All authors edited and commented on multiple drafts of this article and approved the final version of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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