“The Transition from Medical Student to Resident: A Qualitative Study of New Residents’ Perspectives” From Codes to Themes in Qualitative Research

While this article is not as “hot off the presses” as the others I’ve chosen, I think it’s timely, given that we are all bidding the fourth year students adieu soon to send them off for what the authors of this piece call a “precarious moment in medical training” (p. 1421): the transition to residency. The authors recruited 10 learners who had participated in their residency transition course at the end of medical school and approached them after they had started their residency for interviews (between December and April of that first year). 

Their central finding is perhaps not earth shattering: building their professional identity–or “feeling more like a doctor” as one participant put it–is at the heart of the transition experience (p. 1422). Participants experienced the shift from undergraduate to graduate medical education as abrupt and were particularly flummoxed by “the omnipresence of nonclinical, administrative tasks” (p. 1424). They were excited to take more responsibility–”You’re a crucial member of the care team and that is a fundamental change in your self-conception as a health care provider” according to one participant”--but also found the responsibility “scary” at times (p. 1424). Also (again, no spoiler alert needed here), they were challenged with work-life balance, feeling “tremendous tensions and stress” (p. 1425). 

While the themes the authors found are not necessarily surprising, the way they share these individuals’ particular experiences and voices through these themes offers fresh insight into what it feels like to make the transition to residency. Moreover, as the cool visual they created shows, they offer a really interesting and useful metaphor as a model for this transition: a cell. They describe it this way: 

In this model, the nucleus of the cell represents the learner experience of professional identity development, characterized by ambivalence around autonomy and responsibility and the learner’s striving to maintain learning while balancing and integrating the residency experience into life. Intracellular elements—illustrated as mitochondria, nucleoli, and the Golgi apparatus—highlight the dynamic interactions in the environment between the new resident and patients, colleagues, supervisors, and other medical professionals that lead to cascades of learning and development. A porous nuclear membrane highlights how the new resident influences and is influenced by the surrounding environment. (p. 1425)

But, as you might suspect, I didn’t just choose this for the conceptual model: there’s a methodological point I want to make, particularly for those who are getting their feet wet with qualitative research: there is a difference between a “category” or “code” and a “theme.” Here’s a little diagram to show what the process looked like for them:

coding diagram

In the first step, they generated a bunch of codes with an eye towards their research question. Then they grouped these codes into categories. Then (and this is the critical step), they looked across all of the categories and tried to pull out some “big picture” themes to answer their research question. For instance, two codes were “personal and professional balance” and “nonclinical responsibility.” These each ended up in two different categories, “personal balance” and “context of learning” respectively. Then these two categories (and the codes within them) both contributed to the theme, “abrupt change in educational environment from medical school to residency.”

As you can see, this process involves both subjectivity and rigor. And it generates a theory about the topic (transition to residency, in this case) that is deeply grounded in participants’ experiences

I’d love to hear your thoughts on either this content or these methods and if any of this has gotten you interested in starting a project, reach out for research support any time!

These reflections are based on a 2020 article from Academic Medicine (available through our library): Chang LY, Eliasz KL, Cacciatore DT, Winkel AF. The transition from medical student to resident: a qualitative study of new residents’ perspectives. Academic Medicine. 2020 Sep 1;95(9):1421-7.

cell with labels
From Chang et al., 2020, p. 1425