A survey of newly qualified doctors from all medical schools in the UK, who undertook their first year of clinical work in 2000/2001 found that 42% of them felt unprepared by their medical school for their first clinical posts [1]. The survey also found significant and substantial differences between medical schools in how well prepared their graduates felt.

There is no consensus on how to train students to be good doctors or on how to select medical students who will make good doctors [2, 3]. There is a clear consensus however, emphasised by the General Medical Council (GMC) in its document on undergraduate training entitled Tomorrow's Doctors, that medical schools should improve their preparation of students for their first year of working life. Tomorrow's Doctors states that 'students must be properly prepared for their first day as a Pre Registration House Officer'[4]. It has also been suggested that there should be a national licensing programme to ensure all graduates are 'fit for purpose' [5]. Following the publication of the first edition of Tomorrow's Doctors in 1993 [4], all UK medical schools initiated major curricular changes to bring their courses into line with the recommendations. The recommendations include not only a greater attention to preparedness to practice, but also adherence to modern educational theory, focus on attitudes, and integration of basic and clinical sciences [4]. The extent of changes necessary varied between medical schools, but all schools underwent major curricular revisions and changes to student assessment practices, with some introducing for example problem based learning. The GMC visited all medical schools to advise on the changes and to monitor progress.

Lack of preparedness has been linked to stress in junior doctors [6], and it is therefore important to investigate what might help junior doctors feel better prepared. A cohort study in Manchester found that graduates from a new problem-based learning course felt better prepared than graduates from the traditional course for 12 out of 19 of the competencies required of a newly qualified doctor [7]. However, it is not known whether there have been improvements at other medical schools in how well junior doctors feel they have been prepared for their first year of clinical work.

Our aim in this study is to report on the views of newly qualified doctors in 2003 and 2005, compared with those in 2000/2001, about their preparation for their first year of clinical work. The purpose is to begin to investigate whether the increased attention to preparedness for practice, manifested through curricular changes at UK medical schools, has resulted in improvements in the way newly qualified doctors feel.

Questionnaires were sent to 5330 doctors in 2000/2001, 4257 doctors in 2003, and 4784 doctors in 2005. The response rates were 67%, 65%, and 43% respectively (the denominator for the 2005 survey excludes doctors covered by the deanery and postgraduate centres that declined to participate). In the 2005 survey, graduates of the medical school within the deanery that declined participation were under-represented. There were no other significant differences in response rate by region or method of distribution, but female doctors were significantly more likely to respond (p < 0.001).

Substantial and significant variation in preparedness between doctors from different medical schools, which was originally reported in the 2000/2001 study [1], was still present in the responses from 2003 and 2005. Figure 1 shows the percentages of graduates from each medical school who agreed or strongly agreed that they were well prepared, by cohort. From this figure it can be seen that in the 2003 cohort the percentage of graduates who felt well prepared ranged from 33% to 85% by medical school (pink squares), and in the 2005 cohort, the percentage of graduates who felt well prepared ranged from 30% to 89% (blue diamonds). Figure 1 also illustrates the improvements in preparedness between 2000 and 2005: it can be seen that since 2000/2001, preparedness has increased in 19 schools; dropped in three schools (numbers 4, 6 and 9); and stayed stable in one school (number 15).

Within each cohort, there were respondents from schools with new courses and respondents from schools with unchanged or 'old' courses. Figure 2 shows that, within each cohort, a statistically significantly higher percentage of the respondents from schools with new courses felt well prepared.

The fact that such a high percentage of the newly qualified doctors in 2000/2001 did not feel well prepared for their first year of medical work was a concern. The results from the more recent qualifiers are reassuring for two reasons. First, they show that preparedness has improved significantly. Second, they suggest that changes in medical school courses may be partly responsible for the improvements. There is evidence from qualitative studies of junior doctors that certain aspects of modernised courses, for example periods of shadowing, are related to improvements in preparedness [8].

There were also improvements in preparedness in the absence of course change, suggesting other factors also affected preparedness. There are many changes which may have resulted in increased preparedness, including: increased attention by teachers to preparedness for practice; changes in student selection; and factors related to improvements in junior doctors' working environments including reduction in hours and increased supervision [9]. The changing demographics of medical school leavers, particularly the increase in graduate entrants, may also have affected the results, since graduate entrants have previously been shown to feel better prepared [10]. In the future it would be interesting to try to quantify the relative effects of these various factors upon preparedness.

The results of this study show a greater impact upon preparedness of course changes between 1999–2002 than between 2002–2004. Schools which changed their courses later appear to have experienced less benefit. There are a number of possible reasons for this. Late-changing schools may have taken measures to improve preparedness prior to their full-scale course change, for example by introducing a programme of shadowing. There could also have been methodological reasons for this difference. For the 2005 survey, the less intensive follow-up of non-responders and the indirect distribution of questionnaires via postgraduate deaneries and hospital administrators almost certainly had an adverse effect on the level of response. The first two surveys were linked to career surveys, while the 2005 survey was linked to a survey about caring for cancer patients. This may also have affected the response rate. These are potential limitations of the study, since the non-responders may have been self-selected, introducing bias. The effect of the missing graduates (working within the deanery which declined participation in the 2005 survey) is also not known. However, because there is a clear trend in the results evident across the surveys – improvements in 2005 compared with 2003, and in 2003 compared with 2000/2001 – we feel that the decision to compare the surveys is justified.

The major limitation to this study is the use of a subjective outcome measure. While subjective measures such as preparedness have strong face validity, there is no good evidence that those who feel more prepared are in fact more prepared. In a systematic review of studies which compared physicians' self assessments of ability with independent assessments of their ability, only 7 out of 20 studies demonstrated a positive correlation [11]. Formal independent assessments are now compulsory for junior doctors in the UK, and in the future it would be interesting to compare preparedness with scores in work place assessments.

The results of this study are encouraging, but they give cause for some continuing professional concern because, despite the improvements, in 2005 the percentage who agreed or strongly agreed that they had been well prepared was still only 59%. There was still striking variation between the responses of doctors from different medical schools which ranged from 89% who agreed or strongly agreed at the top of the ranking to only 30% at the bottom for the survey in 2005. Whether the results should cause public concern is less clear. As stated above, there is no good evidence that those who feel unprepared are in fact unprepared; and doctors' first year of medical work provides a supervised transition from medical student to fully registered medical practitioner.

This paper provides evidence that medical schools have given increasing recognition to the importance of preparing doctors for their first year of practice, and that they have implemented course changes to improve preparedness. Further studies are required to explore the relationship between subjective and objective measures of preparedness, as well as to follow up the long-term impact of the course changes. It is essential to study junior doctors' views about their training and competencies, especially during the present period of rapid evolution in the UK of both undergraduate and postgraduate medical education and training.