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.