How do foundation year and internship experience shape doctors' career intentions and decisions? A meta-ethnography

Abstract

Purpose: Foundation years or internships are an important period for junior doctors to apply their knowledge and gain clinical competency. Experiences gained during the foundation years or internships are likely to inform newly qualified doctors' opinions about how they want to continue their career. We aimed to understand how medical doctors' internship experiences influence their career intention/decision.

Methods: We conducted qualitative evidence synthesis using meta-ethnography. We searched six electronic bibliographic databases for papers published between 2000-2020 and included papers exploring how foundation years or internship experiences shape doctors' career intention/decisions, including in relation to migration, public/private/dual practice preference, rural/urban preference, and specialty choice. We used the GRADE-CERQual framework to rate confidence in review findings.

Results: We examined 23 papers out of 6085 citations screened. We abstracted three high-level inter-related themes across 14 conceptual categories: (1) Deciding the personal best fit both clinically and in general (which option is 'more me'?) through hands-on and real-life experiences (2) Exploring, experiencing and witnessing workplace norms; and (3) Worrying about the future in terms of job market policies, future training and professional development opportunities. Confidence in findings varied but was rated high in 8 conceptual categories.

Conclusions: Our meta-ethnographic review revealed a range of ways in which internship experience shapes medical doctors' career intentions/decisions allowing us to produce a broad conceptual model of this phenomenon. The results highlight the importance of ensuring sufficient, positive and inspiring clinical exposure, improving workplace environment, relationship and culture, refraining from undermining specific specialities and communicating contractual and job market policies early on to young doctors, in order to attract doctors to less popular specialties or work locations where they are most needed. We propose our conceptual model should be further tested in new research across a range of contexts.

Keywords: Foundation year; career decision; experience; intern; specialty choice.

Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRIMSA) flowchart

Figure 2. Line of argument

Note: The final phase of meta-ethnographic analysis is to develop a conceptual model or line of argument that is abstracted from, but more than the sum of, the themes. This figure illustrates our conceptual model which is the journey of career intention decision-making and how foundation years and internship influence such journeys. These junior doctors’ intentions may be shaped early during medical school training, this can be cemented or changed during the chaotic and stressful foundation year and internship training period, which is the focus of our synthesis. Foundation doctors and interns need to decide on the “more me” option of possible career choices (category 1-5), draw on experience in the workplace and relationships with different groups of people (category 6-12), and also think about the future implications of career options (category 13-14). These categories are intertwined and overlapping. We also acknowledged many other factors including personal and family background and personal values may play a significant role in the career-decision making, and doctors could further change their mind during specialist training; moreover, the career decision is also influenced by the job market and employment terms and conditions. These factors extracted from previous reviews are represented (in “blue clouds”) outside of the main categories identified by this review, though it should be noted that this is by no means an exclusive list of factors that influence career intention or decision.