#KeyLIMEPodcast 213: ‘Tis now the witching time of night’ (Hamlet)

Do you remember your first night on call as a resident? – How did it feel to finally be a “real doctor”? Did you feel prepared? Anxious? Could something have been done to help you feel more secure in your position as the first person called to handle a patient?  Linda’s pick this week examines the transition period experienced by residents and the gap in knowledge between medical student and resident.  Do the themes and study results resonate with you? Listen in here.


KeyLIME Session 213

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Walzak et al., Working in the dead of night: exploring the transition to after-hours duty Med Educ. 2019 Mar;53(3):296-305


Linda Snell (@LindaSMedEd)


Think back … for some of you waaaaay back … to your first night on call, or night shift, as a resident. Perhaps it was on the first day as a ‘real’ doctor! How did you feel?

You are not alone.

The transition from medical school to resident is considered one of the most difficult and challenging, looked forward to with some dread by many medical students. Suddenly you are less supervised, the first one called if someone is sick. Nobody countersigns your medical orders …

Med schools have sought to mitigate the anxiety and prepare trainees for this transition, with shadowing programs for students, sim scenarios, boot camps, orientation programs, even the structure of the curriculum itself (having a ‘real’ clerkship where the student is an active member of the team). Yet suddenly patient care weighs heavier than trainee learning, and there is a need for change in mind set – from ‘the learning orientation of medical schools to the performance orientation of medical workplaces’.

The authors propose that this ‘transfer of skills’ can be looked at through the lens of work-based learning, where learning affordances include ‘participation in a clinical workplace that offers affordances for learning; these include caring for appropriate patients, learning from peers and being mentored by supervisors.’

This transition is perhaps best characterized and epitomized in after-hours duty. The principal investigator  is a senior resident/junior attending who wanted to create a simulation session for first-year residents to ease the transition to being on-call.


“To better understand the transition experienced by residents, this research mapped the gap between student and resident experiences during on-call.

Specific questions:  (i) What experiences do medical students have on-call, and what do they expect of residency after-hours on-call?, and (ii) What challenges do residents experience in their first after-hours on-call?

To provide theory-based suggestions to enhance learning during this transition.”

Key Points on the Methods

Qualitative interpretivist paradigm, semi structured phone interviews of e-mail-recruited 8 senior students, 10 early residents, mainly female, from varied schools and specialties.

Open-ended questions: describe experiences of being on call, expectations about or challenges experienced (medical students and residents, respectively),  what they thought had prepared them for the transition, and about anxiety and stress. Contrasted student and resident experiences.

Description of the analysis is a bit skimpy: ‘coded and developed a framework’

Key Outcomes


  • shift in responsibility;  students anticipated the increased responsibility without anxiety; in contrast, residents’ experiences of the transition were of sudden and significant increases in responsibility, with many roles, uncertain knowledge and little chance to learn.
  • supervisory support; students felt supported but buffered, residents felt decreased levels, affected by context
  • contextual conditions; student concern re fatigue, wellness; residents concern acuity of patients – ‘survival’ of trainee and patient.
  • clarity of expectations; was unclear to both levels

Unique ‘are findings uncovering of the impact of having independent decision making thrust upon them overnight as a result of their isolation, lack of available team members and the resulting lack of opportunity to discuss patient care decisions or even expectations of autonomy.’

Residents were ‘leaving learning behind’ in the pursuit of survival’

Affordances to WBL decreased in residency. ‘As participants transitioned to residency, they experienced difficulties in navigating informal, experiential learning, particularly in the relatively high pressure on-call situation.’

Key Conclusions

‘Students were not able to anticipate the challenges they would face as residents on-call, and residents perceived the transition as sudden with little emphasis placed on learning’.

The authors conclude ‘residents experienced the transition to the on-call environment as particularly challenging because it involves: (i) a sudden shift in multiple responsibilities, most heavily for patient well-being; (ii) challenges in accessing supervisory support; (iii) difficult working conditions, and (iv)ambiguity in expectations.’


  • graduated responsibility
  • threshold to ask for help lower
  • clarification of roles
  • debriefing after off-hours shifts with opportunities to learn

Spare Keys – other take home points for clinician educators

Attention to methodology; especially analysis description in qualitative research.

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