Ready or Not, Here We Come: A Qualitative Study of the Transition From Graduate Medical Education to Independent Practice

<b>Background</b> The transition from graduate medical education (GME) into independent practice is challenging for new attendings despite achieving "readiness for practice," by Accreditation Council for Graduate Medical Education (ACGME) Milestones. Most medical literature on this transition is specialty-specific and rarely involves assessment of new-to-practice attendings (NTPAs). <b>Objective</b> Lack of attending readiness results in compromised patient care. To inform GME leaders and managers, we sought to identify areas of struggle for NTPAs across specialties. With this information, we hope to spur national GME curriculum evolution, better support our NTPAs, and ultimately provide better patient care. <b>Methods</b> Qualitative freelisting was used in 2021 to explore how NTPAs, educational program leaders, and managers perceive the transition struggles. Response lists were collected electronically, then cleaned and categorized by the research team using iterative inductive combination of similar concepts. Salience index scores (Smith's S) were calculated and plotted graphically to identify inflection points for each group, above which domains were deemed salient. <b>Results</b> One hundred eighty-six participants completed surveys, yielding 518 individual responses and a response rate of 34%. Of the ACGME competencies, systems-based practice domains were most frequently salient, including "workload" and "billing." "Confidence," "supervision," "work-life balance," "decision-making," and "time management" were salient struggles in all groups. Each group had domains only achieving salience for them. Professional development domains including "confidence," "imposter syndrome," and "culture" achieved salience in different groups. <b>Conclusions</b> This study identifies domains of struggle for NTPAs, which fall outside ACGME competency frameworks including workload, new environments, and professional development. Domains identified by NTPAs, program leaders, and managers were not identical.