“The transition from med school to residency is super stressful. You go from, as a med student, having very little power to, as a resident, signing orders that usually get acted upon. So, it’s a big jump in responsibility, and one that literature shows is a source of anxiety for incoming interns,” clinical assistant professor and hospitalist Matthew Soltys, MD, MME, said. “One way med schools across the nation are trying to ease that stress is through these courses.”

Enter Transition to Residency.

Soltys created this course to fill the gap in the education and preparedness for medical students before entering their residency programs wherever they are headed next. After completing a rigorous four-year academic and clinical program, medical students downshift in effort for a couple months before the intense education and practicum in their intern year of residency. Research shows that by the time residency programs begin, many newly graduated medical students feel less confident in their clinical acumen or rusty in their patient relations.

“The Transition to Internal Medicine Residency course gives fourth-year medical students a final chance to work with the faculty here at the University of Iowa prior to starting residency,” Soltys said. “It is designed to prepare them for their residencies by teaching them the skills they may not know, refining their skills, or giving them the space to ask questions. Additionally, it serves as a way to teach M4s things they may not have been taught during clerkship or their sub-internship, but are very medicine-specific.”

The Association of American Medical Colleges (AAMC) oversees undergraduate medical education in the United States. They define 13 Core Entrustable Professional Activities (EPAs) for Entering Residency, which include skills like taking a patient history, handing off a patient, ordering and interpreting diagnostic tests, and doing basic procedures as a physician. Residents are expected to be able to complete all 13 EPAs on their first day of residency without oversight or observation.

The department’s Objective Structured Clinical Examinations (OSCEs) test these activities prior to beginning work on wards and in clinics. Their cumulative results and anecdotal data that Soltys gathered in his research demonstrate that the majority of first-year residents are not confident in their abilities to perform all of these tasks independently when beginning their residencies. Using this information, Soltys designed his Transition to Residency course to cover all 13 Core EPAs, refreshing students’ knowledge and bolstering their confidence.

The OSCEs were also developed by the Education team in the Department of Internal Medicine at the University of Iowa. Read more here.

This course occurs after Match Day and before graduation, making the barrier to entry for interested medical students low, and the opportunity for success in the course nearly certain.  Soltys said, “When medical students match, they have a high intrinsic motivation to learn as much as possible prior to graduation as they don’t want to let their future patients or residency programs down. To take advantage of this motivation, we designed the course to be pass-fail. One needs only to show up and be engaged in the course content led by multiple levels of providers, including faculty, nurse managers, and residents on the Distinction in Medical Education (DIME) pathway serving as near-peer educators.”

Modeling the structure of the course after existing transition programs across the country, Soltys also synthesized information from published studies on student readiness. He interviewed departing M4s, first-year Internal Medicine residents who were also alumni of the Carver College of Medicine, the department’s Education division providers and staff, the college’s Medical Evaluation Committee (MEC), and Associate Dean for Student Affairs and Curriculum, Amal Shibli-Rahhal, MD, MS, MME.

He then piloted this two-week elective with co-course directors Justin Smock, MD, and Manish Suneja, MD, in April 2023, with seven departing M4s who demonstrated interest to review all the aspects of patient care that they learned through their time in medical school. All seven students passed the course, and helped iterate the course for future attendees.

“Much of my M4 year was spent outside the hospital and it had been numerous months since I had even examined a patient or thought about a differential diagnosis,” first-year resident and pilot participant, Stephanie Seay, MD, said. “The TTR course was a nice refresher and reminded me why I love Internal Medicine so much. The course included several talks about common concerns seen on Internal Medicine wards, including topics such as mental status changes, inpatient diabetes care, cirrhosis, and electrolyte derangements. These talks highlighted workup and management rather than pathophysiology, encouraging us to assume our new role as interns.”

The Transition to Residency education team made use of the Center for Procedural Skills and Simulation (CPSS) to practice Code Blue, Rapid Response, and Goals of Care simulations, in addition to other hands-on workshops and lectures including point-of-care ultrasound. In addition, the simulation center at the VA Iowa City Healthcare System was used for a procedures workshop.

“The simulation ‘rapid response’ exercises in particular allowed me to feel more confident and prepared to step into this role,” Seay said. “During these simulations, we walked through how to promptly assess and manage common urgent issues like hypotension and tachycardia. Now two months into residency, I still have a LOT to learn but I feel grateful to have started the year with more confidence and excitement due to my participation in the TTR course. I think it’s a great opportunity and highly encourage other IM-bound students to participate!”

“Currently, this course is only offered through our department for departing M4s,” Soltys said. “It is our hope that the medical school will want to offer a similar course for all specialties in the future.”

The Transition to Internal Medicine Residency course will run again in 2024, with 16 M4 students already enrolled in the elective. If you know someone who would like to participate in this growing program, contact Matthew Soltys, MD, MME, at matthew-soltys@uiowa.edu.

Soltys offered his thanks to everyone who participated in this successful pilot course.

Course Leaders
Justin Smock, MD – Co-Course Director
Matthew Soltys, MD, MME – Course Director
Kathleen Steenlage – Course Coordinator
Manish Suneja, MD – Co-Course Director

Clinician Educators
Nicholas Behne, RT
Ann Broderick, MD, MS
Andrew Bryant, MD
Dennis Firchau, MD
Katherine Harris, MD
Jennifer McDanies, RN
Charles Rappaport, MD
Matt Smith, MD
Jennifer Strouse, MD
John Wilde, DO

DIME Pathway and Near-Peer Educating Residents
Mazen Aiche, MD
Taylor Cox, MD
Alex Garza, MD
Rachel Genova, MD, PhD
Reed Johnson, MD
Luke Morrey, MD
Alex Paschke, MD
Sruti Prathivadhi-Bhayankaram, MD
Lisa Wehr-Maves, MD, MPH 

Additional Acknowledgments
VA Simulation & Education Center
CPSS
Internal Medicine Residency Administration