As stated in Goldacre et al. [13
], "most people starting a new professional job probably will, and probably should, feel unprepared to some extent". Nevertheless, this should not stop researchers and medical teachers from trying to provide the best preparation and education possible. This is especially important in the health care sector, where inexperience can lead to mistakes which affect patients' health [14
]. In this study we analysed junior doctors' feeling of preparedness in relation to self-assessed deficits at the beginning of their clinical career. Preparedness and self-assessed deficits need to be addressed, as they can be associated with longer procedure time and higher costs, but, most of all, because they might induce more mental stress for junior doctors and might interfere with patient safety [14
]. Junior doctors with at least some months of professional experience should be best qualified to retrospectively assess the ability of medical education to prepare them for being a doctor. Furthermore, they are more aware of deficits in certain areas, as they already had to answer the expectations of superiors, colleagues and patients and experienced the gap between medical school and clinical care [6
]. The retrospective assessment of preparedness and deficits also represents a reflection on what has been experienced, rather than what is anticipated.
In the initial descriptive analysis of our participants, we found that approximately 66% of the participating junior doctors did not feel well prepared for their job after finishing medical education. This result supports the result of another German study by Jungbauer et al. [5
] in which two thirds of the questioned alumni of seven medical universities in Germany reported to feel badly prepared for being a doctor, too. These high percentages were not supported by researchers from other countries [see for example [13
]]. In comparison to our 2005 cohort of medical graduates, Goldacre et al. [13
] found that only 23.8% of the 2005 cohort of UK medical school graduates (strongly) disagreed that their medical school had prepared them well for the jobs they had undertaken during the first postgraduate year. Goldacre et al. [13
] also discovered differences in preparedness with regard to medical schools and differences with regard to the time of assessment. Cave et al. [17
] found that 15% of respondents of their study felt poorly prepared by their medical school for starting work in the year 2005, whereas, in the same year, 61% of Irish interns felt insufficiently or poorly prepared [18
]. The reasons for these differences in time and location are yet unclear. They might be associated with differences in medical education, with differences in expectations of students or junior doctors, with differences in questionnaire assessment, differences in health care systems, or they might also be due to response bias. Though the source of these differences is not clear yet, they have to be kept in mind when comparing results between different countries or different times of assessment.
We also found that many participants experienced deficits in important areas of clinical skills or knowledge (especially ECG interpretation, social medicine & rehabilitation, documentation & quality control, resuscitation, intubation). Interestingly, only one of the items, namely social medicine & rehabilitation, was not statistically associated with the feeling of preparedness in the χ2
-test. Therefore, it seems as if German junior doctors, though they find themselves lacking an adequate amount of knowledge in social medicine & rehabilitation, do not perceive this area as essential for being well prepared for patient care. American students, too, reported deficits in knowledge of the U.S. health care system (knowledge of health care systems being a part of the subject "social medicine" in Germany) [19
]. Altogether 96% of American students felt that understanding health policy is important and approximately 50% were dissatisfied with medical school course work. Nevertheless, this study did not assess the association between this dissatisfaction and the feeling of preparedness.
A study by Hastings et al. [20
] found the generation of appropriate working diagnoses and the consideration of physical, social and psychological factors to be the two most frequent consultation weaknesses in students. In our study these weaknesses are, amongst others, represented in the topics "deficits in treatment or therapy planning", "deficits in differential diagnosis", and "deficits in social medicine and rehabilitation", three of the areas in which a large percentage of junior doctors reported deficits, respectively. With regard to resuscitation and intubation, our findings are also supported by an investigation of Hayes et al. [21
] where 49% of internal medicine residents in Canada did not feel adequately trained to lead a cardiac arrest team. Similar to the results of Bojanić et al. [22
] though, the participants of our study felt well prepared for history taking and physical examination. Because of the above outlined similarities, we think that these results are, at least to some extent, also true for other young doctors.
Our main hypothesis was that post-graduates' feeling of preparedness might be especially influenced by specific contents of the medical curriculum. Indeed, out of a list of 15 items of medical education, we found that especially self-assessed deficits in ECG interpretation, deficits in therapy planning, and deficits in intubation were independently associated with feeling poorly prepared for the job as a clinically working junior doctor, irrespective of confounders like age, gender, chosen specialty, or previous work experience in the medical field. These results are in accordance with findings of Hoppe et al. [16
], who found significant positive correlations between satisfaction during the clinical part of medical education and the feeling of having appropriate skills regarding physical examination, acute critical situations, therapy planning, communication with colleagues and critical evaluation of information. An interesting finding was that deficits in intubation, rather than resuscitation in general, showed a significant influence on the feeling of preparedness in our study. Other authors, too, addressed emergency training in general as possible obstacle for the transition from medical student to practicing doctor and found that students valued acute emergency training in a preparation programme after graduation [23
]. Taking into account that the range of experience might be due to the chosen specialty, it should be considered that emergency medicine or acute trauma were reported to be posts predominantly held by men, while women tend to choose "non-invasive" posts more often [24
]. Nevertheless, deficits in intubation turned out to be a "gender-independent" factor in our multivariate analysis, and should therefore be considered more intensely in medical curricula or in practical settings. The other two items, ECG interpretation and therapy planning, are to be considered as core competencies of medical education. In the long term, the three items should be strengthened in medical curricula in Germany in order to improve junior doctors' feeling of preparedness after medical education.
Our study has some limitations which should be mentioned. The response rate was rather low, so it remains unclear if the participants of this study represent a certain subgroup of doctors who feel more or less prepared than the non-respondents (response bias). Furthermore, the anonymous approach did not allow for evaluation of the non-respondents. Nevertheless, the overall effective response rate can be regarded as adequate for survey studies [25
] and corresponds to previous results of response rates of physician surveys. Another limitation is the reliability on self-reported ratings of deficits and preparedness by junior doctors. Thus, results may also be subject to bias in terms of response style and common method variance [26
]. However, Shubert et al. found self-reported high levels of preparedness to be correlated with good performance [28
], a finding which has to be regarded in the context of patient safety. Finally, the retrospective evaluation of preparedness, which we used in our study, may lead to bias. Therefore, we included personal and workplace factors as possible confounders into regression analyses, as these factors might have influenced the retrospective appraisal of preparedness after finishing medical education. Feedback of superiors, as well as living without a partner did indeed turn out to be associated with the feeling of preparedness, demonstrating the complex interactions which have to be considered when using self-assessments. Feedback was also identified as influencing factor on preparedness by other authors [29
], stressing the importance and the benefit of the direct interaction between superiors and junior doctors, e. g. during "bedside teaching". Nevertheless, the inclusion of the above mentioned confounders did not alter the effect of deficits in the three identified core competencies on the feeling of preparedness, which underlines their independent influence.